Head First – Stories of Mind and Body
Dr Alastair Santhouse
Friday 13 May 2022
Summary by Frank Kelley
Dr Alastair Santhouse is a Consultant Neuropsychiatrist at The Maudsley Hospital. He is Past President of the psychiatry council at the Royal Society of Medicine. He is the author of Head First: A Psychiatrist’s Stories of Mind and Body (2021).
You can read a Guardian review of his book at:
Head First by Alastair Santhouse review – a medical memoir with elegance and integrity | Health, mind and body books | The Guardian
In a lucid and engaging talk he set out some of the issues and explores how we ended up here in 21st century medicine. In secondary care, an organic explanation for the patient’s symptoms is made in only about 50% of consultations. For common presentations in primary care, the figure is far less. The costs of this – financial, clinical and societal – are huge.
He grew up reading the problem pages of magazines for teenage girls and comparing his answers with theirs. He was interested in the The Tall Tales of Baron Munchausen. This gave the name to Munchausen’s syndrome, a psychological disorder where someone pretends to be ill or deliberately produces symptoms of illness in themselves.
In the 1950s the sociologist Talcott Parsons developed the concept of the sick role. The sick person is exempt from normal social roles, is not responsible for their condition and has the right to be taken care of. In return they should try to get well, should seek technically competent help and cooperate with the medical professional.
Al’s early experience as a medical doctor led him to think about a variation to this sick role. Patient’s seeming to be ill, and taking on the sick role, but without having a diagnosable illness.
He looked through research findings on cultural differences in the experience of illness. With older Americans the Italian Americans were greatly concerned about pain and would experience widespread pain. The Jewish Americans were more concerned about the causes of their pain. Hence the Italian Americans welcomed pain relief while the Jewish Americans worried pain relief would obscure the cause of their symptoms. Older white Americans were very stoic and just put up with pain rather than seek help or diagnosis. They would use metaphors rather than direct language about pain.
We want to understand our lives. Daniel J Boorstin wrote: The greatest obstacle to discovery is not ignorance – it is the illusion of knowledge.
The ancient Greeks believed that the body was made up of four main components or Four Humours. These Four Humours needed to remain balanced in order for people to remain healthy. The Four Humours were liquids within the body- blood, phlegm, yellow bile and black bile. This was not only a model of physical illness, it was also a model of personality. This illusion of knowledge was the dominant medical model from antiquity up to the nineteenth century. In 1860 Oliver Wendell Holmes stated I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be better for mankind-and all the worse for the fishes.
Medicine based on the four humours was only overturned by the growing understanding of disease processes, particularly those for infectious diseases. One consequence of this growing knowledge was that treatments were increasingly tailored to illness and diagnosis.
There are problems with this nineteenth century revolution in medicine. In The End of Medicine (1975) Rick J Carson argued that the medical metaphor of the body as a machine has constrained our way of thinking and that the psychological causes of symptoms got forgotten.
Dr Henry Maudsley was a psychiatrist who founded the hospital where Al works. In 1895 he described The Sorrow Which Has No Vent in Tears May Make Other Organs Weep.
It is conventional to think of symptoms in terms of illness and pathology rather than a normal experience. A survey of the prevalence of muscle twitches found them in normally healthy people. A BMJ survey in New Zealand found only 10-11 % of people had been free of symptom in recent days.
Al made the counter-intuitive claim that symptoms are normally medically unexplained. The average across medical specialisms is that around 50% of symptoms are unexplained. This goes from a low with dental (37%) and chest (41%) medicine. The highest rates of unexplained symptoms are in neurology (62%) and gynaecology (66%).
Not surprisingly for a psychiatrist working with medical colleagues Al pointed out that unexplained medical symptoms are often associated with depression and anxiety. The Sorrow Which Has No Vent can mean that when something really miserable happens it can be too hard to talk about it.
He also thinks doctors can make things worse. Explanations using medical pathology can seem easier to understand and explain. Doctors can respond to unexplained symptoms by over investigating and by missing out on simpler psychological explanations. It is rare for prolonged investigations to lead to a new accurate diagnosis, It also means that any psychological explanation comes very late and is of often not very well received. A key factor in maintaining symptoms is by focussing on them. This is a process that is built into over investigation.
There is also the defensive view that over investigating doctors cannot be accused of missing something. A randomised control trial of headache patients found that investigations reassure doctors rather patients.
Psychiatry is medicine and psychiatrists could offer their colleagues patients help, for example, kidney donors and people making end of life decisions. Psychiatrists should always be available for explanations.
Thank you very much to Dr Alistair Santhouse for an eloquent and connected expression of his theme. This was well received by our members who would enjoy talking with him again.