It\u2019s All In Your Head: True Stories of Imaginary Illness<\/em>. London: Vintage, 2016; first publ in hardback 2015 by Chatto & Windus<\/p>\nReviewed by Professor Edward Shorter<\/p>\n
The very subtitle of the book makes one nervous: \u201cstories of imaginary illness.\u201d If there is one phrase that psychosomatic patients \u2013 who have symptoms without lesions \u00ad\u2013 do not want to hear it is that their problems are \u201call in their heads.\u201d Even though O\u2019Sullivan may use the phrase ironically, it does take us back to the days when discovering organic causation was the Mecca of medical practice and psychiatry was left to \u201cthe shrinks.\u201d Of course things are more complicated, and O\u2019Sullivan, a neurology consultant at the National Hospital for Neurology and Neurosurgery knows this well. The book does make some finer distinctions so that \u201call in your head\u201d doesn\u2019t come out and hit us in the face. But still, O\u2019Sullivan says that \u201cpsychosomatic refers to physical symptoms that occur for psychological reasons . . . How many are aware of the frequency with which our emotions can produce serious disability where no physical disease of any sort exists to explain it?\u201d So in other words the origin of such symptoms is clearly psychological. These patients amount, she says, to fully a third of the cases seen in general practice and in neurology.<\/p>\n
The book is a kind of odyssey of patients O\u2019Sullivan has seen whose problems seem to have been caused by mental distress \u2013 a tour interleaved with explanations of historical figures such as the Parisian neurologist Jean-Martin Charcot, who once peopled this scene.<\/p>\n
O\u2019Sullivan has gone to such lengths to obscure the patients\u2019 actual identities that one is never entirely sure whether the \u201cPaulines\u201d and \u201cMatthews\u201d that parade through these pages are more fictional than real \u2013 though their complaints are real. And O\u2019Sullivan, it must be said, writes beautifully, a low-key golden flow of prose that makes the book simply a good read. There are no references. No authorities are invoked. This is the author, a veteran neurologist, speaking to us from the heart.<\/p>\n
But is what the heart says true? How reliable is her analysis that psychosomatic symptoms are \u201cphysical symptoms that mask emotional distress\u201d?<\/p>\n
Right off the bat, there are problems with this stress-causes-functional-illness model. There are several major causes of psychosomatic symptoms, some of which get short shrift.<\/p>\n
One, O\u2019Sullivan tells us about classical psychosomatic symptoms that are caused by \u201cstress\u201d or by the emotional overlay of underlying organic disease. Her patients\u2019 emotional woes are apparent to her in the course of many clinical interviews, and she ends up referring many of them to a \u201cpsychiatrist.\u201d This is the most useless referral imaginable, as psychiatrists shun and fear psychosomatic patients and can usually do little for them because the patients themselves reject the whole notion of \u201cpsychogenesis\u201d; patients usually accept such referrals only with the greatest reservation, convinced \u2013 not entirely incorrectly \u2013 that they are being turfed.<\/p>\n
Two, O\u2019Sullivan is silent about a huge source of psychosomatic illness, namely the phenomenon of suggestion. Patients who can be suggested into illness require no deep psychological problems, no intractable \u201cstress,\u201d to become symptomatic. They simply are suggestible.<\/p>\n
A perfect illustration of suggestibility is epidemic hysteria: Sally begins vomiting and suddenly all the ten-year-olds in the schoolyard start vomiting as well. The public health authorities rush in. There is alarm in the press. An organic cause is never found but everybody is better the next day. It is an epidemic of suggestion that has invested the schoolyard.<\/p>\n
The culture can be a source of suggestion as well, a subject on which O\u2019Sullivan is silent. The culture can tell us that \u201cfatigue\u201d or \u201cpain\u201d are acceptable models of presenting illness, and these patients turn up in physicians\u2019 surgeries with \u201cmyalgic encephalomyelitis\u201d (ME), known as \u201cchronic fatigue syndrome\u201d (CFS) on the other side of the Pond. They do not in fact have an occult organic illness called \u201cME\u201d but have suggested themselves into their chronic pain, fatigue and dizziness because the culture says those are appropriate symptoms. (And the culture has largely ceased to sanction \u201cparalysis\u201d as a convincing symptom \u2013 too easy to disprove with a negative Babinski.)<\/p>\n
Three, frank psychiatric illnesses may spin off somatic symptoms. Patients with melancholic depression will light up the medical charts like a Christmas tree. Their aches and pains are legion, and disappear once the melancholia \u2013 one of the most treatment-responsive illnesses in psychiatry \u2013 is successfully treated. Catatonia shoots off somatic symptomatology, the stupors, tics and stereotypies often misdiagnosed as organic disease and the catatonia not recognized. Why does this matter?Catatonia is another highly treatment-responsive disorder, but there\u2019s nothing \u201cpsychosomatic\u201d about it. In medicine, therefore, the concept of psychosomatic can get one into rough psychiatric water.<\/p>\n
It is striking that O\u2019Sullivan sees deep sadness as a source of psychosomaticity rather than as a symptom of glaring psychiatric psychopathology. \u201cI have met many people whose sadness is so overwhelming that they cannot bear to feel it,\u201d she writes. Yoo hoo!\u00a0 Such melancholic patients are indeed candidates for psychiatric treatment, not for repeated neurological assessments.<\/p>\n
There is, finally, a fourth variety of apparent \u201cpsychosomatic\u201d illness. But it is quite foreign to the other three and is usually not included in reviews of the topic. It is malingering. One rather has the feeling that some of O\u2019Sullivan\u2019s patients \u2013 \u00a0their gaze strictly averted from hers, their long silences \u2013 were malingerers. (She presents one.) You can\u2019t prove that someone is not fatigued, or not in pain. But you can prove that they don\u2019t have multiple sclerosis or another upper motor neuron lesion. So malingerers choose symptoms that can\u2019t be disproven. And many physicians who work, for example, in insurance medicine, cast a cynical eye upon many of the complaints that O\u2019Sullivan takes for true-bill.<\/p>\n
How best to treat these patients? O\u2019Sullivan has good words for a procedure that has largely passed from medicine, namely the amobarbital (amytal) interview. But it is increasingly seen as outmoded and dangerous (the barbiturates have undeservedly acquired a bad reputation, and most physicians are simply not in the habit of prescribing them).<\/p>\n
O\u2019Sullivan believes in letting the patients have it full blast: Your \u201cdisability has a psychological cause.\u201d Sorry. The patients are left open-mouthed, since virtually every psychosomatic patient in the history of the world has had a profound belief in the organicity of his or her woes. And even though we have exalted \u201cnever lying to patients\u201d to a beacon of medical ethics, in fact there are moments when a bit of evasion may prove therapeutic.<\/p>\n
\u201cShahina\u201d comes in with a contracture of the fingers of one hand. Another consultant recommends a botulinum injection. Bingo! The contracture releases instantly. Shahina is cured! Now, usually you take your therapeutic victories where you can get them. But O\u2019Sullivan presses on. She tells Shahina that normally the botulinum works only after a day or two. \u201cThe speed at which your hand responded to the toxin makes me wonder if there is a chance that the spasm in your hand might have had a psychological rather than a physical cause.\u201d<\/p>\n
Shahina responds, \u201cYou think I\u2019m mad?\u201d No, of course not but…<\/p>\n
This is actually a model of what not to do: throw patients into confusion with the relentless urge to enlighten them about their supposed psychological problems.<\/p>\n
For other patients, as I have argued above, the psychiatrist is held out as the solution of choice. This is a problematic idea, and it is dismaying to see it propagated so vehemently in these pages. Psychiatrists tend to be baffled by such referrals. \u201cThis is a patient whose chief complaint is chest pain? C\u2019mon!\u201d<\/p>\n
The general internist, the rheumatologist, or another neurologist should be the physicians of reference, because only they are able to build the necessary therapeutic alliance, to keep the myth of organicity semi-intact. It is this myth that patients require to retain their self-respect, while the real therapy takes places in the context of the doctor-patient relationship. What actually works is spending a lot of time with these patients and letting them tell and, if necessary, retell their stories. This is cathartic. But it is advice that is most unwelcome to many clinicians because it takes so much time.<\/p>\n
It is not really fair for me to second-guess Dr O\u2019Sullivan from the comfort of my armchair thousands of miles away. Physicians on the front line of medicine, at Queen\u2019s Square and elsewhere, have to cope as best they can \u2013 and with relatives that make Himmler seem like Santa Claus. (O\u2019Sullivan\u2019s patience in dealing with these furies is remarkable.) The take-home message is that the book is a great immersion in psychosomatic problems. One may quibble about some of the author\u2019s therapeutic choices but this is for the Thursday afternoon seminar room. If you want to get a head-on feeling for the clinical experience of psychosomatic patients, read this book.<\/p>\n
<\/p>\n
Edward Shorter is Jason A Hannah Professor of the History of Medicine in the Faculty of Medicine of the University of Toronto, where he also has the academic rank of Professor of Psychiatry. Among his books is From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era<\/em> (New York: Basic Books, 1992)<\/p>\n <\/p>\n
<\/p>\n","protected":false},"excerpt":{"rendered":"
Suzanne O\u2019Sullivan, It\u2019s All In Your Head: True Stories of Imaginary Illness. London: Vintage, 2016; first publ in hardback 2015 by Chatto & Windus Reviewed by Professor Edward Shorter The very subtitle of the book makes one nervous: \u201cstories of imaginary illness.\u201d If there is one phrase that psychosomatic patients \u2013 who have symptoms […]<\/p>\n
Read More…<\/a><\/p>\n","protected":false},"author":263,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2965],"tags":[],"class_list":["post-1007","post","type-post","status-publish","format-standard","hentry","category-book-reviews"],"yoast_head":"\nWellcome Book Prize Winner 2016 - 'It's All In Your Head' reviewed - Medical Humanities<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-humanities\/2016\/06\/23\/wellcome-book-prize-winner-2016-its-all-in-your-head-reviewed\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Wellcome Book Prize Winner 2016 - 'It's All In Your Head' reviewed - Medical Humanities\" \/>\n<meta property=\"og:description\" content=\" Suzanne O\u2019Sullivan, It\u2019s All In Your Head: True Stories of Imaginary Illness. London: Vintage, 2016; first publ in hardback 2015 by Chatto & Windus Reviewed by Professor Edward Shorter The very subtitle of the book makes one nervous: \u201cstories of imaginary illness.\u201d If there is one phrase that psychosomatic patients \u2013 who have symptoms [...]Read More...\" \/>\n<meta property=\"og:url\" content=\"https:\/\/blogs.bmj.com\/medical-humanities\/2016\/06\/23\/wellcome-book-prize-winner-2016-its-all-in-your-head-reviewed\/\" \/>\n<meta property=\"og:site_name\" content=\"Medical Humanities\" \/>\n<meta property=\"article:published_time\" content=\"2016-06-23T11:21:07+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/blogs.bmj.com\/medical-humanities\/files\/2016\/06\/Its-All-in-Your-Head-195x300.jpg\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"8 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-humanities\\\/2016\\\/06\\\/23\\\/wellcome-book-prize-winner-2016-its-all-in-your-head-reviewed\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-humanities\\\/2016\\\/06\\\/23\\\/wellcome-book-prize-winner-2016-its-all-in-your-head-reviewed\\\/\"},\"author\":{\"name\":\"\",\"@id\":\"\"},\"headline\":\"Wellcome Book Prize Winner 2016 – ‘It’s All In Your Head’ reviewed\",\"datePublished\":\"2016-06-23T11:21:07+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-humanities\\\/2016\\\/06\\\/23\\\/wellcome-book-prize-winner-2016-its-all-in-your-head-reviewed\\\/\"},\"wordCount\":1577,\"commentCount\":0,\"publisher\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-humanities\\\/#organization\"},\"image\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-humanities\\\/2016\\\/06\\\/23\\\/wellcome-book-prize-winner-2016-its-all-in-your-head-reviewed\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-humanities\\\/files\\\/2016\\\/06\\\/Its-All-in-Your-Head-195x300.jpg\",\"articleSection\":[\"Book Reviews\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/blogs.bmj.com\\\/medical-humanities\\\/2016\\\/06\\\/23\\\/wellcome-book-prize-winner-2016-its-all-in-your-head-reviewed\\\/#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-humanities\\\/2016\\\/06\\\/23\\\/wellcome-book-prize-winner-2016-its-all-in-your-head-reviewed\\\/\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-humanities\\\/2016\\\/06\\\/23\\\/wellcome-book-prize-winner-2016-its-all-in-your-head-reviewed\\\/\",\"name\":\"Wellcome Book Prize Winner 2016 - 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