It’s All in Your Head
Author: Suzanne O’Sullivan
This book is a very lucid exploration of psychosomatic disorders, conditions in which emotions present with physical features as an exaggeration of the body’s normal response to stress. It reveals how their complexity and chameleon-like nature baffles even doctors who struggle to understand them (pages 5, 85 and 186). Central to the narrative are real patients with psychosomatic disorders, people ‘whose sadness is so overwhelming that they cannot bear to feel it’, and who replace the sadness by unconsciously thinking themselves ill and developing severe and inexplicable physical disabilities (pages 5 and 15). The author’s stated objectives for writing the book were to prevent future patients finding themselves ‘bewildered and alone‘, and to convince medical professionals that psychogenic disorders are real; indeed she argued that ‘the very manner in which patients with psychosomatic illness pursue a diagnosis provides the most compelling nature of the illness‘ (pages 16 and 148-153).
The author approaches the subject from the perspective of the patients whose physical and emotional suffering is real, but like Cassandra, ‘do not feel believed’ (page 97). This is partly because many in society view psychosomatic disorders as ‘the charlatans of illnesses’, and question ‘the reality and legitimacy‘ of the victims’ suffering (pages 56-57 and 97). At the heart of the book therefore are the very gripping and touching stories of such patients which portray different dimensions of the disorder. Take the case of Camilla for example; she had locked away her painful emotional past ‘in a box in her head’, and her psychogenic epilepsy was the ‘monster’ which protected the box. Or take the case of Liz whose diagnosis of dissociative seizures ‘threatened all the security that the diagnosis of epilepsy had inadvertently offered’; and Brenda, whose recurrent dissociative seizures put her at risk every time she is intubated and ventilated on the intensive care unit (pages 259, 301, 287, and 11-14). The book also gave a good account of other forms of psychogenic disorders with subjects such as Matthew, ‘a man on a treadmill looking for a way off’; Yvonne, whose sudden blindness underlined unresolved family tensions between herself and her family; and Alice, whose migrating symptoms was a reflection of sadness ‘looking for a way out’ (pages 64-65, 95, 173-177).
A major part of the book is oriented at explaining the mechanisms behind psychosomatic disorders. For example, the author described the concept of dissociation as a state in which ‘feelings, thoughts or memories become disconnected from one another’, and ‘one part of the mind is not aware of the other’ (pages 144 and 297). She also defined the state of conversion as when ‘the subconscious mind reproduces symptoms that make sense to the individual’s understanding of how a disease behaves’ (page 89). She also went to great lengths to differentiate psychosomatic disorders from several conditions which mimic them. For example, she distinguished malingering, where illness is feigned for financial gain; Munchausen syndrome, in which subjects ‘manufacture or imitate illness…for the care and attention that illness brings’; and hypochondriasis, where subjects pursue every symptom ‘until it is the pursuit itself rather than the symptoms that lead to an inability to function fully in the world’ (pages 170, 161, and 254).
The most practical quality of the book, for doctors, is the author’s description of her management approach to psychosomatic disorders. This ranges form the painstaking exploration of the usually complex history, to the delicate process of explaining the diagnosis to the patients and their relatives (pages 45-49). The author particularly dwelt on what is perhaps the most challenging aspect of the management, the unwillingness of many patients and their families to accept the diagnosis. She explored the manifold emotions that underlie this denial such as anger and fear. She also sensitively addressed the understandable concerns patients have about accepting a diagnosis that may mean ‘they are relinquishing their grip on physical disease, and with it losing all validation of their suffering’ (page 77). The book examined several other factors that encourage the denial of the diagnosis, explaining how, for example, the poorly understood disease mechanism, and the absence of positive diagnostic tests, leave room for doubt to grow, and for questions to flourish (page 126).
The author made many recommendations to help physicians improve their approach to patients with psychosomatic disorders. Most importantly, she stressed that it is ‘absolutely necessary for both the patient and the doctor’ to ‘believe in the truly subconscious nature of their patient’s psychosomatic symptoms’ (page 141). She encouraged doctors to ‘be less afraid of this diagnosis, more willing to confront it and more compassionate to the sufferers’ (page 311). She particularly urged doctors to treat people with psychosomatic disorders with ‘the same respect that we would give to anybody else with any other diagnosis’ (page 311). She stressed the importance of distinguishing terms such as medically unexplained symptoms, functional disorders, conversion disorders, and dissociative disorders (pages 16-19). She also dispelled many myths about psychosomatic disorder, for example when she established that, in the majority of cases, there is no history of childhood sexual abuse (pages 275-285).
The quality of the book is greatly enhanced by the numerous historical anecdotes the author sprinkled throughout the text. For example, she gave a detailed history of the evolution and understanding of hysteria through the eyes of Hippocrates, Galen, Jean-Martin Charcot, Pierre Janet, Sigmund Freud, and Josef Breuer (pages 78-84, 120-122, 141-145, 187-191 and 273-274). She also related the fortuitous discovery of electroencephalography by Hans Berger when he was investigating telepathy (pages 40-41). Equally fascinating were the gripping stories of the famous neurological patients Mary Glover, Blanche Wittman, and Bertha Pappenheim; and the excellent descriptions of diverse cultural psychosomatic disorders such as amok, koro, grisi siknes, and the jumping Frenchmen of Maine ((pages 80, 116-123, 188-191 and 208). The book also included detailed discussions on chronic fatigue syndrome or myalgic encephalopathy, neurasthenia, consciousness, attention, perception, and memory (pages 234-246 and 193-198).
This subject is important across several fields of medicine although the focus in this book is on the neurological manifestations. The author’s prose is clear, her sentences carefully crafted to achieve the aims of the book. Refreshingly, she avoids superfluous words and unnecessary autobiographical diversions which plague many books. Her review of the causes, triggers, gender differences, and diagnostic pitfalls of psychosomatic disorders is a must-read because it is detailed, enlightening, all-encompassing, and myth-shattering. The text is peppered with touching stories, deep insights, and restrained humour. Her opinion that psychosomatic disorders are psychiatric or psychological, and not neurological, appears to be a debatable point, but there is otherwise nothing else to take issues with throughout the book.
This excellent book addresses a condition that is poorly understood by medical and non-medical people alike. In a most comprehendible elucidation, the author concretised the concept of psychosomatic disease, not only as a real illness, but one with clear signs and treatments. She shows how it manifests across the breadth of medical specialties, and she clearly demonstrated what is, and what is not, psychosomatic. The book succeeds in firmly establishing psychosomatic disorders as real illnesses and the source of serious suffering, and it points out how to recognise and manage them. I highly recommend it to all doctors.
Publisher, Place, Year: Vintage Books, London, 2015
Number of chapters: 9
Number of pages: 326
Star rating: 5