I am always interested in reading about the brain. In previous posts I have looked at neuroscientists V.S. Ramachandran and the late Oliver Sacks and some of the amazing things that can happen to our brains. There is Alien Hand Syndrome in which the subject feels that their hand is possessed by an uncontrollable outside force resulting in its actual movement. Then we have Blindsight, a condition in which patients who are effectively blind because of damage to the visual cortex are able to carry out tasks which would ordinarily appear to be impossible unless they can see the objects. And there is Cotard Syndrome, a disorder in which a patient asserts that he or she is dead, even describing symptoms such as smelling rotting flesh or worms crawling over the skin.
The human mind is indeed a great mystery. So recently I was interested to hear about a new book It’s All in Your Head, a look at the world of imaginary illness, the anxiety induced by hypochondria and the psychosomatic illness. They are different phenomena and the author Suzanne O’Sullivan provides a clear explanation. In hypochondria, which is also known as illness anxiety disorder, a small symptom may be magnified by the anxiety of the patient causing psychological distress. A psychosomatic illness is very different. The patient has a significant amount of physiological suffering, but medical tests or physical examination fail to turn up any physical cause. What is important is not any anxiety, but the actual symptoms.
These conditions are surprisingly common. O’Sullivan claims that as many as a “third of people seen in an average general neurology clinic have symptoms that cannot be explained. In those people, an emotional cause is often suspected.
There is no doubt that there is a great deal of stigma attached to these conditions. The title of the book alludes to this negative perception. But because something is psychological does not diminish its relevance. The situation has improved but we still live in a world that takes a dim view of those who are psychologically unwell.
Psychosomatic symptoms can be extremely varied. At the milder end you have tiredness or pains. At the extreme end you can see seizures or even blindness, although these are rarer. It is the latter which affected Yvonne. After an accident in which she had been sprayed in the face with window-cleaning fluid, she convinced herself and her family that she was blind. Unable even to get around her house, she was put on disability benefits with a full-time carer. After six months of tests doctors were unable to find anything thing wrong with her eyes. This might sound like a case of Andy Pipkin from Little Britain. But Yvonne does not appear to have been malingering. In one session with O’Sullivan, she gave her doctor a present:
“I have something for you,” she said, and handed me a card. On the front was a flower-filled field overlooked by a single tree. It was drawn in coloured pencil. The words inside said thank you, it was nice to have somebody to chat to every day.
“I made the card,” Yvonne said.
“You made it!” I could not hide my surprise.
“Yes, I borrowed pencils and paper from the woman in the bed next to me,” Yvonne replied.
“But if you can’t see, how could you draw?”
“I can feel the pencil marks on the paper,” she answered. She did not seem in the least affronted.
I looked at the picture again. All the colours were correct – the tree green, the bark brown. Not a single outline was broken, not a single leaf or flower out of place.
One doctor joked that she wouldn’t be winning any Oscars for her performance. O’Sullivan, though, does not think that Yvonne was faking it. She may have had patients who feign disability, but she argues that this is very rare. Sophisticated tests on the brain can now determine that with most sufferers of psychosomatic disorders there is no deliberate intent. Drawing a picture does not seem like the action of someone trying to play the system. Yvonne had subconsciously persuaded herself that was blind. After six months of psychiatric help and family counselling, Yvonne’s vision was “restored.”
Camilla was a highly successful lawyer with a beautiful home and two children:
… one day, while on a work trip to Cumbria, she started feeling strange. Her right hand began to tremble, then her left one. She tried to ask for help but could not speak. Soon her limbs were flailing. She slumped from her seat, her head banging on the floor despite the best efforts of a colleague to assist. She was still shaking when paramedics came to cart her off to hospital.
It later emerged that they were caused by the buried trauma of her first child’s death years earlier when his buggy had rolled into the path of a car.
Not all her cases produced successful outcomes. Shahina came to see the doctor with a paralysed and contorted hand that left her seriously disabled. She underwent every kind of investigation before it was revealed that there was a high chance that her problem was psychosomatic. But when she and her family received the diagnosis they were outraged. They refused to accept it. They left the hospital and never came back. This shows how unnerving such diagnoses can be for patients. We tend to want to cling to real physical diagnoses
It would be remiss of me not to mention that O’Sullivan’s work has been the subject of some controversy. In particular, her characterisation of he case of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) as psychomatic raised a lot of hackles with the ME Association and its Medical Adviser, Dr Charles Shepherd:
“Whilst accepting that physical symptoms can be caused by a psychological illness, far too many patients with these unexplained symptoms are now being conveniently lumped together with a dustbin diagnosis known as a somatic syndrome – leaving no incentive to carry out research aimed at finding an underlying cause, or an effective drug treatment. This is bad and lazy medicine.”
O’Sullivan states that around 70% of patients who have these inexplicable conditions are female. She speculates that as women are more likely to suffer traumatic sexual abuse, the physical illness might be a response to that. This speculation is interesting, but it is just that, speculation. Perhaps, one day, with the advance of neuroscience, we will understand what is really going on. But for the moment we just don’t know. Whatever the reality, many of the people that O’Sullivan describes are clearly suffering. We owe them compassion.
I haven’t read It’s All in Your Head yet, but I have heard O’Sullivan interviewed on a ABC Radio National Australia’s All in the Mind podcast about imaginary illness.