Mixed Bag #14: Alastair Santhouse on Psychological Medicine

“Mixed Bag” is a series where I ask an expert to select 5 items to explore a particular topic: a book, a concept, a person, an article, and a surprise item (at the expert’s discretion). For each item, they have to explain why they selected it and what it signifies. — Awais Aftab

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Alastair Santhouse is a consultant neuropsychiatrist at the Maudsley Hospital, London. He has spent his career working at the clinical interface of body and mind, in liaison psychiatry and neuropsychiatry. His book Head First (published in the UK by Atlantic, USA/Canada by Avery) is a rallying call to rethink how we view health and illness. You can follow him on twitter: @Dr_Psychiatry.

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Book—Andrew Scull, Hysteria: The Biography (2009)

Santhouse: I’ve always loved reading. There are not many genres of books that I don’t like, with my reading list alternating between fiction and non-fiction, classic and contemporary. There’s nothing more important for psychiatrists than to read widely. It allows us to see the world through different eyes, to empathize with other views, to feel the common threads of humanity that bind us. The great authors, observers of human nature and the human condition, have as much to teach us as any textbook. But since this piece is about psychosomatic medicine, I’ll need to pick my favorite. And although the temptation is always to show off a little, to lightly point to an unreadable and authoritative tome as a reflection of one’s erudition and refined intellect, I have always valued in an author readability and wit, to wear one’s learning lightly. In this respect, it is hard to beat Andrew Scull’s book Hysteria: The Biography. This is a marvelous book, because it is really impossible to make sense of psychosomatic medicine without understanding its history, and nobody does medical history better than Scull. We understand the origins of hysteria, rooted as it was in the patriarchal worldview that dominated for millennia, and its iterations over time. It is hard not to wince at the superstition, blame, and persecution by the medical profession of individuals with symptoms we would now call “functional” (or some variation of that term; a satisfactory compromise term has never been found). But without understanding how we arrived at our current understanding of persistent or medically unexplained symptoms, from Hippocrates to Galen, Mesmer, Charcot, and Freud to our current iteration, it is hard for the topic to make sense.

Article—Eliot Slater (1965), Diagnosis of “hysteria”, British Medical Journal.

Santhouse: Choosing a paper sent me scurrying in two different directions. I considered selecting a paper, of which there are many, that showed the frequency of medically unexplained medical symptoms in primary and secondary care. The papers all document a well known and stable truth. About half of all patients referred to secondary hospital care emerge from their outpatient appointment without an adequate underlying organic explanation to account for their symptoms. In some clinics, such as gastroenterology or gynecology, it is the majority of our patients. This is an enduring truth that we struggle to incorporate into clinical practice, despite the data (itself a strange and hard to understand fact given the love modern medicine has for empirical data).

There are many reasons why we don’t act on what we know to be true. One of those reasons flows from the classic paper by Eliot Slater, a neurologist of renown, in his 1965 paper, Diagnosis of “Hysteria,” published in the British Medical Journal. It was a paper that set back the whole area of psychological medicine for decades. He famously concluded at the end of his paper: “The diagnosis of ‘hysteria’ is a disguise for ignorance and a fertile source of clinical error. It is in fact not only a delusion but also a snare.”

In saying this, he induced, or rather reinforced, an anxiety in doctors that they were commonly missing important diagnoses, that all medically unexplained symptoms were really just undiagnosed medical illness. In my experience, doctors don’t need much encouragement to tap into the fear of missing a diagnosis, which is the stuff of nightmares (as well as complaints and possible legal action). It leads to repeated investigations for patients, of iatrogenic harm, and mistrust amongst patients who can feel ‘fobbed off’ by a psychological approach. It also deprives them of the psychological treatments they need to get better. The paper itself is a reminder that it’s not just patients who we need to be talking to about psychological medicine, but it’s other doctors too.

Person—Professor Sir Simon Wessely

Santhouse: Although psychosomatic medicine, in its various guises, has been around for millennia, the modern practice of psychological medicine is a relatively recent one. Prior to the 1970s, as Aitken and colleagues write, liaison psychiatry services were all but nonexistent in the UK, although perhaps they had been around in North America for a few decades prior. This has put me in the slightly unusual situation of meeting many of the pioneers of British liaison psychiatry as I was embarking on my career, and seeing the specialty develop and mature over the last quarter of a century. For most liaison psychiatrists, at least in the UK, their careers will have been influenced by Simon Wessely (now Professor Sir Simon Wessely), and many, including me, owe a debt of gratitude to him.

Simon is a single-handed force of nature, publishing over 600 papers, finding time to act as co-director of King’s Centre for Military Health Research, the first ever Regius Chair of Psychiatry in the UK, former president of the Royal College of Psychiatrists, as well as former president of the Royal Society of Medicine, amongst many other things. It has been a huge benefit to liaison psychiatry to have such a high profile and charismatic figure leading the way, and when he retires (which is frankly hard to imagine him doing) everyone will lament that he’s the sort of psychiatrist ‘they don’t make ‘em like anymore.’

Concept—The humoral theory in medicine

Santhouse: Over the recent decades, medicine has both been thought of, and practiced as, a science. Our ability to peer into the body is a beauty to behold. We have imaging technologies that were unimaginable a century ago. Understanding of pathology has advanced in a tidal wave of information. Ever more refined investigations and targeted treatments have led to an assumption that physical symptoms can be traced back to a bit of the body having gone wrong, and that more investigations will eventually lead to an uncovering of the pathology, and thence a cure.

For many health encounters, this is a comforting illusion. Simple formulations lead to a simplistic understanding of illness. These are based on a disease-damage model that fails to factor in the myriad other factors, commonly psychological and social, that influence illness presentation.

This way of being stems from a need to explain and control the world around us, to demystify and manage the fear of illness. As a concept, the need to understand everything in an encompassing whole, to eschew complexity in favor of comforting simplicity, is as old as medicine itself. For me, the humoral theory of medicine, developed by Hippocrates, and refined by Galen and others after him, was a thing of beauty. It described so much. It helped the world to make sense, allowed us to understand health and illness, personality, the seasons. As a concept, its elegance and ability to explain everything was compelling. Cleverer men than me believed it wholeheartedly. Yet, despite being the underpinning of medical practice for over a millennia, the theory was wrong. The world is as it is, and not as we want it to be. Let us not make the same mistake with a compelling, yet simplistic concept of health and illness again.

Surprise item—The shelf above my desk

Santhouse: I have a shelf above my desk at work. On the left, as I look up, there are textbooks. Some of these are ones I inherited from my predecessor in the post, many of which date back to his own medical student days in the 1960s. Brain’s textbook of clinical neurology (how apt, I always think, nominative determinism before it even had a name); various monographs on hospital management for doctors (why don’t I just throw them away? But I can’t seem to let go of these quaint cultural items, written in a time when most doctors managed patients, not budgets); and some more modern textbooks of medicine, psychopharmacology, and neuropsychiatry (I was worried about having acquired ‘dusty bookshelf syndrome,’ an affliction that affects senior consultants as they progressively drift out of date, and the most recent book on their shelf is from over a decade ago).

On the right of the shelf are a range of knick-knacks, framed poems, some piled up cards and letters, sent to me by different patients over the years. These are the things that mean most to me, my legacy, the knowledge that I have, in my own small way, made some difference in the world. Conversations about psychological drivers of physical symptoms have not always been comfortable conversations to have, particularly so when I first started out in liaison psychiatry, a time when FND (functional neurological disorder) had not yet come into use as a diagnosis, and advocacy groups were decades away.

Being referred by a hospital physician to see a psychiatrist when the complaint was a physical one was, at least in the past, not always easily accepted by patients. Those early items on my shelf—the magnetic cat for paper clips, the little red plastic dog meant for some sort of stationery (although I never worked out which), coasters to rest my mug of tea on—all of those have become treasured items, encouragement that with the right treatment and approach people are able to understand and conceptualize the complex interactions of mind and body, to make sense of their symptoms, and importantly, to recover. In the last quarter century, the landscape for psychosomatic medicine has improved immeasurably, but this shelf of items, my personal journey in liaison psychiatry, will always be close to my heart.

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See previous posts in the “Mixed Bag” series.

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