It’s All in Your Head by Suzanne O’Sullivan

Winner of the Wellcome Book Prize last month, ‘It’s All in Your Head: Stories from the Frontline of Psychosomatic Illness’ by Suzanne O’Sullivan is a collection of case studies about patients who have been diagnosed with psychosomatic disorders. Based on her clinical experience as a consultant neurologist, O’Sullivan recounts the stories of some of her patients whose medically unexplained illnesses are thought to be “physical symptoms that mask emotional distress”.

The subtitle of previous editions ‘True Stories of Imaginary Illness’ was quite misleading in that it suggested that the case studies are all about hypochondriacs. However, O’Sullivan does not claim that the symptoms she has seen in her patients are “imaginary” in the sense that they are deliberately made up. Instead, they are every bit as real and debilitating as those known to be caused by a physical disease. While, it is well-known that stress can manifest itself physically in all sorts of “normal” ways such as crying, sweating and blushing, it is the more alarming symptoms such as blindness, seizures and paralysis which can be particularly distressing for patients.

Each chapter in the book deals with a specific patient case study and O’Sullivan also weaves in some interesting historical background about how psychosomatic illness has been treated in the past. In many cases, her patients have had a traumatic experience which they have often buried for many years such as Camilla whose seizures began after the death of her child. Unfortunately, the case studies have no real conclusions as O’Sullivan is unable to find out what happened to her patients after they are referred elsewhere, but their stories are still revealing in terms of how a diagnosis is reached and how patients and their families react to it.

The ‘Rachel’ chapter about ME (myalgic encephalomyelitis) has been particularly controversial amongst those who believe the condition has a viral cause rather than a psychosomatic one. O’Sullivan fully acknowledges the uncertainties surrounding the exact triggers: “I will not be obtuse. I believe that psychological factors and behavioural issues, if they are not the entire cause, at the very least contribute in a significant way to prolonging the disability that occurs in chronic fatigue syndrome. Do I know that for sure? No, nobody does; but I am influenced by the lack of evidence for an organic disease.” This is one of many reminders throughout the book that medicine is a frustratingly inexact science and we are still a long way away from fully understanding the origins and treatment of many illnesses, both psychological and physical.

The vast majority of patients in O’Sullivan’s case studies are furious when they are told by doctors that their symptoms are likely to have a psychological cause. They believe that they are not being taken seriously or that a physical disease has been misdiagnosed. O’Sullivan is upfront about having to learn over the years about how to deliver this information in a sensitive way which isn’t misinterpreted by patients or causes them more distress due to the stigma surrounding the diagnosis. Given that as many as a third of GP consultations are taken by those who are found to have no physical explanation for their symptoms, the lack of understanding surrounding psychosomatic disorders also has far-reaching financial implications for healthcare systems around the world.

Overall, psychosomatic illness is an aspect of medicine which needs to be researched and talked about far more than it currently is. It becomes increasingly clear from reading the case studies that we also need to be more compassionate towards those who have psychosomatic disorders. Hopefully, ‘It’s All in Your Head’ will start a wider conversation about a much misunderstood area of medicine and for that reason alone, it is a deserving winner of this year’s Wellcome Book Prize.