Pseudo-fitters. Regular callers. Attention-seekers. A cry for help. To many who have worked in prehospital care, these terms will be familiar.
In the opening chapter of It's All in Your Head: Stories from the Frontline of Psychosomatic Illness, Dr. Suzanne O'Sullivan, a consultant neurologist and neurophysiologist postulates that on an average day, as many as a third of people who go to see their general practitioner have symptoms that are deemed medically unexplained (O'Sullivan, 2016).
Are these patients ‘faking’ their illnesses to gain attention, perhaps stealing valuable resources from those with genuine medical needs? Some surely will be. Malingering, or the simulation of illness for external gain, is prevalent in around 30% of patients being assessed in a litigation or disability-evaluation setting (Bass and Wade, 2019).
Dr. O'Sullivan suggests that the prevalence in general clinical practice, though, is far, far less—so much so that trying to ‘catch patients out’ is entirely unhelpful. The vast majority of patients with ‘medically unexplained symptoms’ are suffering illness entirely outside of their conscious control. So, are we doing these patients a disservice by casting them off as ‘fakers’? This engaging book provides some answers.
Dr. O'Sullivan frames her experiences with psychosomatic illness through seven distinct patient stories, starting with ‘Pauline’, who developed an apparent urinary tract infection (UTI), then arthralgia, then apparent life-threatening appendicitis. Pauline went on to lose all strength in her legs before developing seizures. She first became unwell at the age of 15. O'Sullivan didn't become involved in her care until some 12 years later, by which time Pauline was confined to a wheelchair with severe pain and swelling in her leg. The morning Pauline was told there was no medical explanation for her pain, she began to suffer debilitating seizures.
Through these patient stories, Dr. O'Sullivan charts not only her patients' journeys, but her own too. This was, after all, not her chosen area of interest—she openly tells of how she became interested in somatisation by patients, disbelieving of their psychiatric diagnosis, often presenting to neurology. By ‘humanising’ psychosomatic illness, the author asks us to consider not only what we can do for these patients, but also how we might want to be treated if we were to be struck down by medically-unexplained symptoms.
Psychosomatic illness
Dr. O'Sullivan opens with common examples of how the mind affects the body—tears are a physiological response to a feeling. Blushing is also a physiological, visible reflection of inner feelings. The sweat that graces our brows when delivering a speech or presentation is a completely real symptom, unrelated to any organic disease process or physical activity.
We accept these phenomena without second thought. What the book asks of us is to understand psychosomatic illness in the same way: as physical manifestations of psychological distress.
Terminology
In the Diagnostic and Statistical Manual of Mental Disorders (DSM), you will find the subject matter described as ‘somatic symptoms and related disorders’. Dr. O'Sullivan helpfully attempts to clear up some of the confusion surrounding the terminology—a valiant effort considering the DSM describes a multitude of sub-classifications.
This can make reading around the subject matter difficult; even more so where many diagnoses are difficult for patients to accept, let alone understand, generating even more terms as clinicians and patients attempt to make a taboo subject more palatable.
If, like me, you enjoy this book and want to read further around the subjects it covers, Table 1 provides some key terms, though by no means is it an exhaustive list.
| Somatic symptom disorder | Bodily symptoms causing distress with no medical explanation |
| Conversion disorder | Neurological symptoms of emotional aetiology in the absence of organic disease |
| Functional neurological disorder | See ‘conversion disorder’ |
| Dissociative seizures | Non-epileptic seizures, aka pseuo-seizures, pseudo-fitting, psychogenic non-epileptic seizures (PNES) |
| Malingering | ‘Faking’ symptoms for financial or personal gain |
| Factitious disorder/Munchausen's | Feigning illness to assume the ‘sick role’ |
I thoroughly enjoyed this book. Those expecting a ‘clinical’ read should be aware that the book was written with a wider audience in mind, but I do not feel that this detracts from the material.
As a student paramedic, I believe the key message for prehospital providers is simple: try not to undo the hard work already carried out by the neurologists and psychiatrists of this patient group. These patients are at extremely high risk of being ‘re-medicalised’. Throughout the book, O'Sullivan is very sympathetic of how we as emergency providers work under time pressures and with limited access to notes; but a recurring theme is that months, even years, of work can be undone by a single encounter with a well-meaning emergency department clinician, diagnosing organic disease or treating functional seizures with powerful doses of benzodiazepine.
Of course the differential diagnosis of seizure is complex—even without considering the context of a paramedic attempting to do so without notice, on a dance floor with no access to health records. There are however features which are suggestive of dissociative seizure including the following (Rao and Hixson, 2018):
Conclusion
Malingering and factitious disorders (Munchausen's) are very rare, and trying to ‘catch out’ patients is unhelpful. Patients with psychosomatic illness are experiencing very real symptoms that are not under their conscious control. Furthermore, accepting a psychosomatic diagnosis can be very difficult for patients. Therefore, tactful communication is key.