In 1895, two neurophysiologists issued a book-length report on experiments they had been conducting with a group of young women suffering from a cluster of mysterious ailments. In a series of often dramatic case histories, the authors described the revolutionary new technique they had been using with these patients: listening to them. To be sure, the experiments were not double-blind, the publication wasn't peer-reviewed, and both real and potential conflicts of interest went undisclosed. But the technique showed promise, and one of the report's authors, Sigmund Freud, would go on to gain a measure of fame.
The book was Studies on Hysteria,and the technique was called "psycho-analysis" (the hyphen would eventually disappear). Too often, we overlook just how radical the practice of listening to these young women was. When the most famous of them, Anna O., described it as the "talking cure," she didn't mean that the physician was talking—she was. Along with the other patients described in the book, she had been experiencing what was then known as "hysteria," which is to say, medical symptoms with no apparent organic cause. Some of the symptoms were mere nuisances: a persistent cough, the occasional squint. Others were right out of Oliver Sacks: paralysis, loss of sensation, blindness, hallucinations, glossolalia, and so on. With the help of psychoanalysis, these symptoms improved. Not always completely and not always forever, but nevertheless, the patients began to feel better.
A bit more than a century later, in 1997, the World Health Organization (WHO) released a study based on information gathered from primary-care patients in fourteen countries in Africa, Asia, Europe, and the Americas. It found that some 20 percent of these patients suffered from multiple "medically unexplained symptoms," one of a cluster of terms used by physicians for illnesses with psychological rather than physical causes (others include psycho-somatic disorders, conversion disorders, and functional disorders). The rate is even higher in clinics like the one where Suzanne O'Sullivan works. O'Sullivan, a consultant neurologist and neurophysiologist at the National Hospital for Neurology and Neurosurgery, University College London, tells us that up to a third of the patients who arrive at neurology clinics turn out to be suffering from psychosomatic illnesses. Her book Is It All in Your Head? tells some of their stories.
Take, for example, one of the book's shorter case histories, about a patient O'Sullivan calls "Mary." A married mother of two daughters aged eleven and fourteen, Mary arrives at the clinic suffering from blepharospasm, a condition in which muscular spasms sporadically force the eyes shut. By the time O'Sullivan meets with her, the spasms have gotten so bad that Mary is unable to open her eyes at all. She is administered diazepam, and after two days in the hospital she improves enough to go home. A month later, however, she is found wandering the streets, disoriented, in her nightgown. Brought back to the clinic, Mary is unable to remember her name, how many children she has, or indeed anything at all. Shown a series of pictures of famous people and asked to say whether they are dead or alive, she gets every single one wrong.
As O'Sullivan explains, none of this quite adds up. Most blepharospasm sufferers can open their eyes at least a little—not Mary. Most amnesiacs retain some long-term memory—but not Mary. And of course, nobody gets every question wrong—even if she were simply guessing the answers, the laws of probability dictate that she should have gotten half right. Furthermore, her brain scan and EEG show no signs of organic illness.
What, then, might account for the patient's peculiar symptoms? O'Sullivan uncovers the solution when Mary mentions, in an offhand way, that her husband has recently been accused of abusing a child. "And do you know what the worst of it is?" Mary says to O'Sullivan. "It was his own sister that called the police. Who does that sort of thing to their own family?" Mary's symptoms, O'Sullivan realizes, represent a refusal to recognize what her husband has done to that child, and, presumably, what he may have done to his own children. She is literally closing her eyes to the truth. O'Sullivan very gently tells her so.
Naturally, Mary refuses to believe that her condition might be the result of what O'Sullivan tactfully calls "stress." She declines to speak to a psychiatrist and leaves angry, never to return. Is It All in Your Head? consists of a series of stories like this one, all very finely crafted, and all following the same essential pattern, though usually with a better outcome. Patients present themselves with neurological symptoms—seizures, paralyzed limbs, burning sensations—that don't quite make sense based on what we know about how the nervous system works. By listening and observing closely, O'Sullivan discovers that these symptoms are the result of psychological rather than organic processes. She then presents her conclusions to the patients and their families, who generally meet them with skepticism, if not outright hostility. In most cases, though, she is able to persuade them, and the patient goes on to make a full recovery.
This is an important book. O'Sullivan makes a powerful argument for taking psychosomatic illnesses seriously and treating the people who suffer from them with respect. This last point is especially critical: Psychosomatic diagnoses carry with them a stigma that can make treatment much harder for patient and physician alike. O'Sullivan wants us to understand that these conditions are real—just as real as laughing or crying or any of the other ways our bodies "somatize" emotions. And it appears that her argument has convinced not only many of her patients but a lot of her readers. In Britain, where it came out in 2015, Is It All in Your Head? received the prestigious Wellcome Book Prize, along with a number of enthusiastic reviews. I would not be at all surprised if a movie, or at least a miniseries, were in the works.
At the same time, there is something troubling here. Every few pages, somebody miraculously sees again, walks again, or recovers from crippling convulsions. By the third chapter, the book starts to feel less like a medical text than a Pentecostal revival. Speaking of dissociative seizures, for example, O'Sullivan tells us that "they often disappear almost the instant the diagnosis is delivered." I understand that books like this must, of necessity, make certain compromises on realism for the sake of readability. But to suggest the possibility of complete, instantaneous cure for these conditions strikes me as disingenuous, even dangerous.
People suffering from psychosomatic disorders—not to mention anxiety, depression, masochistic tendencies, and so on—don't suddenly get better simply because you tell them what's wrong with them. Try it on somebody tonight and see how it goes. Or better still, have somebody try it on you and see how it feels. Consciously, people may believe that they want to get better, but unconsciously, they often don't. Their symptoms, like Mary's, serve a purpose, usually a protective one. Even if you could suddenly release them from these outward signs of their suffering, to do so might be profoundly damaging.
Freud had not quite figured this out in 1895, but he would soon enough. I felt a growing impatience as chapter after chapter passed with no discussion of his contributions. But then, when it finally came, I almost fell out of my Eames chair. "For all the shortcomings in the concepts proposed by Freud and Breuer in Studies," O'Sullivan writes, "the twenty-first century has brought no great advances to a better understanding of the mechanism for this disorder." No great advances in understanding psychosomatic disorders since Freud—and she waits until page 175 to tell us? It was only on a second reading that I figured out what had happened, or at least formed a working hypothesis: Somebody had cut the Freud passages out of the beginning of the book and pasted them into the middle (the giveaway, if you really want to know, is an incongruous reference to "Pauline"). I suspect this may reflect the author's reluctance to contend with those two great Freudian themes, sex and aggression. Even when they do put in an appearance, as in Mary's case, they are kept, like Freud himself, at a comfortable, comforting distance.
O'Sullivan is right, of course, that Studies on Hysteria had many conceptual shortcomings. Nobody felt this more acutely than Freud, which is why he spent the next four decades reworking his theory to better fit the clinical reality that psychological problems are actually quite difficult to treat. Many of his greatest discoveries emerged from his effort to explain why this was. In 1895, his answer was repression. Soon he would refine his theory to include resistance, then the transference, then primary masochism, then character structure, then the superego, and, finally, the death drive. By the end of the 1920s he had realized that even if you can overcome repression, even if you can ease the patient past his or her resistance, even if you can manage the transference, and so on, it's still the case that at the end of the hour the patient has to get off the couch and go back out into the world—a world which, as he observes in Civilization and Its Discontents (1930), is at best indifferent and more often downright hostile to our well-being. At that point, the patient may well need all the psychic defenses at his (or her) disposal.
It's too bad that O'Sullivan did not consult with any of the psychoanalysts who have studied and treated psychosomatic disorders over the past century, often with some success, but never with sudden success. Ultimately, my concern is that by suggesting that such rapid cures are possible, O'Sullivan risks inadvertently reinstating the hierarchy she has been working so hard to dispel. The reader is left with the sense that these "imaginary" disorders can be cleared up with a few kind words, unlike "real" ones, which require actual treatment. Obviously, this is not her intention, and while the implication detracts from the book, it does not ruin it. As that WHO study makes clear, there are many people out there whose bodies are expressing, in some distorted form, emotional pain. It's entirely possible that by taking their conditions seriously, Is It All in Your Head? could help some of them, which is more than most books can claim.
Ben Kafka is an associate professor in the department of media, culture, and communication at New York University and a psychoanalyst in private practice in Lower Manhattan.
