"When words are not available our bodies sometimes speak for us--and we have to listen," says Dr. Suzanne O'Sullivan in Is It All in Your Head? This fascinating casebook with historical insights--compiled by a seasoned neurologist who is now a consultant at the National Hospital of Neurology and Neurosurgery in London--offers a thorough examination of the significant yet complicated role emotions play in physical illness and the stigmas attached to psychosomatic disorders.

In 1995, O'Sullivan started her first training post as a neurologist. She ultimately found that she was drawn to the evaluation and care of those whose illnesses originated not in the body, but in the mind. O'Sullivan believes the body constructs a multitude of ways to express emotion. Sometimes those manifestations are benign, such as blushing when embarrassed or feeling dizzy when overwhelmed. There are other instances, however, where the body's reaction to stressors can be much more pronounced and dramatic, causing the body to seriously malfunction. This can lead a person to suffer illnesses such as chronic fatigue and more complex and incapacitating neurological disorders such as seizures, paralysis and even blindness.

Through a series of case studies, O'Sullivan details the many ways in which physical symptoms can mask emotional distress, as "neurological disease manifests in elusive and strange ways." This book documents the "brave people" she has encountered who display medically unexplained neurological symptoms. When patients learn that their physical distress is based on a psychological cause, O'Sullivan bears the brunt of their frustrations. After more than 20 years as a physician, she has seen how the "system" has often failed these patients and the ways in which a diagnosis of psychosomatic disorder affects how they perceive themselves and how others perceive them. Sometimes, patients find themselves trapped between the worlds of physiological medicine and psychiatry. And in many instances, neither community takes responsibility. The stigmas attached to patients who endure psychosomatic disorders--accounting for about one-third of every general neurology practice--and how little has been done to improve their care and management were largely instrumental in spurring O'Sullivan to write this book.

Many of O'Sullivan's patients suffer not only from disability, but also undergo invasive medical testing and procedures that produce a lack of evidence to support their symptoms--"a disease is sought but not found." A psychosomatic diagnosis is a hard pill for some patients to swallow--many become angry, sad and defensive, claiming it's like being told they're crazy, or faking or lying about their illnesses. Such a diagnosis can seem like an insult rather than an explanation. There are scenes with a very bright, wheelchair-bound, paralyzed patient, who is fond of doing extensive research about his condition on the Internet, and another consult with a happily married wife and mother who is experiencing an onslaught of seizures. In both of these instances, when the patients were given the good news that no neurological disease was found--no brain tumor for the paralyzed patient and seizures non-epileptic in nature--they reacted as though it would have been easier to be diagnosed with a physiological disease than to have to deal with the implications of a psychosomatic conclusion.

O'Sullivan demonstrates how she must often act as a psychological detective because the subconscious and psychiatric dissociation are often culprits for physical infirmity: "How an illness evolves is of great importance if you are ever to find a cause." This is evidenced in the intriguing case of a middle-aged woman who loses her vision after a cleaning solution comes in contact with her eyes. A lengthy battery of tests and clinical exams prove inconclusive to offering a cause of her blindness. It is later discovered that the patient had been avoiding dealing with significant stressors in her marriage. "Often the physical symptom is there in place of the emotional upset," explains O'Sullivan.

O'Sullivan believes that having a compassionate discussion often leads a patient on the road to a cure. She asserts that with intense psychiatric follow-up and intervention, negative feelings can be discharged and thus some patients--unfortunately, not all--can and do recover. In many instances, she has to buck peer protocols in order to adhere to her diagnoses.

O'Sullivan seamlessly weaves in historical facts, quotes, examples and theories about psychosomatic illness and its study by notables throughout the ages: Hippocrates, Pierre Janet, Jean-Martin Charcot, Josef Breuer and Freud among others. The details of each case are offered in layman's terms and are further supplemented with richly drawn scenes of doctor-patient dialogue. These enhancements deepen O'Sullivan's probing of the often unfathomable mystery of the intimate mind-body connection. This, along with neurological approaches to identifying triggers of psychosomatic illness and subsequent treatment, offers plentiful information for those in medical fields and patients--and for those who love and care for and about them.

While the stories in Is It All in Your Head? are intellectually and factually diverse, some are challenging to read--aspects of patient suffering become quite harrowing at times. Additionally, the delivery and impact of a psychosomatic diagnosis and subsequent patient response further tug emotionally at readers. O'Sullivan never trivializes the patient or what he or she is experiencing. Rather, she respects the strength of her patients and encourages them to find ways to address underlying psychological problems in order to overcome some incredible--some might even call them mind boggling--challenges in life. --Kathleen Gerard

photo: Jonathan Greet

Suzanne O'Sullivan, M.D., has been a consultant in neurology since 2004, first at the Royal London Hospital and currently in clinical neurophysiology and neurology at London's National Hospital for Neurology and Neurosurgery, as well as for a specialist unit based at the Epilepsy Society. She has developed an expertise in working with patients with psychogenic disorders, alongside her work with those suffering from physical diseases such as epilepsy. Though Is It All in Your Head? True Stories of Imaginary Illness is her first book, Dr. Sullivan says she "lived this book for twenty years" before she actually wrote it. She was inspired to write it for all of her patients--past and future.

Have psychosomatic disorders increased due to the excess stress in our world today?

No, psychosomatic disorders are not increasing in frequency. They have always been very prevalent because life has always been hard for some reason or another. Also it's important to note that these disorders do not only arise because of stress. Sometimes they are a feature of how we worry about our bodies and how we respond to injury, and nothing at all to do with how successful or happy we are.

Have TV entertainment (medical dramas), media (especially extensive coverage of late about viruses like Zika) and the Internet exacerbated psychosomatic disorders?

While these sources do influence how we account for psychosomatic disorders, I don't think they exacerbate them. If I don't feel well, and I have read that there is an outbreak of food poisoning in my area, then I am bound to wonder if my illness is due to that food poisoning. If the food poisoning didn't exist I would find another attribution.

Are psychosomatic disorders more prevalent in developed or underdeveloped countries?

Actually there is no difference in rates of psychosomatic disorders between different countries with different poverty levels or health services. A World Health Organization study compared rates in places as diverse as the USA, Brazil, Nigeria, India, Chile. The rates were comparable in each place.

How did you select the cases presented in the book?

I tried to choose cases that represented the disorder fairly and with each case making its own distinct point--one person's story to show the flitting, elusive nature of the symptoms and the next to open a discussion into cause or treatment.

Do you have a personal favorite case of those explored in the book?

I could not possibly say that one person is a favourite. Having said that... I was always very impressed by the case of "Pauline," a young woman who had multiple medically unexplained illnesses (paralysis, seizures, pain) spanning her whole adult life. That she could take the diagnosis of psychosomatic disorder on board and feel the benefit of it when she had barely known anything else was an astonishing testament to her.

Did you learn anything new or surprising through the writing of this book?

I knew these disorders were ubiquitous, but the extent is brought home to me at every event and interview I do in conjunction with this book. Everybody I meet has a story to tell of how this problem has touched their lives. It has been great when people feel able to share their personal experiences rather than keep them secret, which I fear happens very often.

Working with psychosomatic patients seems gratifying.

Yes, it's rewarding to see some of the incredible recoveries patients make when they are listened to and managed properly. I have seen people who have been in wheelchairs for years learn to walk again.

What's the most difficult aspect of your work?

It's a challenge to get people the help they need for psychosomatic disorders. There is a lack of treatment facilities. Despite how common this problem is, health services simply do not give it the attention it needs. It is seen as a "lesser" sort of medical problem, and that is very frustrating.

Do you have any regrets in ever having given an incorrect diagnosis?

I have never regretted giving a psychosomatic diagnosis. Like any medical problem, the diagnosis will sometimes be wrong. So, of course, I have been wrong. As a doctor, to do your best, you must make sure that you listen to every patient properly, keep an open mind and investigate appropriately. If you do that, and then you are wrong, it is still difficult, but the patient will usually understand, and you can forgive yourself.

Do you have any personal experience (yourself, family, loved ones) with suffering from psychosomatic illnesses? If so, how has that affected your work?

Neither my family nor I have ever had a psychosomatic disorder, meaning something that disables. But I, like everyone, get psychosomatic symptoms. If I am stressed, I can feel dizzy or I get a headache. In fact, I welcome these symptoms. They are my early warning system. They remind me to look after myself physically and psychologically.

You write in the introduction that you became a neurologist in order to "emulate the people I had learned from, the individuals who inspired me."

Yes, I trained with wonderful neurologists in Dublin, where I went to university. They cared about their patients and were passionate about neurology as a practice. They were very inspirational.

If you could not be a neurologist, what kind of doctor would you be? And if not a doctor, what then?

I love neurology and do not want to change, but I have wondered if I might also have found great reward in being a psychiatrist. The mind is an impenetrable, powerful organ that fascinates me. And of course if I were not a doctor, I would be writer!

Throughout the book, you refer to notable historical figures who have dealt with psychosomatic disorders throughout the ages. Is there one in particular with whom you most identify?

I find the French neurologist Jean-Martin Charcot to be a very interesting and inspirational figure. I would not say that I identify with him--he was a genius! He made pivotal discoveries in neurology. He also brought great respect to psychosomatic disorders, then referred to as hysteria. He was the first person to study hysteria scientifically. He was also an interesting man outside of medicine. He was an artist. He saw great value in combining arts with medicine, as I do.

Are you a fan of literature by contemporary neuroscientists?

It is impossible to love neurology and books and not be a huge fan of Oliver Sacks. His writing is very beautiful. He writes about people, not about patients or diseases. His work is illuminating and original.

Who is the audience for this book?

I think of this as a book for everybody. It is a book about people and the amazing strength they have to overcome life's challenges. And it's about humanity and the interplay between our psychological state and our physical state.

Will you write a second book?

Yes, I am very happy to be working on a book about the brain, told through the stories of the incredible patients whom I have had the honour to work with. --Kathleen Gerard