In Context
Book
“Your disease is not real”
Psychosomatic illnesses in their mild form are often
overlooked by society as attention-seeking behaviours—
and the sufferer simply branded a hypochondriac. After
all, with all the organic, life-threatening, and debilitating
diseases that exist, empathy for something that is not
considered real may be less forthcoming. For those that
experience symptoms of greater concern, a diagnosis may
be attributed, treatment and medication administered,
but without success. After undergoing test after test the
doctor tells you nothing has been found. The doctor may
then discharge you, or refer you to another specialist for
further tests, unable to provide any meaningful diagnosis.
At this point consultant neurologist Suzanne O’Sullivan
(National Hospital for Neurology and Neurosurgery, London,
Published Online
May 26, 2015
UK) may be called upon to assess this enigmatic illness that
http://dx.doi.org/10.1016/ is clearly present, but eluding clinical diagnosis.
S1474-4422(15)00085-X It’s All in Your Head, written by O’Sullivan, is an en-
It’s all in the mind lightening account that explores with intelligence and
Suzanne O’Sullivan,
Chatto & Windus, London, 2015.
compassion the catastrophic effects of psychosomatic
Pp 326. £14·99. illnesses, mostly manifesting as epileptic seizures, paralysis,
ISBN 9780701189266 and debilitating pain. With a genuine interest from both
a neurological and psychological perspective, O’Sullivan
recounts a history of these illnesses without judgment.
“Laughter is the ultimate psychosomatic symptom.”
How many people know that? There is no medical
explanation of how the brain produces laughter, and there
are many different types. However, laughter is not a life-
threatening problem. Not like seizures, crippling pain, and
fatigue so intense that life has lost its purpose or work
becomes impossible, and no one has any answers or can
offer further treatment options. O’Sullivan, in addition to
treating those with physical disease, specifically epilepsy,
sees patients who present with such disorders: “I believe
in and accept the unconscious, uncontrollable nature
Andrzej Wojcicki/Science Photo Library
984
of a psychosomatic disability”. Trained as a neurologist
O’Sullivan concedes that her professional interest is not
commonplace, but it is precisely her role as a doctor—“to
allay the patient’s fears and dispel confusion about the
diagnosis”—that she feels drives her.
“Psychosomatic disorders are not neurological disorders.
They belong to the fields of psychology and psychiatry. I
am not a psychiatrist. I am a neurologist”, she explains. She
presents her case studies within a contextual framework
of medical research, drawing on the work of eminent
predecessors who exhaustively pursued a medical basis for
hysteria, which O’Sullivan dubs the “ancestor of psycho-
somatic illness”.
One patient, Matthew, is paralysed and confined to a
wheelchair, and he is convinced he has multiple sclerosis.
Following MRI scans of his brain and spine, and an electrical
study of his nerves, his neurological pathways were found
to be intact, yet he could not achieve voluntary move-
ment. Pauline had symptoms ranging from unexplained
pain and swelling in her joints, fatigue, urinary tract
infections, paralysis, and eventually seizures. Using video-
telemetry and EEG monitoring, her brainwave patterns
did not indicate epilepsy, despite her collapses and loss of
consciousness. O’Sullivan describes Pauline’s illness as a
dissociative seizure, one that occurs in the subconscious
rather than being caused by brain disease. Some patients’
histories point to an obvious cause—abuse, trauma,
depression-related or previous chronic illness—but not all
cases are so readily understood.
The conclusions reached by O’Sullivan are met with
anger, disbelief, and frustration—she explains to her
patients that she believes the illness is real, however, the
most difficult hurdle is how to convince them to receive
the appropriate treatment, the first step being a psychiatric
assessment. They cannot grasp the concept that their
illness may be triggered, or exacerbated, by an emotional
rather than physical cause. Thus their reluctance to be
referred to a psychiatrist, protesting that they are not crazy,
but physically ill.
It would be hard, after reading this book, to look at
psychosomatic illness as an irrelevance. It could be argued
that an illness that cannot be defined in medical terms is
the worst kind. When an explanation is out of reach—what
then? This book addresses this circumstance with great
success. There is one piece missing in these stories though.
O’Sullivan’s role is to rule out neurological disease and
refer the patient to a psychiatrist. Whether they recover,
ultimately, is left to our imagination.
Jules Morgan
www.thelancet.com/neurology Vol 14 October 2015