It’s All in Your Head review – enduring mystery of psychosomatic illness

Suzanne O’Sullivan qualified as a doctor in 1991. She is now a consultant at the National Hospital of Neurology and Neurosurgery in London. This, her first book, is an account of her experience over 20 years of the many conditions that exist in that much disputed no man’s land between psychological and physical illness. The patients she examines in these pages often have dramatic symptoms – blindness, paralysis, seizures, intense pain and chronic fatigue – but they are symptoms related to no identified disease or physical cause. By the time these patients come to O’Sullivan they have generally exhausted every scan and endoscopy the NHS can provide, as well as the patience of doctors and specialists in different fields. She is often there to tell them the last words that they generally want to hear: that the very real agony that they may feel in head or gut or back or limb is all in their mind.

To O’Sullivan that is never a trivial diagnosis, no matter how it sounds. Psychosomatic illness, the experience of physical symptoms brought about by emotional states, is not a new phenomenon, though arguably it has reached pandemic proportions with the self-diagnostic possibilities offered by the internet. O’Sullivan traces it at least as far back as Hippocrates in 400BC, who noted, for example, that emotion alone could trigger sweating and cause the heart to beat double time. As a result of such observations Hippocrates believed that a physician must treat disturbances in the mind as well as the body. Two millennia before Freud he was analysing the dreams of his patients for signs of mental distress that might be causing physical illness.

The evidence for what were later called “hysterical” patients is not only traceable back to the beginnings of medicine, it is also common to all cultures. A 1997 World Health Organisation study showed that rates of illness with “medically unexplained symptoms” were almost identical in developed and undeveloped countries – availability of healthcare had no effect on the numbers – and accounted for 20% of patients worldwide, many of them entirely incapacitated. A 2005 study suggested that the annual cost to the American health system of psychosomatic illness was $256bn – then double that of diabetes.

It is figures such as these that lead O’Sullivan to argue that the medical profession can rarely be an objective science. That diagnosis necessarily starts from the principle that “everybody’s experience of illness is their own… moulded by life experience and personality”. And, further, that “if you take 100 healthy people and subject them to the exact same injury you will get 100 different responses. That is why medicine is an art.”

Some of its more avant-garde subjects have faced O’Sullivan in her treatment room. Her experience of this type of patient began when she was just qualified as a junior doctor, watching a woman she calls Yvonne being questioned by her consultant. Yvonne, after an accident in which she had been sprayed in the face with window-cleaning fluid, had convinced herself and her family that she was blind. After six months of tests doctors had found nothing wrong with her eyes. She was by this time on disability benefits with a full-time carer, unable to get around her house. O’Sullivan and her fellow junior doctors, certain she could see, found it hard not to suppress giggles as Yvonne described her condition. They were reprimanded by the consultant. The cause of Yvonne’s blindness was psychological rather than physical – a response, it later seemed, to unbearable tensions in her marriage. It was to her no less real, however: she had subconsciously persuaded herself that she had lost her sight. After six months of psychiatric help and family counselling, O’Sullivan reports, Yvonne’s vision was restored.

It is O’Sullivan’s contention that “psychosomatic disorders are physical symptoms that mask emotional distress”. In the 19th century sufferers of such conditions were paraded by the celebrated neurologist Jean-Marie Charcot, who revealed to sold-out audiences how such states could be induced by suggestion and hypnosis. Even with fMRI scans and advances in neural imaging, the means by which thought alone can conjure physical pain is an unfathomable mystery. “One day a woman loses the power of speech entirely and the next she speaks in the voice of a child. A girl has a lump in her throat and becomes convinced she cannot swallow. Eyes close involuntarily and no amount of coaxing will open them.” Each of O’Sullivan’s patients is different; however, buried trauma or stress (itself an undefined cause and effect) seems often to be a trigger.

Sometimes the proximity to a “real” illness causes transference. A person with a family member with a brain tumour is more likely to experience violent headaches. The close friend of an epileptic is more prone to dissociative seizures. There is some evidence that doctors treating motor neurone patients become acutely aware of their own muscle cramps. Sometimes the media can prompt psychosomatic epidemics. In the 1990s O’Sullivan was inundated with patients who thought they had symptoms related to candida, which had been popularised as being rife at the time. These symptoms had been widely disseminated in magazines and newspapers as a feeling of being run-down, constantly bloated, with itchy ears and a craving for sugar. Almost everyone, if they paid undue attention to their bodies, O’Sullivan suggests, might have noticed those symptoms. A few put them down to candidiasis. “Patients rarely ask me about candida any longer,” O’Sullivan notes. “In the 21st century exactly the same symptoms are more likely to be attributed to gluten sensitivity or allergies.”

A lot of information can be a dangerous thing. Matthew arrives in her clinic in a wheelchair, apparently unable to walk and utterly convinced he has multiple sclerosis. His problem began when he experienced a feeling of pins and needles in his foot a few times while sitting working. The doctor who examined him told him to “stop thinking about it and it will disappear”. But Matthew was among those individuals who could not stop thinking about it. Months after he started to tick off the other early warning signs of MS – tiredness, dizziness and the rest – he had become housebound and had lost the power to use his legs for no reason other than that belief.

O’Sullivan believes in the “reality” of Matthew’s symptoms in turn, but her suggested referral to a psychiatrist, as so often, is met with anger and suspicion (sometimes, in similar circumstances, she has received legal letters). In reality, her diagnosis in such instances is as much philosophical as medical. It lies in the fact that much about the relation of mind and body is unknown and possibly unknowable. The tendency to respond to every inexplicable bodily sensation may be ignored in most of us, but not in all of us, particularly if it becomes part of a pattern masking or deflecting some other stress. Who is to say that transference is “imaginary”? Certainly no one who has ever blushed, or felt tension in their neck and shoulders because of “stress”. Is there a cure for this human condition? You might begin by reading O’Sullivan’s book, but though it may put some minds at rest, I suspect others will not get far into it before calling their GP for an urgent appointment.

It’s All in Your Head is published by Chatto & Windus (£16.99). Click here to order it for £13.59