Review: Suzanne O'Sullivan, It's All in Your Head

This is another book picked up by chance in Waterstone's and a most unusual one too. It's quite easy to find books which narrate the case histories of patients seen by private psychotherapists (Stephen Grosz's The Examined Life is a recent example, reviewed on this site 3 February 2014) or, in the case of Adam Phillips, by a former NHS child psychologist. But this book is by a consultant neurologist with a special interest in epilepsy who in the course of her work (both NHS and, I assume, private) encounters patients whose symptoms have no identifiable organic base and are thus, sooner or later, classified as psychological in origin.

The symptoms are major and disabling - seizures, convulsions, paralysis, blindness. They are symptoms which have led to ambulances being called, A and E working flat out, consultants being telephoned, provisional diagnoses and medication being prescribed - and to no avail. 

For the most part, they are symptoms which if not organically caused, would once have been assigned to the category of hysteria. Dr O'Sullivan devotes some pages to the history of hysteria within modern clinical medicine, starting with Charcot and Janet and continuing to Breuer and Freud. But - perhaps on editorial advice - she gives no bibliographic references at all, not even a Further Reading list. This is a pity since part of the interest of this book lies in the fact that it is written from the perspective of a neurologist with an orthodox medical training and wide experience of conventional clinical practice in Ireland and the UK. It thus gives an unusual insight into what hospital neurologists nowadays know and think about psychosomatic or psychogenic disorders.

But the book uses case histories rather than theoretical argument or research review to guide our understanding. One of the first things to strike me about these case histories was the prominent position of the patient's parents, partners and other carers. Of course, if you are confined to a wheelchair you are going to have carers. But the carers are often present in the kinds of unhelpful way which R D Laing and A Esterson flagged up many years ago now in Sanity, Madness and the Family: the carers present themselves as authoritative in regard to the medical history and current feelings of the patient. They also have strong views on what will count as an acceptable diagnosis. O'Sullivan does not really engage with the facts she extensively reports and the patient is always referred as an individual to a psychiatrist and never everyone involved to family or marital therapy.

She frequently makes the point that the psychogenic illnesses she encounters are found in people who often have no conscious awareness of being anxious, depressed or stressed and who indeed often enough proclaim themselves happy and worry-free. You could say, this is why they have ended up in A and E rather than in the armchair of a private psychotherapist. At one point she remarks, "Perhaps those who deny stress do so because they do not feel stress, having converted it to something else" (p 243) - that "something else" being a somatic symptom. But this is not an incidental "Perhaps" feature. It seems to be the heart of the matter - the patients she is seeing suffer from conversion disorders in which the body expresses (in a terrifying manner) what the conscious mind, the tongue cannot.

This is a very interesting, quite brave book. It is consistently humane, even towards the occasional malingerer who makes it all the way to the neurologist's telemetry suite - in the final chapter, there is a charming, warm portrait of just such a person. We know a lot about the world of those who can be articulate on the analyst's couch, much less about those whose body takes the brunt of their illness.