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doi:10.1093/brain/awv299 BRAIN 2016: 139; 300–302 | 300 DORSAL COLUMN Book Review Functional disorders: a neurologist’s account The back cover of this book states that ‘a neurologist explores the very real world of psychosomatic illness’, although I note that in the current real world the internet bloggers are already firing off irate responses to the provocative title with its imputation that they have ‘imaginary’ illnesses. Despite this avalanche of online abuse (to which psychiatrists working in this field have become inured), the book has received favourable reviews in the national press, which suggests a considerable interest in the subject and is also a testament to good writing. In the introductory chapter, O’Sullivan defines the problem clinicians have in classifying the diverse manifestations of functional neurology. She describes the recently introduced definitions listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the prevalence of these disorders and the enormous cost to the health care system. There are a few errors: somatic symptom disorder is not a ‘rare and devastating problem’, it affects 5–7% of the population; illness is not ‘a response to a disease’, it is a collection of diverse symptoms; and patients do not ‘unconsciously think themselves ill’, they really believe that they are. There is also excessive use of the word ‘subconscious’ with its Freudian connotations. The bulk of the book involves descriptions of case histories with complex somatoform disorders familiar to most neurologists (and liaison psychiatrists like myself who have to treat them). These include a young polysymptomatic wheelchair-user who is self-catheterizing; a woman with functional blindness; a young man convinced that he has multiple sclerosis despite evidence to the contrary; a patient who develops a functional movement disorder after a trivial limb injury; another with functional blepharospasm; as well as chronic fatigue syndrome and many patients with nonepileptic seizures. The accounts of the various illnesses (and abnormal illness behaviour) are interesting and written in an engaging style. O’Sullivan is clearly a good listener and her formulations of her patients’ complex presentations are accessible and plausible. She explains the dilemmas faced by neurologists in managing these clinical conundrums: how to deliver news of reassuringly negative results, IT’S ALL IN YOUR HEAD: TRUE STORIES OF IMAGINARY ILLNESS By Suzanne O’Sullivan, 2015 London: Chatto and Windus EAN: 9780701189266 Price: £16.99 managing patients and families in denial, attempts to explain the nature of dissociation, dealing with demands for more tests etc. O’Sullivan is keenly aware of the role that developmental factors, previous illness experience and beliefs and expectations can have in shaping a functional neurological disorder. My main criticism is the excessive reference to the term ‘subconscious’ and to the writings of Freud, Charcot and Janet and their influence on thinking in this field. She might have mentioned that Russell Reynolds, a neurologist writing in the British Medical Journal in 1869, noted that ‘. . . some of the most important disorders of the nervous system. . . may depend on the morbid condition of an idea, or of idea and emotion together. . . Such symptoms often exist for a long time and disappear entirely on the removal of the erroneous idea’. Just so. I have never forgotten a mischievous lecture by the late Sean Spence to a mixed audience of North American psychiatrists and neurologists as he calmly announced that the Freudian contribution to functional neurology was a diversion that lasted over half a century. I would have liked more discussion of modern theories and explanatory models, for example as outlined by Spence and the recently proposed broader Received August 14, 2015. Accepted August 14, 2015 ß The Author (2015). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For Permissions, please email: [email protected] Book Review BRAIN 2016: 139; 300–302 | 301 Figure 1 A simple cognitive model of physical symptoms. From Price and Leaver (2002). Reproduced with permission from BMJ Publishing. biopsychosocial models, which include psychological concepts such as attentional bias, expectations, prior experience and cultural beliefs (e.g. Edwards et al. 2012). Far from being arcane disorders ignored by neurologists, there has been a resurgence of interest in functional disorders, driven by collaborative research between neurologists, psychiatrists and neuropsychologists (Fig. 1). Two meetings on functional movement disorders in 2005 and 2011, both held in the USA, led to the publication of influential textbooks and an awareness that these disorders are much more common than had previously been thought (Hallett et al., 2006, 2011). The subject is alive and well in the UK, where the UK Functional Neurological Symptoms Group (UK-FNS) was established in 2011 and now meets annually in October. These meetings are multidisciplinary and involve discussions of recent research and free exchange of ideas as well as a web forum (Carson et al., 2012). O’Sullivan can be reassured that there is now a cohort of young neurologists (and psychiatrists/neuropsychologists) with an active interest in these disorders, who have made a major contribution to our understanding of them in the last decade. Finally, O’Sullivan asks the $64 000 question: ‘Why, when neurologists know that conversion disorders are so common, are we so ill-equipped to deal with them’? This leads to a discussion of the stigma associated with medically unexplained symptoms (MUS) and a lack of understanding by doctors of mind-body interactions. But in what other profession would education be so decontextualized, allowing neurologists to train without any curriculum time devoted to the detection and management of one third of their outpatient case load? Regrettably, the situation in medical school is not encouraging, as doctors in training are currently taught medicine and psychiatry as if they were different disciplines, perpetuating the mind-body split that permeates our health care system. Attitudes to teaching are relevant because patients with MUS comprise one-fifth of the workload in primary care and one-third to one-half of all patients attending specialist outpatient clinics. It is regrettable therefore that teaching of MUS across medical schools remains highly variable, with little evidence that formal teaching on this topic takes place in medical or surgical specialties (Howman et al., 2012). In the absence of formal teaching it is not surprising that the outcome for these patients is often negative. This book is a constructive contribution and should lead to a greater awareness and understanding of these common and neglected clinical problems. It deserves to be widely read, not only by patients and relatives, but also by neurologists and doctors in training. Christopher Bass Consultant in Liaison psychiatry, John Radcliffe Hospital, Oxford OX3 9DU, UK E-mail: [email protected] Advance Access publication October 21, 2015 References Carson A, Brown R, David A, Duncan R, Edwards MJ, Goldstein LH, et al. Functional (conversion) neurological symptoms: research since the millennium. J Neurol Neurosurg Psychiatry 2012; 83:842–50. 302 | BRAIN 2016: 139; 300–302 Edwards M, Adams RA, Brown H, Pareés I, Friston KJ. A Bayesian account of hysteria. Brain 2012; 135: 3495–12. Hallett M, Fahn F, Jankovic J, Lang AE, Cloninger CB, Yudofsky SC, editors. Psychogenic movement disorders: neurology and neuropsychiatry. Philadelphia, PA: Lippincott Williams and Wilkins; 2006. Hallett M, Lang A, Jankovic J, Fahn S, Halligan PW, Voon V, et al. editors. Psychogenic movement disorders and other conversion disorders. Cambridge: Cambridge University Press; 2011. Book Review Howman M, Walters K, Rosenthal J, Good M, Busziewicz M. Teaching about medically unexplained symptoms at medical schools in the United Kindgdom. Med Teach 2012; 34: 327–29. Price J, Leaver L. Beginning treatment. BMJ 2002; 325: 33–5. Russell Reynolds J. Certain forms of paralysis depending on idea. BMJ 1869; 2; 378–80.