Friday, 12 June 2015

Book Review by Nasim Marie Jafry: 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 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 I'm afraid I find her style to be 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 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 diagnosis/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. Neither does she mention orthostatic intolerance, the inability to be upright, stand for long, another cardinal feature. 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'.

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.

***Update: 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 school was just taking root). 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'.

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.


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