Book review: It’s All In Your Head by Suzanne O’Sullivan

MY LATE grandfather was a terrible hypochondriac. Even his closest friends would meet him with the phrase “Hello, Sam, what are you dying of today?”

OSullivan focuses readers attention on two undoubtedly psychosomatic symptoms  laughter and crying. Photograph: Jonathan Greet

It’s All In Your Head: True Stories Of Imaginary Illness

Suzanne O’Sullivan

Chatto & Windus, £16.99

Part of the success of Suzanne O’Sullivan’s phenomenal book is that I now feel exceptionally guilty for all the times I tetchily dismissed his symptoms.

O’Sullivan is a consultant in neurology, specialising in epilepsy, and her interest in the field of “imaginary” illness stems from meeting patients apparently suffering from seizures that were quantifiably not epileptic fits. The book is presented as case studies of seven people (anonymous, of course) who suffered from psychogenic, psychosomatic disorders. As she defines them, these conditions – which cause real, chronic and acute distress – are symptoms that could not be explained by any physical cause or disease. So, for example, Pauline suffers from urinary tract infections, joint pain and food intolerances, and after a routine operation, she finds she is paralysed, then starts to have debilitating seizures. Yet all tests prove negative and no physical or neurological cause can be determined for her illness. Another subject, Yvonne, goes blind – but all the evidence indicates that she can see. In these cases, O’Sullivan suggests, psychiatry holds the key to wellbeing.

O’Sullivan begins and ends the book with essays on two areas where we very readily accept that the mind can cause the body to alter: when we cry and when we laugh. Of laughter she writes “It is a physical display of emotion, its mechanism is ill-understood, it is not always under our voluntary control, it affects our whole body, it stops our breathing and speeds up our heart, it serves a purpose… if we can collapse with laughter, is it not just as possible that the body can do even more extraordinary things when faced with even more extraordinary triggers?” Put like that, it seems eminently sensible. But such is the stigma attached to psychiatric disorders, sufferers will probably be belittled and disbelieved.

One of the most heartbreaking aspects of the book is the regularity with which, when all diagnoses except the psychosomatic have been discounted, the patient’s reaction is not one of relief, but exasperation. “Are you saying that I’m mad?” is the common refrain. Often patients cleave to their self-diagnoses – epilepsy, brain tumours, Lyme disease, all the more esoteric conditions the internet helpfully gives them access to – because there is a safety in admitting to a physical problem, but an abhorrence of admitting it may be mental in origin.

One of the effective ways O’Sullivan counters the prevailing attitude is by honestly and openly admitting to having changed her mind about psychosomatic disorders. She recounts how, with fellow students, she yearned to “catch out” a sufferer, to prove they were faking their illness. It takes a degree of bravery to confess to one’s own gaucheness. That is not to say that there are no malingerers, or that conditions like Munchausen’s don’t exist. O’Sullivan is extremely sensitive about that in particular: we might realise that somebody is “faking” their symptoms – but “faking symptoms” is not something a well person does. Another way O’Sullivan courts the reader into empathy is by recounting her own experience of psychosomatic illness.

The statistics bring the reader up sharp. O’Sullivan estimates that one third of visits to a GP have symptoms that are “deemed medically inexplicable”. A 2005 study from Boston extrapolated that psychosomatic disorders cost the US $256 billion a year (while, for example, diabetes costs $136bn). She provides a history of the interface between medicine and psychiatry, via Charcot, Janet and Freud. This throws up an odd fact. Hippocrates attributed hysteria to the uterus, in particular that the uterus was “an animal within an animal” and able to wander around the body.

O’Sullivan quotes 18th century Scottish physician Robert Whytt in an epigraph – “the colours of the chameleon are not more numerous and inconstant than the varieties of hypochondriac and hysteric disease”. Curiously, psychosomatic disorders do “wander”. As she says, “most diseases politely restrict themselves to a finite number of symptoms”, whereas psychosomatic disorders are flagrant. In the case of Alice, what begins as headaches soon progresses to chest pains, paraesthesia, numbness, paralysis and convulsions. “But it is not an animal or an organ that wanders, it is sadness. And it is looking for a way out,” O’Sullivan writes. One of the indicators of a psychosomatic disorder is just how many wildly different symptoms the patient reports. The two most common – pain and fatigue – are also amongst the most complex, as we have no way to measure either.

What causes these conditions? It seems as if trauma in some form is usually responsible. But as with pain and fatigue, trauma is a broad category. We cannot know the traumas of others, or even if they would appear as traumas to us. It is not the case that every trauma is necessarily a sexual trauma: false accusation, grief, emotional claustrophobia and smothering can all take their toll. That firm but gentle capacity for empathy as well as privacy is the trademark of this remarkable book. There is a telling exchange with one patient, when O’Sullivan tells them she is wondering about a psychological cause. “But it feels so real, it can’t be nothing” he replies.

“It feels real because it is real” is her eminently humane and truthful reply.