As a nervous young thing in my 20s I suffered from an alarming case of the shakes – proper bobblehead-doll stuff, hard to hide – whenever I was faced with an even mildly fraught encounter: academic, romantic or bureaucratic. The tremors only stopped when I taught myself to locate the fear instead in the pit of my stomach; my guts might now be in flitters, but at least I made a less puzzling or comic interlocutor.
As Suzanne O’Sullivan points out in her rich and wise study of psychosomatic illness, we have all been there or thereabouts, converting our emotional turmoil (and even elation) into physical symptoms of greater or lesser gravity.
The more serious somatic disorders have been recognised since the time of Galen, who around 150 AD wrote of a woman whose racing pulse “points to a troubled mind”. But such “imaginary” ailments remain vastly misunderstood by physicians and patients alike – not to mention the family, friends and colleagues whose attitudes to the hapless somatiser may be ruinously enabling or painfully dismissive.
O’Sullivan, born and educated in Ireland, is a consultant neurologist at the Royal London Hospital. As a medical student she was tempted to laugh at the “worried well”, the transparent hypochondriacs and shameless malingerers who any doctor meets regularly. But 20 years of practice have shown her how much real suffering can be accompanied by so little evidence of organic disease.
Much of her book, which recently won the Wellcome Book Prize for writing about health and medicine, comprises sadly compelling accounts of bodies wracked and lives corralled by real illness with no apparent origin.
There is Pauline, a 27-year-old who has suffered seizures, infections and paralysis since her mid teens. There is Matthew, who thinks he has MS and arrives with a hefty ream of medical articles and a strained-looking wife. And Camilla, a successful lawyer suddenly prey to violent seizures that leave her feeling degraded by medical attention and public scrutiny, even mockery.
Many, or most, of these patients will ardently deny the presence of any stress or trauma that might have brought on their symptoms. This is one of the larger contradictions O’Sullivan describes. We live at a time when it’s readily credited that emotional vexation will lead to physical infirmity, and conversely (for better or worse) that “we can think ourselves better” with a positive outlook or attitude. And yet it is extremely hard for O’Sullivan’s patients to admit to any predisposing backstory.
Illness always seems to have fallen out of a clear black sky; as John Donne put it in his sick-bed Meditations: "This minute I was well, and am ill, this minute." O'Sullivan's job is thus, once the presence of physical disease has been ruled out, to lead the patient as sensitively as possible towards the realisation that something else has been causing his or her illness.
The task is just about as difficult as it sounds, given the complex of fear and conviction typically in play. O’Sullivan mostly sticks, in her writing and in the consulting room, to the current medical terminology, describing “conversion disorders” and “dissociative seizures”. But there comes a time when she has to venture to some word with the prefix “psycho” in it, and here is where things go awry. It’s not unusual to have an aggrieved patient say to her: “So now I’m a psycho, am I?”
It is sometimes preferable in these people’s minds to continue suffering their physical symptoms rather than give in to a diagnosis of what they will still, in rage and fear, call “madness”.
The problem is compounded when there hovers a suspicious and supportive community around a preferred diagnosis. O’Sullivan devotes a chapter to the story of Rachel, who clings to the relative consolation of chronic fatigue syndrome and baulks at the notion her thoughts and feelings may be part of the clinical picture.
These patients seem to believe, perhaps despite themselves, in a strict mind-body dualism that historically has had little currency even among the sternest materialists. As O’Sullivan points out, psychosomatic illness has not always felt so shameful. Of course nowadays we recognise that historical ailments such as hysteria and neurasthenia did not really exist as such – there were no wandering wombs, nor flayed nerves – but by the end of the 19th century patients and doctors alike were at ease with the idea that in these diseases mind and body were subtly convolved, and might be therapeutically prised apart.
O’Sullivan interleaves among her case studies a history of medical understandings of the action of feelings on flesh: from 17th-century theories of hypochondria, through the neurologist Jean-Martin Charcot’s studies of hysteria, to Freud’s clinical detective stories about the devious ways the mind acts on the body.
Though she is critically aware that some of these physicians themselves began new trends in imaginary illness, O’Sullivan can seem at times a touch too credulous about the model of the unconscious mind that they developed. Are we really to believe, in a straightforward way that Freud would likely never have countenanced, that emotional problems “leak out” into bodily pain?
Several of the clinical tales in It's All in Your Head conclude with O'Sullivan sending her patients off for psychiatric assessment or a course of cognitive-behavioural therapy, as if their problems are solved with the realisation they've unconsciously contrived their symptoms.
But what if such knowledge is only the start of a more troubling insight into one’s case, or into the state of being a person? What if, like many self-conscious hypochondriacs, you watch the relay between worry and pain play out time and again, till at last a definitive disease comes to take you away?
O’Sullivan’s book does not describe the metaphysical chasms that illness opens up, but it is an impressively vivid and sympathetic argument for the reality of the mind’s more harrowing inventions.
Brian Dillon is the author of Tormented Hope: Nine Hypochondriac Lives. His most recent book, The Great Explosion, has been shortlisted for the RSL Ondaatje Prize