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

 

 

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

  1. I honestly can’t say I believe in psychosomatic disorders at all (they have a pretty dismal track record), but I do find the insight of Dr. Shorter and especially Dr. Pies to be very interesting. I have one of the diseases which the author, Dr. O’Sullivan has portrayed as psychosomatic, ME/CFS.

    Dr. Shorter’s comment that psychosomatic patients “… strive to produce symptoms that are medically believable, that cannot be disproven….” resulting in complaints of fatigue and pain would seem perhaps particularly directed at ME/CFS. But if so, it would reflect a lack of understanding of ME/CFS … despite the name, it is not about fatigue. And many of the symptoms which do disable ME/CFS patients are objectively observable, such as low blood pressure, swollen lymph nodes, and failure to perform as well on a maximal CPET 24 hours after the first one.

    It also makes me wonder if symptoms in other “psychosomatic” disorders are similarly ignored or grossly over-simplified by some practitioners. How many of these disorders, like ME/CFS, involve a collection of pretty similar symptoms which patients develop whether they have previously heard of their diagnosis or not?

    I also must take exception to Dr. Shorter’s recommendation to mislead patients with silence, neither supporting their biological assumptions nor explaining the doctor’s psychosomatic beliefs. Not only does this result in huge delays (years or more) for patients who end up with a different biological diagnosis, eventually the truth does become apparent and results in an often incurable breach in trust with that doctor and often with the entire psychiatric or medical profession. Much I dislike most of what O’Sullivan has to say about anything, I’d prefer her misinformed honesty to a misinformed deceit. Patients are not children, doctors are not infallible, and at the end of the day we have the right to make our own informed medical decisions.

    I found Dr. Pies’ comments to be a lot more appropriate and thoughtful, especially with the caution that a premature psychosomatic diagnosis interferes with uncovering biomedical disease, often putting an end to the diagnostic process entirely. Though I suspect the statistic put forth of a 4% rate of misdiagnosis is grossly understated. I think that O’Sullivan’s acceptance of such an error rate reflects the greater drive to minimize medical expenditures, especially in a country with socialized medicine. Maybe that 4% (or 40% or even 100%) misdiagnosis rate would be acceptable to politicians and those looking to curry favor with them. But being one of those few or many is not acceptable to those being misdiagnosed, nor to their families. Nor should it be acceptable to the rest of society which may one day join them, or will at least be footing the bill while a lack of appropriate treatment keeps them more disabled than they need to be.

    However I do have reservations regarding Dr. Pies attributing unexplained symptoms to a a central dysfunction in the brain. I have read some studies and other papers involving these explanations in both ME/CFS and other disorders, and can’t say I’ve found them to be well-conducted, well-supported, or at all convincing. In the case of ME/CFS at least, they are completely ignoring peripheral symptoms, and failing to account for potentially central abnormalities such as low blood pressure. Maybe such explanations will pan out someday, but they seem rather vague and insubstantial thus far.

    Liked by 6 people

  2. R ME/CFS
    Just read Shorter’s View. Not long on knowledge, it seems.
    A thought:
    One way to muck up a patient’s head and cause conflict is when the patient comes open- handed and heavy-hearted to the physician, begging the nectar of healing – only to be fed the dung of an unjustified and innaccurate psycholigising, which the patient must take, at the risk of otherwise being deemed “awkward” and worse….Been there done it.
    To draw on transactional analysis , the caring nurturing, parental figure of the doctor is turned into the ogre who feeds the child (the patient) on poison – and the child is already ill. That is a recipe for psychological conflict and by psychosomatic theory for more ill health.
    What is more if the patient has any underlying/accompanying psychological conflicts, it becomes most perilous to discuss them if the physician is a fundamentalist psychogeniciser, who will seize on anything to confirm his/her prejudice. Give such doctors an inch………
    Now, prejuidice may not be involved – I believe there is some good practice among those who issue psychosomatic diagnoses, based on proper exclusion diagnosis and in the hope, sometimes justified, that therapy will work – as at time in pseudo seizures. But when a doctrine of false illness belief rules the roost as for ME/CFS, there is no chance of proper exclusion, for if we are found to be organically ill, we will “cling onto the findings to remain ill, for secondary beneftis” – so better not test for much at all. This has informed practice in the UK. It is indefensible, possibly even in budgetary terms. Where this practice is not observed challenged, a high number of CFS/ME referrals are found to have a different condition.

    Even in psychosomatic disorders, the implication from Shorter, that symptoms are subjectively perceived is dubious. Is central pain subjective? There may be no obvious cause, but the pain pathways light up. If we are to be true non-dualists then we should be interested in what might be “lit up” even in central pain of psychological origin, in which case the pain is far from subjective – a term which verges on the implication of symptom exaggeration and/or hypochondria. Non dualism does not end once the patient has been convinced that his/her e.g. pain is of psychological origin. The patient still has the right to ask “But what is it doing to my brain”, esp.if the therapy is not working.

    Possibly Whitlock and co have an insight into the pathology of “hysterical” symptoms for which drugs might be developed. Just as therapy and pharma are used side by side in depression. The word “subjective” leads all too easily to the medicine of dismissal and despair.

    Liked by 2 people

  3. Dear Suzanne O’Sullivan,

    I am contacting you in relation to your book ‘Its All in your head’. As a trained doctor you will be aware of the need to differentiate between real organic biological illnesses backed up by scientific research findings and clinical findings on one hand and psychosomatic and imagined illnesses on the other hand. There are vast differences between and one should not mix them up. Failure to carry out accurate lab tests with high sensitivity and specificity should not not be an excuse to label patients ‘psychosomatic’. I remember one case where an Irish medical doctor claimed a woman had ‘woman problems, depression and neurosis’ and recommended a psychiatrist for her, when in fact she had Cancer. She died from Cancer because the Irish doctor was happy enough to label her psychosomatic (and insult her for being a woman). Many doctors are too dismissive of patients today, pointing to a lack of professionalism, thoroughness and integrity. In the Chapter ‘Rachel’ you portray ME / CFS as an imaginary illness based on false beliefs, and this subjective belief of yours is reinforced throughout the book. You will need to educate yourself about certain medical and scientific facts concerning ME and CFS, which I have itemised below
    – Firstly in 2015 the NIH and IOM recognised ME / CFS as a serious, biological, physical, multisystem disease in it’s report and re-named it SEID. They used extensive research and medical doctors and scientists with expertise in the illness to develop this report and name change.
    – There is scientific evidence of infections and immune system, neurological, endocrine, mitochondria and cardiac abnormalities in ME and CFS, please read http://www.me-ireland.com/scientific.htm
    – There are diagnostic protocols and biomarkers for the illness, read http://www.me-ireland.com/structure.htm#8 I am in corespondence with senior NIH officials involved in verifying these biomarkers in subgroups of patients, through ongoing intra mural and extra mural studies. I have found the NIH personnel to be very respectful and professional in their work and attitudes. There is no room for psychosomatic nonsense and it’s lies.
    – Many of your psychological assertions have been analysed and debunked on http://www.me-ireland.com/bogus.htm
    – For a good overview of ME, CFS and Fibromyalgia, please read http://www.me-ireland.com

    I am sure this will provide you with the necessary information to clear up your misunderstandings.

    Best Regards
    David Egan

    Liked by 3 people

  4. I haven,t looked at Suzanne O’Sullivan’s work but was interested to read this in the hope of finding some up to date news via a trusted source on the scientific exploration on the phenomenon of dissociation. I was momentarily excited by Dr pies comments and looked at the references which were to a 1967 and a 1974 paper and his own paper reviewing old literature which is also 16 years old. I was left with a feeling that this critique didn’t play fair. In the absence of good guidance from modern science, clinicians are left with trying to do good work with people who are suffering. Criticizing someone for putting some ideas into the vacuum doesn’t seem fair, though as I said I haven’t read her book.
    Having said that I have learnt many things from your work and have appreciatively commented in the past, and I may be speaking without all the facts, in which case I apologise.

    Like

    • Thank you for your comments. One of the difficulties mapping Suzanne O’Sullivan’s work into the contemporary literature is that she is discussing ideas that have disappeared. “Dissociative states” are tied to the discredited diagnosis of “multiple personality disorder,” which you are now more likely to find in a movie than in an evidence-based discussion. Her notions of physical symptoms as expression of emotional conflicts were recognized by the 1960s as based on inadequate understanding of physical symptoms and untestable ideas about emotional conflicts. I asked a contemporary research oriented psychoanalyst (there are a few) to comment on O’Sullivan’s formulations and he declined, I think for good reason.

      I think the burden is on a writer like Suzanne O’Sullivan is to at least provide references for the more controversial ideas she is presenting. The excerpts of her book and her direct quotes in media coverage never do this. A reader who wants to examine her claims with open-minded skepticism is forced to do work that she should have done herself. I personally found it was difficult to find references in the contemporary literature.

      I understand that Dr. O’Sullivan gave a talk at the Royal College of Psychiatrists’ International Congress as part of her book launch. I can’t imagine her being invited to give such a talk at the American Psychosomatic Society, which has worked so hard to become evidence-based and distance itself from some of the ideas it was associated a half-century ago.

      Liked by 5 people

  5. “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….”

    I would interested in Prof Coyne’s analysis of this commentary that appeared last February in response to the IOM Committee’s report [1]:

    http://www.freezepage.com/1424484834CZFJDNHSFV

    1 Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness.
    Editors. Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome; Board on the Health of Select Populations; Institute of Medicine. National Academies Press (US); 2015 Feb.

    Like

  6. Thank you for the blog, James. I am glad to see others, such as Ronald Pies, taking a stand against the poor reasoning that leads to “psychogenic” explanations of serious illness. It seems so many researchers and clinicians either uncritically accept this narrative, or else consider it somehow unworthy of their critical analysis.

    Tony Ward and I recently conducted a comprehensive evaluation the evidence supporting “psychogenic” explanations of illness in the neurological domain. We found that most evidence claimed in support is flawed, and that which is solid provides little support for the claim (currently in press, Perspectives on Psychological Science):

    https://www.researchgate.net/publication/283476227_Psychogenic_explanations_of_physical_illness_Time_to_examine_the_evidence

    This issue is about more than some harmless “loose thinking”. Receiving a “psychogenic” diagnosis can harm patients in so many ways. The psycholological harms are often underestimated: patients are taught that they have “incorrect beliefs” about their illness, and that f they fail to recover, it is due to their lack of “acceptance” of the psychogenic explanation. Even well meaning doctors will tend to minimise the severity of their condition (indeed, O’Sullivan incorrectly states that many of these illnesses resolve on their own, which is not the case. Many are lifelong and intractable). But the harms go way beyond the psychological. These explanations provide us with a false reassurance that we have the “answer’ to these illnesses, thereby preventing research into their real causes. They can also impact on future care and treatment options: an initial “psychogenic” misdiagnosis can delay diagnosis of a rare disease by up to five years (when compared with other types of misdiagnosis).

    This is an issue of enormous importance in contemporary Medicine and Psychology, and it desperately needs our attention.

    Liked by 1 person

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