OSullivan - Its all in your head: true stories of imaginary illness

I was convinced the woman was afflicted not by a bodily disease, but rather that some emotional trouble grieved her, and it happened at the very moment I was examining her that this was confirmed. Someone coming from the theater mentioned he had seen Pylades dancing. At that instant, her expression and the color of her face were greatly altered. As my hand was attentively holding the womans wrist, I observed her pulse was irregular, then suddenly violently agitated, which points to a troubled mind.

Galen, c. AD 150

I qualified as a doctor in 1991. For fledgling doctors their first great dilemma comes when they are asked to choose their specialty. Some parts of the decision are easy. You either want to operate on people or you dont. You can react quickly in an emergency or you cant. Some want to be a scientist in a laboratory. Others would prefer to spend their time with patients. Medicine has room for every type of person. It is sometimes harder to make the more refined career decisions that follow. You know that you want to be a surgeon, but which part of the body do you want to operate on? Are you fascinated by the heart, where a single missed beat can put life in immediate peril? Or do you want to experience the highs and lows of the fight against cancer cells?

Despite all the possibilities, I knew from an early stage in my training what my decision would be. I wanted to be a neurologist. When I made that choice I thought I knew what it meant and where it would take me. I wanted to emulate the people I had learned from, the individuals who had inspired me. I enjoyed the detective drama of the job, unraveling the mysteries of how the nervous system communicates its messages, and learning all the things that can go wrong. Imagine a man who cannot move his right leg and cannot feel his left leg Wheres the lesion? Whats the disease? Or a woman who is otherwise well but finds she cant write and cant identify her fingers. Ask her which is her index finger and she will be baffled. What part of the brain, when damaged, causes that? Neurological disease manifests in elusive and strange ways. There is a sort of epileptic seizure that is triggered by brushing your teeth. There are strange temporary paralytic disorders that strike after eating salty food.

I started my first training post in neurology in 1995, expecting to look after people who had diseases of the brain and nerves and muscles, conditions like multiple sclerosis, stroke, migraine, and epilepsy. I could not have predicted how far I would find myself drawn into the care of those whose illness originated not in the body, but in the mind.

Examples of how the mind affects the body are everywhere. Some are so commonplace that they are not regarded as anything out of the ordinary. Tears are only salt water produced by ducts in the eye. They are a physiological response to a feeling. I cry if I feel sad, but happiness can have exactly the same effect. Sometimes tears are triggered by a memory or a piece of music or a painting. They occur in response to anger or laughter. The instantaneousness of it all has always amazed me.

The body has a multitude of ways through which it can express emotion. Blushing occurs when the blood vessels of the head and neck dilate and become infused with blood. It is an instantaneous physical change seen on the surface but reflecting a feeling of embarrassment or happiness that is held inside. When it happens I cant control it. That point is important. My blushes betray a feeling, and even when they increase my embarrassment, I cannot stop them.

Sometimes the bodys reactions are more dramatic than a brief blush or the odd tear. Even quite exaggerated bodily responses to emotion are easy to accept if the circumstances are right. In the early nineteenth century, the French novelist Stendhal, in Naples and Florence: A Journey from Milan to Reggio, described how he felt when he first encountered the great frescoes of Florence. I was seized with a fierce palpitation of heart, the wellspring of life was dried up within me, and I walked with a constant fear of falling to the ground. Perhaps what Stendhal described seems extreme to some of us, but to others it may seem absolutely obvious that, on the day one first encounters the frescoes of Giotto, ones legs will weaken and ones heart will miss a beat.

There are many modern examples of the tendency to collapse in response to excitement. Think of young people fainting at pop concerts, for example. Of course, many such collapses are easily explained by the physiology of the body. A young girl is in a hot, crowded space. Her blood vessels dilate to cool her, venous pooling draws her circulation downward away from her head, and for just a moment, her brain is deprived of oxygen: she collapses and consciousness is lost. She has fainted due to nothing more than the bodys physical response to a physical trigger.

And yet when scientists examined just this phenomenon, they concluded that not every swooning, swaying teenager could be accounted for in this way. In 1995 the New England Journal of Medicine published an article in which young people who had collapsed at a music concert were interviewed. Of the four hundred brought to medical attention, forty were examined. Sixteen of those forty lost consciousness in a faint that was felt to be entirely explained by physical triggers heat and dehydration leading to falling blood pressure, circulation drawn away from the brain, and subsequent collapse. Others had panicked when they found themselves trapped in a crowd, leading to hyperventilation that constricted the blood vessels going to the brain and, again, a brief blackout followed. But the doctors also observed that not every collapse could be attributed to heat or dehydration or the crush of the crowd; some had occurred in the context of only one trigger: an overwhelming surge of emotion an emotional collapse, with no physical cause to account for it.