What is the Symptom Imperative?

One reason sensations can come and go and change over time

[Peter] did well in [Sarno’s] program and became pain-free in about three weeks. Shortly thereafter, he began to feel anxious and began to have some of his old stomach trouble again. This was the symptom imperative at work . . . an indication of the power of the unconscious conflict within. - John Sarno, The Divided Mind

The Symptom Imperative has been called John Sarno’s greatest observation and it’s a hallmark of The Mindbody Syndrome (TMS). But what is the Symptom Imperative exactly? How does it work? Well in case you’re unaware let me first just say something about The Mindbody Syndrome: TMS is the idea that psychological stress (so an internal stress response) can create or maintain scary sensations. Sometimes TMS starts after a physical injury, sometimes after an emotional injury but, whatever the situation, we tend to get preoccupied with sensations, we think there’s something seriously wrong with us, and the emotional reason for this stress response—what’s causing these sensations to persist—fades into the background. For this reason John Sarno says that TMS is a protective mechanism that distracts us from emotional conflict or rage or whatever we might be upset about because instead we’re focused on all these awful sensations. That might sound crazy but that idea has helped me and many others get out various syndromes and there’s even a successful clinical trial.

THE SYMPTOM IMPERATIVE

The Symptom Imperative is perhaps the most defining characteristic of TMS and at its most basic level it simply means that the manifestations of TMS vary over time. The sensations can change or shift or go away and then come back. This happens sometimes over minutes, weeks, months, years. Oftentimes a sensation will really grip us and then maybe we’ll get used to it a little bit or we do a physical intervention that we think will help it and then some other sensation comes along and completely slams us and we’re back in that fear cycle. That’s the symptom imperative, that there’s almost always something going on. This is a hallmark of TMS because as Howard Schubiner, an eminent mindbody physician says, very few actual diseases behave this way and when nothing is truly found wrong with someone then TMS might explain what’s happening.

Now as to the purpose of the Symptom Imperative, Steve Ozanich explains it this way in his classic book The Great Pain Deception:

An imperative is something that demands attention or action . . . As long as there is unresolved conflict, the mind will continuously shift symptoms to keep fear alive, as a purposeful distraction . . . the symptom imperative is a hunter—preying on fear.

In other words if we keep thinking something is wrong with us and we don’t acknowledge there’s something we’re upset about the stress response will continue to run wild and the Symptom Imperative will continue to create different sensations to continuously capture our attention and keep our minds focused on the idea that something is wrong with us.

Now there are at least two kinds of Symptom Imperatives: there’s one where we’re unaware that TMS is happening and the other kind where we do know about TMS and yet the symptom imperative continues anyway. So let’s take a look at both kinds.

KIND 1: WHEN WE’RE UNAWARE OF TMS

I remember back when I was unaware I was experiencing TMS I would often get really scared about at least one sensation. For instance when my shoulder was freezing it was very painful and took up all my attention but after it was frozen the pain was more manageable and it was like, phew that’s over, I can take a breather now. Then my other shoulder started freezing. And the terror started all over again. I had many, many things like this with both persistent pain and protracted withdrawal sensations. I’d have waves of panic that would abate and I’d be like phew that’s over and then my head would start pounding or I’d get dermatitis or feel like I had the flu, whatever. Just when I thought I might be okay or it might be manageable I’d get slammed with something else. I had no idea what was going on at the time.

Now the reason all these different kinds of sensations can happen whether physical or psychological is because it’s the same underlying stress response causing them all. Once danger signals are firing in the brain we might start to interpret everything as dangerous and our minds respond with pain, panic, IBS, derealization, things that happen when the mind is under threat. We can also become very suggestible to danger which is why forums and groups where people just talk about “symptoms”, talk about how they’re sick all the time, to beware of this, don’t eat that, that nothing can be done, that time is the healer if there is one at all, all this can make us worse by increasing this stress response and there’s a social contagion element to all this as well where you can pickup other people’s sensations.

Also, perhaps most importantly, it’s the same psychological process that drives the Symptom Imperative and that’s important because that’s the key to resolving this and more broadly The Mindbody Syndrome. But when we’re still in this first kind of the Symptom Imperative, the unaware phase, we don’t know about that yet and so the Symptom Imperative can go on for years. I had various sensations for five years that just went on and on and on. I just assumed my nervous system was incurably sensitized or that drugs had ruined me or whatever. But once I started employing a TMS approach the sensations, well, they still moved around but by then it was of a different kind.

KIND 2: EXTINCTION BURSTS

The other type of Symptom Imperative might be what therapist and author Alan Gordon calls Extinction Bursts.

“For many [people in pain], just as their fear decreases, just as their symptoms start abating, just as they begin making some real progress—pow! They get blindsided by intense pain. This, of course, terrifies them, and they get sucked right back into the pain-fear cycle.” - Alan Gordon’s The Way Out.

Now we could substitute pain here for anxiety or sadness or rashes or fatigue or whatever. John Sarno observed how all these things are connected and can replace each other. Now the reason sensations can change or worsen when we start to make progress, well, Alan Gordon gives this example: long ago there was an experiment with a rat who learned to use a dispenser by pressing a lever to release food. But one day the dispenser broke. So the rat just hit the lever rapidly over and over and over again until eventually he gave up. This is what could be called an extinction burst, the last desperate attempt to achieve a desired result.

I guess it’s kind of a metaphor because once we start to become aware that maybe we’re okay, we’re not damaged, and maybe our fear drops a bit, the brain starts hammering away at us with more fear and different sensations to remind us we’re supposed to be scared. Now why does it do this?

John Sarno talks about how once we catch on that there’s nothing wrong with us, that we’re just stressed out about something, the brain might fight back. In fact Sarno called his last book The Divided Mind because he sees a conflict between the conscious mind (sort of us) and the unconscious mind (stuff we’re not aware of). The stress response or TMS is coming from the unconscious mind and it’s trying to drag our conscious mind into muck, into the stress. It wants us to stay focused on physical or psychological sensations because the unconscious mind wants us to pay attention to something, anything that will make us scared so we focus on something that is apparently wrong with us. But this is misleading.

Because what the mind truly perceives as dangerous is an emotional threat that it doesn’t want us to focus on because the mind thinks it’s too painful for us to know about. So to resolve this we have to use our conscious minds to teach ourselves that we’re okay, that we’re both physically and emotionally safe, even if we don’t feel that way. This might include acknowledging the sources of stress in our lives and the fearful or rageful emotions inside us driving the sensations.

Now as to handle the Symptom Imperative, these extinction bursts, it’s just to stay the course. When we’re aware of TMS and the sensations are changing then we have it on the run which is a positive development. If we’re not unaware of TMS it might just run somewhere else and trick us again. But when we know it’s on the run and it’s popping up here and there we can call it out. When we get more confident, we laugh at it. Or we can ask the mind what else you got? Bring it on. You’re going to have to do better than that to trick me. We can tell the mind to stop distracting us from our emotions. There are lots of ways we can enhance a TMS understanding through this kind of work and the Symptom Imperative will stop and go away. This can take time to implement and fully understand it. And it won’t necessarily mean we won’t feel another sensation ever, we’re humans after all, but they’re usually minor and short-lasting because we have TMS knowledge as part of our minds now.

If you want to know more about how The Mindbody Syndrome works I have a resource page here on my Substack. I hope this post is of some use to you. Until next time.