Guest blog reviewing Suzanne O’Sullivan’s It’s All in Your Head With an Introduction

all in your headSuzanne O’Sullivan’s It’s All in Your Head may have won the Wellcome Book Prize, but mental health professionals like Simon Wessely are notably silent – despite O’Sullivan advocating the same policies they promote.

An endorsement of the book from a professional who should know better represents either blind loyalty to a particular point of view, not having read the book, or simple incompetence.

could not put it down

one psychosomatically informed

wonderful book

I’ve been asked to comment on the book and I eventually will. Reading reviews and excerpts from it, I’m confident that I can dismiss the book without having to read it. Indeed, my blog post will be a further explanation of why – with so much out there – we need to develop strategies to screen and dismiss some items as unworthy of further attention. Life is too short…

I get a lot of requests to comment in the social media. Some are based on my reputation as an evidence-minded skeptic . Some occasionally draw on my past life as a strategic family therapist who discredited the family psychosomatic model of diabetes and anorexia.

Both reputations are relevant, but I still find it hard to find something to bring the current scientific literature against  O’Sullivan’s book in the materials I’ve seen. The book consists of chapters that are carefully selected armchair clinical stories that amount to anecdata. But the stories also involve such outlandish, confused, and discredited assumptions that it is tough to contrast them with anything in the contemporary literature.

There were vague references to neurologists. It is too bad that Oliver Sacks is dead and can’t defend himself against Suzanne O’Sullivan’s far out claims that her book is an homage to him.

Contemporary Freudian psychoanalysts would strongly object to the ways in which O’Sullivan compares her case histories to Freud’s. Psychoanalysts would be also embarrassed by their awareness that many of Freud’s famous case histories turned out to have neurological difficulties upon follow-up. At least one, Dora, was up to other mischief, as feminist Robin Lakoff and I described in our book, Father Knows Best.

Most psychoanalysts would be embarrassed by Suzanne O’Sullivan’s explaining physical complaints as expressions of emotional conflicts. The discrediting of that view was devastating to the prestige of psychoanalysis.

As I will explain in a later blog, the view that physical symptoms are expressions of unconscious conflicts was the object of ridicule and nearly destroyed psychosomatic medicine in the second half of the 20th century. The organization recently tried to distance itself from the swing of psychosomatic medicine with an editorial declaring that the journal Psychosomatic Medicine was being renamed as   Psychosomatic Medicine and Biobehavioral Medicine.

You can still dig out explanations in the 1950s and 60s psychosomatic medicine literature of why women are more likely to have migraines. That’s because these women have penis envy and a migraine headache symbolically represents a blood engorged penis. If you brought up this issue at the annual meeting of the American Psychosomatic Society, many people would consider you uncivil and walk away. You can be damn sure that there will be no endorsements of Suzanne O’Sullivan’s book from the American Psychosomatic Society or invitations for her to speak at their annual convention        .

hippocratesSuzanne O’Sullivan locates herself in a long tradition traceable back to Hippocrates. Many of Hippocrates ideas to which she still subscribes were hilariously wrong. For instance, she notes that her patients with unconscious emotional conflicts are women and that their physical complaints shift from organ system to organ system from one medical visit to the next.

Hippocrates’ explanation was that these women were not having enough sex and the neglected uterus traveled around their body, lodging in organs, and creating problems for them. The solution is that some compassionate man could relieve them of their troubles by having wandering uterussex with them.

I will get to these and other juicy examples. But one problem I face is the kinds of things that Suzanne O’Sullivan is talking about have few or no quality references in the current literature.

Many issues have died and professionals who currently identify themselves as in the field of psychoanalysis or psychosomatic medicine don’t want to bring them up anymore. Other issues were never addressed in the literature. Suzanne O’Sullivan’s bizarre case formulations sometimes exist only in her own head. Formulations are not tested in conversations with patients, but her labels are stuck on their heads with minimal observation or discussion.

I would love to see any outcome data for O’Sullivan’s patients, particularly serious physical conditions that were missed because of her discouragement of further medical surveillance and testing.

state of meBut until I get to blogging about Suzanne O’Sullivan, I can provide readers with a very thoughtful review in Goodreads of her book that was written when the book first came out. The reviewer, Nasim Marie Jafry is known for her thoughtful reviews combining the literary with the scientific. You can find her other reviews here [. But she is also a talented novelist herself. Here’s what Elizabeth Baines, author of The Birth Machine and Too Many Magpies says about Jafry’s autobiographical novel, The State of Me:

The amazing feat of this novel is to give one a physical sense of the pain and frustration of this condition [myalgic encephalomyelitis (ME) ], and yet to be bouncing with life, the inner life in the irrepressible psych of Helen.”

I think this talent is displayed in the following review. It should  encourage you to get a copy of Jafry’s novel [get the Kindle edition here ] with the money you might save not buying Suzanne Sullivan’s dreadful book. I would say that both books are fiction based on experience, except I am less confident that Suzanne Sullivan’s book is based on experience, rather than preconception.

Nasim Marie reviews It’s All in Your Head: True Stories of Imaginary Illness

I imagine the publisher was excited by Dr O’Sullivan’s ‘ideas’ – I saw the words ‘groundbreaking’ and ‘controversial’ in one of the blurbs. Imaginary illness carries notions of madness across the centuries, as readers we are intrigued – and seduced. However, having read in detail the chapter ‘Rachel’, which deals with a young woman with ‘ME/CFS’, I can say that the book is certainly not groundbreaking, but rather, in the case of ME, an irresponsible recycling of a dying – very dangerous – narrative which has been perpetuated by psychiatrists since the nineties. And having dipped into the other chapters, I’m afraid I find her style to be rather unengaging and toneless, though I wonder also if that is a kind of clinical constraint.

So her *ideas* must be sparkling and new if I am to be pulled in.

While vigorously suggesting that patients with myalgic encephalomyelitis (ME) have false illness beliefs, she then bases the entire chapter on her *own* beliefs. There is no evidence whatsoever to prove that ME is psychosomatic. There is however growing robust evidence that ME is a complex, multi-systemic neuroimmune illness, and the key to unlocking the puzzle is ever nearer – biomedical researchers worldwide are excited and hopeful about finding a unique biomarker. Dr O’Sullivan acknowledges that there is evidence of immune abnormalities but then chooses to ignore them completely and goes off on her wild somatisation spree. She seems not to *want* the science to progress, so zealous is she in her beliefs.

The whole chapter on ‘Rachel’ is manipulative and incoherent, illuminating only in what it omits. I know what the gaps are, so I can see the huge holes. She wrongly says that graded exercise (GET) is the most effective treatment, even although this treatment has been thoroughly discredited, it makes patients worse. This psychologising of ME is extremely harmful to patients, as patients and true specialists have been pointing out for years.

I have had virally-triggered ME since 1983 – I was nineteen years old, an undergraduate, unlucky to get a nasty enterovirus – and was diagnosed by a consultant neurologist, after EMG and muscle biopsy and many blood tests, which confirmed abnormalities. I had been ill for eighteen months at the time of diagnosis, steadily getting worse, and, of course, had never heard of ME then, few people had (I didn’t go upstairs to my room and google). My initial treatments included a plasma exchange with immunosupression, and anti-viral drugs. And yet Dr O’Sullivan denies hotly in her book that immunotherapy is used for ME, anywhere. She also seems unaware of the anti-cancer drug trial going on in Norway just now. The scientists have recently been in London discussing their trial at an annual ME conference, which attracts scientists from all over world.

She also fails to mention the huge confusion caused by the different criteria for ME – the CFS (chronic fatigue syndrome) label was introduced in late eighties in UK and the criteria for ME were widened and diluted, with the result that anyone with unexplained ‘chronic fatigue’ was being diagnosed with ME. This conflation of ‘classic ME’ and CFS has caused a major headache for patients (no pun intended). Patients who *do* have psychiatric-based fatiguing illness are sometimes being misdiagnosed with ME. The conflation has, naturally, caused immense problems with research; moreover, severely ill/bedridden patients with actual ME are not being included in trials.

O’Sullivan also makes no reference to post-exertional malaise (PEM), which is unique to ME – exhaustion (physical and mental) after trivial exertion – she talks only generally of ‘fatigue’. She ignores the disabling cognitive dysfunction – Rachel has some concentration problems but O’Sullivan does not describe the classic ME ‘brain fog’, which all of us w ME experience as a kind of ‘dementia’. We routinely forget everyday words, we mix words up, we forget people’s names, we cannot remember simple facts, we leave taps on. Neither does she mention orthostatic intolerance, the inability to be upright, stand for long, another cardinal feature. Indeed, many people with ME have full-blown POTS (postural tachycardia syndrome). She basically excludes all the symptoms of ME in her discussion, bar ‘fatigue’. She seems to think managing ME is managing fatigue, and Rachel ‘fails’ in her management. Naughty Rachel.

I honestly wonder if Dr O’Sullivan truly believes what she has written or if she needed to pad out her book as she didn’t have enough real psychosomatic illnesses for the pot. And she knows writing about ME as a psychiatric illness will be immediately controversial – even when she is wrong. Whatever her motive, she has failed spectacularly to keep up with the research and she has insulted not only ME patients but the whole scientific community engaged in ME research.

*I just want to add that this may be one of the most revealing passages in the ME/CFS chapter:

‘In my early years training in neurology I encountered many patients with CFS, but more recently neurologists have distanced themselves from this disorder and patients are more likely to seek help from immunologists or endocrinologists. I do not currently see patients for the purpose of diagnosing or treating ME/CFS, but many of my patients with dissociative seizures have a history of ME/CFS, and there is something very interesting in that fact alone.’

There is something very interesting in the fact that Suzanne does not seem to have actually met (m)any patients with classic Ramsay-ME (in 1990s when she was training, the Wessely/CFS/psychiatry school was just taking root, so it’s hard to know what was actually wrong with the ‘CFS’ patients she was seeing).

I reiterate: Rachel, the case study with ME/CFS is, to my mind, an artificial construct, a composite character with the ‘behaviours’ of ME patients – internet diagnosis, increasingly helpless, ‘over-helpful’ parents – that the Wessely school adores. Rachel rejects the psychiatric treatment offered her. We never find out what happens to her, though Suzanne says: ‘The impact of our emotional well-being on our health is not a trifling problem. I only wish I could convince Rachel of this’.

O’Sullivan also fails spectacularly to describe the experience of probably all of us with ME, of pushing ourselves to ‘recover’ only to relapse catastrophically. Her apparent lack of contact with patients who actually have ME – coupled with not following the science – would perhaps explain why she felt that including ME in a book of imaginary illnesses was acceptable.