It’s All In Your Head (Suzanne O’Sullivan)

As antagonistic as the title sounds, I promise it is not meant condescendingly! Suzanne O’Sullivan is a consultant neurologist, and she opens the book with the expectations she held of her future work before specialising in neurology: “diseases of the brain and nerves and muscles”. The reality also involved “those whose illnesses originated not in the body, but in the mind”. She goes on to tell us that these are under the umbrella of psychology, not neurology- but that these patients are sent to her because their symptoms do not immediately strike as psychological.

The subtitle of the book is “stories from the frontline of psychosomatic illness”. Psycho-somatic literally means mind-body: physical symptoms with a psychological cause. This does not mean that either the cause or the symptom are not real. Therefore, these symptoms should not be disregarded. They should be unpicked, just using different techniques to those that would be used for symptoms with a disease-based cause. “Psychosomatic” is not a dirty word. Crying tears due to sadness is technically an example of a psychosomatic symptom.

Suzanne explains the term “psychosomatic” as “[a reference to] a physical symptom which cannot be explained by a disease and is suspected to have a psychological cause”. The most common symptoms are pain and fatigue, but more severe cases in the book include seizures and blindness. Often, Dr O’Sullivan finds herself having a difficult conversation with her patients and their families, and this is where we come back to the title. When she explains her diagnosis, the response tends to be “so you’re saying it’s all in my head?”

The brilliance of the book is the opportunity to learn about psychogenic symptoms. As a patient or as a practitioner, if we can’t immediately understand what’s going on, at least we can empathise. As with any pain, even just being listened to and cared about will start to make a change.

However, there is a gradient. We don’t just talk about pain from disease or injury vs from a psychological cause. My favourite quote shows that there is a middle ground where psychology influences existing pain from a mechanical cause:

“Say, for instance, that somebody with neck pain is found to have wear and tear in their spine on an X-ray. Any middle-aged adult might have this same finding on an X-ray just as part of ageing, but if the patient attributes their pain to it, rather than due to muscle tension or stress, they are much less likely ever to be completely free of pain”

This is why patient education is so important to me! I love working with arthritic joints because people are generally so pessimistic about their arthritis before I tell them that I’ve improved movement and reduced pain in arthritic joints. Because of this pessimism, I never diagnose osteoarthritis without an immediate full explanation of how it happens and how treatment works.

False Positives on MRIIn the same sentiment as the quote, I won’t refer a patient for imaging if I think that their pain is purely from a disc bulge. MRIs are brilliant for things that don’t seem quite right- any symptoms that suggest something more serious are grounds for refferal. For symptoms that fit the picture of a disc bulge and respond well to treatment, I see little benefit in going through the system for imaging.

As the infographic explains, disc degeneration and disc bulging is normal. Do 30% of 20 year olds have lower back pain or sciatica? No- because a disc bulge does not necessarily equal pain. Sciatica can be caused by a muscle with no disc involvement at all, but asking for a scan to confirm this can create pain beliefs that don’t help restore function or relieve pain.

From a healthcare provider perspective, this book is gripping and fascinating. From the perspective of a patient who can relate to the cases, I imagine it’s very relieving. The writing is very accessible, and in the first chapter Suzanne explains the terminology she will use throughout. Medical terminology, that may be useful for someone who is suffering, to use when speaking to their doctors. It is an introduction to the psychology of pain, and I recommend it to anyone affected first or second hand by (as yet) unexplained pain.

It’s All in Your Head: Stories from the Frontline of Psychosomatic Illness


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