Experts weigh in on Suzanne O’Sullivan’s commentary on imaginary illness in The Lancet

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Google Suzanne O’Sullivan and you will find lots of coverage of her book that won the Wellcome Book Prize, but you will not find peer-reviewed articles that she authored. The same thing will happen if you Google Scholar her, where you just get lots of articles that were not written by her.  As a neurologist in charge of a six-bed unit epilepsy at the Royal London Hospital, she is very well connected, even if not well published.

Launch of her book, It’s All in Your Head in 2015 was coordinated with a keynote address arranged and subsequently praised by Simon Wessely at the Royal College of Psychiatrists International Conference. A laudatory review by another clinician who was not a scientist appeared in The Lancet soon thereafter, followed by Suzanne O’Sullivan’s own editorial commentary.

Her Lancet commentary, like O’Sullivan’s book is notably free of citations (except a single one to her book), despite her dispensing what are meant to be authoritative judgments for which we would expect documentation. These are judgments which could have negative implications for patients, some of them clearly harmful.

I routinely encourage readers of my blog to develop analytical and search tools to apply when they encounter reports about the biomedical and scientific literature that rouse their skepticism. But these tools and skills are not much use when focused on Suzanne O’Sullivan’s work. She does not make her sweeping claims in a way that one can follow back into the peer-reviewed literature unless one is guided by other knowledge. Skeptical readers have to rely on sources that time has proven trustworthy.

Yet, in the UK, where all the fuss is being made, professionals are notably discreetly silent, rather than outspoken, when a colleague misrepresents the literature or commits outright fraud. Stay tuned for my forthcoming blog about Hans Eysenck’s blatantly fraudulent data concerning alleged dramatic effects of cognitive behavior therapy on death from cancer, as well as the carcinogenic effects of psychoanalysis.

Suzanne O’Sullivan’s commentary in The Lancet shows no trappings of having been peer-reviewed. But it does have some statements for which I could call in some recognized authorities, with relevant clinical and medical expertise.

This blog post contains their evaluations of the claims in Suzanne O’Sullivan’s The Lancet article. For the first commentary I have the honor of presenting Professor Edward Shorter. For the second, I have Professor Ronald Pies.

shorterIntroducing Professor Edward Shorter, PhD, FRSC

Dr. Shorter is

Jason A. Hannah Professor of the History of Medicine in the Faculty of Medicine and is cross-appointed Professor of Psychiatry. His past research interests include a two-volume history of psychosomatic illness, “From Paralysis to Fatigue” (1992) and “From the Mind Into the Body” (1994). Since the mid-1990s he has emerged as an internationally recognized historian of psychiatry, with numerous publications to his credit. His “History of Psychiatry” (1997) has become the standard text in the field, joined in 2005 by “A Historical Dictionary of Psychiatry” and in 2009 by “Before Prozac”. This volume argues for a reassessment of diagnoses and treatments for mood and anxiety disorders that have been set aside in favour of patent-protected remedies and diagnoses promulgated by the DSM series. He further explores these themes in his latest book, “How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown” (Oxford University Press, 2013).

Professor Shorter also has a readily accessible blog. See, for instance, Why Don’t Doctors Want to Hear About Psychosomatic Problems?

ron-pies-photo-2-1.jpgIntroducing Professor Ronald Pies, MD

Dr Pies is Editor in Chief Emeritus of Psychiatric Times, and a Professor in the Psychiatry Departments of SUNY Upstate Medical University, Syracuse, NY, and Tufts University School of Medicine, Boston. Dr Pies is author, most recently, of Psychiatry on the Edge, a collection of essays drawn from Psychiatric Times (Nova Publishing); and a novel, The Director of Minor Tragedies (iUniverse); and The Myeloma Year, a chapbook of poems and essays.

Professor Pies’ article in Psychiatric Times are readily accessible, but so are his excellent guest blog posts, like Why Psychiatry Needs to Scrap the DSM System: An Immodest Proposal  With more patience than I have, Dr. Pies notably engages in dialogue with critical psychiatry.

Professor Shorter’s Commentary on Suzanne O’Sullivan’s article in The Lancet.

[All quotes are from Suzanne O’Sullivan’s commentary in The Lancet.]

 James, thank you for giving us an opportunity to comment on this interesting paper.  It does indeed contain several questionable assertions.

  1. “Psychiatrists and psychologists are those best placed to help people with psychosomatic disorders.”

No, internists and neurologists are, because they can maintain a therapeutic alliance intact, while these patients look askance at referrals to psychiatrists and psychologists:  They are convinced they are organically ill!   The only treatment, really, is the gift of time, letting the patients tell, and if necessary re-tell, their stories to a clinician who nods sympathetically while not necessarily endorsing the patients’ supposed etiologies.

  1.  “To tell somebody their medical complaint might have an emotional cause is often met with anger.”

Right.  You don’t tell them that.  You assure them that their subjective perceptions of their symptoms are very real, and let’s see if we can’t get to the bottom of this.  Then you let them talk.  This can be very time-consuming.

  1.  “If our subconscious has chosen to mask . . . “

The patient’s subconscious may not have chosen the symptoms.  It’s really the culture that choses them, and patients get from the culture an idea of what is medically “credible.”  Patients strive to produce symptoms that are medically believable, that cannot be disproven, in other words.  This is why the hysterical gait paralyses of the nineteenth century have largely disappeared: The Babinski test “disproved” them.  But you cannot prove that someone is not fatigued or in pain, which is why we see so much of that today.

Re EEGs as a gold standard of epilepsy:  I believe that about 50 percent of interictal EEGs in patients with real epilepsy are normal.

The illustration shows Charcot’s “hysteria,”  not a psychosomatic affection but an iatrogenic one.

My two cents.

Cheers to all,

Ned

Professor Pies’ Commentary on Suzanne O’Sullivan’s article in The Lancet.

Thanks for the paper, James. I’m generally in agreement with Ned’s comments, and have decidedly mixed reactions to O’Sullivan’s editorial. On the one hand, in my experience, it’s true that many medical personnel feel that “disability that occurs for psychological reasons [is] less deserving of our attention than other forms of disability”, leading to discrimination against “psych” patients, who are often dismissed as “crocks” or “malingerers.” O’Sullivan rightly notes (or at least implies) that persons with so-called psychogenic seizures (or non-epileptic seizures) are not deliberately producing these manifestations; i.e., they are not malingering or doing what Munchhausen patients do (i.e., dissociative seizures are not diagnosed as a “factitious disorder”). Thus, it goes without saying that patients with non-epileptic seizures and related syndromes deserve our compassion, understanding and help.

On the other hand, having come from a consultation-liaison background, I am more inclined to take Eliot Slater’s view that many patients diagnosed with a “psychosomatic” disorder—or, in the old terminology, “hysteria”—often prove to have an “organic” (e.g., neurological, endocrine, autoimmune) disorder underlying their problem. The statistic cited by O’Sullivan–that “only” 4% of cases wind up with an “organic” diagnosis–should really not be of much comfort to doctors, even if it is correct: imagine seeing 100 “psych” patients in a year with unexplained somatic symptoms, and eventually learning that 4 of them were not “hysterical” at all, but suffered from multiple sclerosis, systemic lupus, or had auto-antibodies against NMDA receptors producing their “psychiatric” problem [see: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3563251/]

My C-L supervisor used to say, “Hysteria is the last diagnosis a patient will ever receive”, simply because once “hysteria” is in the medical record, nobody will ever take the patient seriously again. Also, the O’Sullivan fails to note that in a substantial percentage of cases, a patient may have both “psychogenic” and epileptic seizures—and that sometimes, the latter is overlooked merely because the former is present. (I know that Al Frances and I have both expressed concern that the new DSM-5 category of “Somatic Symptom Disorders” may promote overlooking such underlying neurological disorders because the criteria are so broad).

My heavy use of quotation marks in this message also signals my uneasiness with terms like “psychogenic” and “psychological.” The best people in neuropsychiatry, like Michael Trimble, have urged a less Cartesian (mind vs. brain) and more integrative approach; e.g.,

“Whitlock 34 and Ludwig 35 have suggested that the primary pathophysiological mechanism involved in the creation and maintenance of dissociative (or “hysterical”) symptoms is an attentional dysfunction resulting from an increase in the corticofugal inhibition of afferent stimulation. As a result of this inhibition, partially processed stimulus information fails to be integrated into ongoing awareness, generating dissociative symptoms as a consequence. Some studies have provided empirical support for this account of dissociation.36 37 Part of the appeal of the approach advocated by investigators such as Ludwig is their emphasis on integrating research and theory from neurology, psychiatry, and psychology in a bid to understand the mechanisms of dissociation.  http://jnnp.bmj.com/content/69/3/285.full#ref-4

Best regards,

Ron