Alastair Santhouse - Head First: Its All in Your Head: How the Mind Heals the Body

I remember Roland well, although I met him only twice. In fact, I heard him before I saw him; I was startled by an alarming noise, somewhere between a cough and a snort, as I approached the waiting room on my return from lunch to start an afternoon clinic.

I sat down with him in my consulting room, and he told me his story. Age thirty-three, he was from Gabon, unmarried, and had come to the UK three years earlier. Since his arrival he had experienced increasing discomfort with his throat, resulting in frequent explosive exhalations. His regular doctor had been unable to make a diagnosis and had rather unusually, rather than referring him to a single specialist for an opinion, made three separate referrals.

Roland had found life in the UK difficult. He had struggled to find work, had no family here, and was unable to see his daughter, who lived with an ex-partner in Gabon. His symptoms had begun several years before and were now worse than ever. As he snorted and spluttered, I found myself distracted by a persistent urge to clean my desk with an antiseptic wipe. It was with some difficulty that I listened to his story. He had been encouraged by friends to see his doctor, who, reading between the lines, hadnt initially worried about his symptoms but had subsequently referred him to the hospital for more opinions.

It was clear to me that the cumulative stress and disappointment in Rolands life had exacerbated a nervous tic, which was now so deeply ingrained in his motor system as to be automatic. I had seen symptoms like this before, in which unusual movements and behaviors, rehearsed often enough, become hardwired. For example, I have seen people present with a strange gait that makes walking unnatural and effortful, seemingly without any deliberate simulation, even when there is nothing wrong with their muscles or nerves. Sometimes patients experience persistent pain or dizziness or can speak only in a whisper, without there being any identifiable physiological cause, even after months or years of medical investigations. The ways in which patients present are as plentiful as the number of symptoms.

When I treat such patients, I acknowledge that these illnesses, even if they have no clear-cut physical cause, are not made up or simulated; they are as real as any other illness, even if their cause is believed to be psychological.

It is difficult to know why an individual will have a particular symptomfor instance, paralysis rather than dizziness or speaking in a whisper. Back in the early 1900s, some psychiatrists believed that an individuals symptoms carried a symbolic significance. For example, someone who witnessed an appalling event might develop blindness. Although this sort of belief is still occasionally mentioned in psychiatry textbooks, not many people believe it.

In Rolands case, his symptoms began with a cough and a sore throat, but his persistent focus on his breathing developed into a preoccupation. His cousin told him that he must have been cursed, an idea that Roland felt was being fulfilled in the shape of serious illness. This worry served only to perpetuate his symptoms, until coughing and exhaling noisily through his nose was as natural to him as breathing. Such presentations are often known as conversion disorders, referring to the theory that psychological stresses are converted into physical symptoms, although it should be acknowledged that there is little consensus on what such presentations should be called. Our disorganized classification system is a reflection of the different ways in which people have understood these symptoms over the years. Some diagnoses, such as conversion disorder, stem from the theory of Freudian psychoanalysis, while other diagnoses, such as persistent physical symptoms, are descriptive, yet both might be talking about the same thing. The term functional disorder is commonly used to indicate that while the structures of the bodythe nerves, muscles, and organsare all intact, their function is impaired. Sometimes the terms used are pejorative or insulting (a heart-sink patient, referring to the effect they have on a doctors morale; a fat folder, used to describe the thickness of a patients notes), and yet others such as supratentorial (pointing to a region of the brain), while respectful and medical-sounding, suggest that the cause lies in the brain and are a wink to fellow professionals that the doctor thinks it is all psychiatric.

As I dictated my letter to Rolands GP, I picked up his file and two letters fell out. The first was from an ear, nose, and throat (ENT) specialist, who had diagnosed a problem with his vocal cords. The second was from a neurologist, who had diagnosed a disorder of the nervous system. I began to worry. Had I completely misread the situation? I wondered whether to commit my diagnosis to the notes, my confidence in it steadily waning. I knew the ENT and neurology consultants to be sharp and capable doctors, not the sort who were casual about diagnoses. My diagnosis seemed even less sound when Roland came back to see me some weeks later, smiling and relieved that his symptoms had all but gone. It turned out that, lacking any confidence in his trio of physicians, he had laid out all his cares to a sympathetic priest, who agreed with him that he must have been cursed and administered holy water, thereby effecting this miraculous cure.