What is psychosomatic illness? (with Suzanne O'Sullivan)
Dr. Suzanne O'Sullivan, a neurologist and clinical neurophysiologist, discusses long COVID, arguing that a significant portion of cases are psychosomatic. She explains how psychological mechanisms, attention, and expectation can manifest as real, disabling physical symptoms, and how to approach such conditions.
Deep Dive Analysis
16 Topic Outline
Misunderstanding Long COVID: Neglected Psychosomatic Aspects
Defining Post-Viral Illness and Psychosomatic Conditions
The Role of Anxiety and Expectation in Symptom Creation
Scientific Evidence for Psychosomatic Long COVID
Personal Anecdote: Anxiety Manifesting as Physical Symptoms
How Attention, Expectation, and Emotion Create Symptoms
Extreme Manifestations of Psychosomatic Illness: Seizures and Paralysis
Challenges in Treating Long-Standing Psychosomatic Conditions
Understanding Chronic Pain and Unexplained Symptoms
Mindfulness vs. Distraction for Managing Physical Symptoms
The Controversy and Misdiagnosis of Chronic Lyme Disease
Functional Disorders: Renaming and Stigma
Cultural Perspectives on Illness: Greasy Sickness Example
Navigating Unexplained Symptoms: When to Stop Testing
Therapeutic Approaches for Chronic Unexplained Symptoms
Supporting Friends and Family with Unexplained Illnesses
5 Key Concepts
Psychosomatic Condition
Psychosomatic conditions involve real, disabling physical symptoms that arise more from psychological mechanisms like ideas about illness, fear, and how one feels about their body, which changes brain connections. It does not mean symptoms are imagined or faked, but rather originate from the mind-body interaction rather than direct physical damage.
Post-viral Illness
A post-viral illness is a chronic fatigue-like condition that can follow a viral infection, lasting for six months or longer. While its mechanism is not fully understood, it is usually self-limiting and most people recover, though it may have a psychosomatic element in some cases.
Nocebo Effect
The nocebo effect is the opposite of the placebo effect, where negative expectations about a treatment or condition can lead to negative outcomes or symptom development. If one expects a virus to cause long-term disability, there is a chance that expectation can contribute to the actual manifestation of symptoms.
Functional Disorder
A functional disorder is a term used in medicine to describe conditions where there are physical symptoms but no clear structural or organic cause found on tests. It is a re-labeling of what was previously called psychosomatic or hysterical conditions, intended to destigmatize, but can obscure the underlying psychological mechanisms.
Culture-Bound Syndromes
Culture-bound syndromes are particular collections of symptoms that occur for specific reasons within small communities, often with culturally specific explanations and solutions. These syndromes, like 'greasy sickness,' can have mechanisms similar to psychosomatic conditions but are interpreted and resolved through cultural frameworks.
8 Questions Answered
Dr. O'Sullivan suggests four main categories: lasting organ damage from severe COVID, a general post-viral illness (like chronic fatigue), misattribution of unrelated new conditions to COVID, and psychosomatic conditions where psychological mechanisms drive real physical symptoms.
People who died of severe COVID tended to be frail, elderly, or have comorbid illnesses, while people with long COVID symptoms often tended to be extra healthy before the pandemic, with a higher prevalence among younger women, suggesting distinct populations.
Evidence includes a significant disparity between the severity of reported symptoms and normal objective test findings, studies showing that an expectation of symptom severity and pre-morbid psychiatric symptoms increase risk, and the observation that initial long COVID concepts arose from social media rather than scientific consensus.
Paying undue attention to bodily sensations can make normal 'white noise' sensations feel abnormal, and anxiety can activate the fight-or-flight system, producing more symptoms. The brain's predictive nature means that expecting certain symptoms can actually make them manifest, similar to the nocebo effect.
It often starts with an explainable physical event (e.g., fainting) followed by fear and anxious attention to the body. This leads to the body behaving as expected (e.g., having a seizure), and if reinforced, can escalate to frequent, severe symptoms like hundreds of seizures a day or paralysis, often exacerbated by medical interventions like excessive testing.
Chronic Lyme disease is often a misdiagnosis for chronic, nonspecific symptoms, with many patients testing positive only through labs that use overly sensitive or non-specific antibody tests. Like long COVID, it can become a convenient explanation for suffering, drawing people into an 'industry' of non-mainstream treatments.
The term 'functional disorder' is used to destigmatize conditions previously called psychosomatic or hysterical, by implying a problem with brain function rather than psychological issues. However, Dr. O'Sullivan fears it obscures the underlying causes, makes the problem seem concrete and harder to change, and may eventually become stigmatized itself.
It's crucial to find a trusted doctor who can help determine when 'enough tests is enough' to avoid false positives and the anxiety of waiting for results. Additionally, it's important to shift focus away from bodily symptoms by finding purpose outside of the illness, and consider physical and psychological rehabilitation.
8 Actionable Insights
1. Limit Excessive Medical Testing
If experiencing mysterious symptoms, find a trusted doctor to help determine when enough tests are enough. Excessive testing can lead to false positives, incidental findings, and increased anxiety, which can exacerbate symptoms.
2. Shift Focus from Bodily Symptoms
Actively find a purpose or focus outside of your bodily symptoms and concerns. A great deal of what perpetuates symptoms is the anxious attention paid to them, so redirecting focus can be helpful for recovery.
3. Challenge Symptom Expectations
Learn and apply distraction techniques to break the brain’s predictive patterns for symptoms. If you expect symptoms to progress in a certain way, your brain can make it happen, so force symptoms in a different direction.
4. Engage with a Good Therapist
Seek psychological rehabilitation with a psychologist, psychotherapist, or psychoanalyst. A good therapist can help manage anxiety, understand emotions, and develop coping strategies, even if the disorder isn’t purely psychological.
5. Practice Non-Reactive Symptom Awareness
Develop a different relationship with your symptoms by noticing them without interpreting them as inherently wrong or bad. This mindfulness approach can reduce stress and frustration, potentially improving your ability to function.
6. Address Fear-Avoidance Patterns
Identify and challenge situations or activities you are avoiding due to fear of symptoms. Breaking these fear-avoidance cycles, often with the help of a psychologist, is crucial for recovery and regaining function.
7. Seek Physical Rehabilitation
If physical symptoms are present, engage in physical rehabilitation with physiotherapists and occupational therapists. This can help re-learn physical functions that may have been ‘unlearned’ due to psychological mechanisms.
8. Support Others without Confrontation
When supporting friends or family with these disorders, avoid confronting their personal theories about their illness or immediately suggesting psychological mechanisms. Instead, encourage a return to normality in a non-confrontational way to avoid alienating them.
8 Key Quotes
If you tell people to examine their body for symptoms, you will find them because our bodies are awash with funny sensations.
Suzanne O'Sullivan
The concept of long COVID arose on Twitter. It didn't rise out of science or any medical establishment.
Suzanne O'Sullivan
Our bodies are really vulnerable to expectations and anxiety and the attention we pay to them. And you don't have to be a psychologically vulnerable person for that to happen. You just need to be in the right circumstance.
Suzanne O'Sullivan
If you expect that contracting a virus will lead to this type of long-term disability, then there is a small chance that that could actually happen to you.
Suzanne O'Sullivan
It's illness sometimes is a story you told yourself. And you need to tell yourself a story that will make you better to get better.
Suzanne O'Sullivan
It doesn't matter what you call it if you can de-stigmatize the concept.
Suzanne O'Sullivan
If we're just changing the name, then it's just an ever-ending, never-ending race to get the next stigmatized word.
Suzanne O'Sullivan
If people get better, I don't care what makes them better. Well, I mean, I do care. There's a limit, obviously, to what I'm willing to accept, what kind of treatment to make people better.
Suzanne O'Sullivan