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September 16, 2019

“It’s All in Your Head”—Medicine’s Silent Epidemic

Author Affiliations
  • 1Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
  • 2Department of Psychiatry, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
JAMA Neurol. 2019;76(12):1417-1418. doi:10.1001/jamaneurol.2019.3043

“It’s all in your head” is a phrase sometimes said by physicians to patients presenting with symptoms unexplained by medical disease. As a neurologist specializing in neuropsychiatry, nothing bothers me more than overhearing medical colleagues proclaim this one-liner at the bedside or snicker about these patients during rounds. Unbeknownst to them, I also hear my patients’ version of being on the other end of this phrase and find myself constantly trying to repair the damage that these words can cause. Whether physicians like to admit it or not, medically unexplained symptoms encompass a vast terrain of clinical practice. In neurology, these symptoms fall under functional neurological disorder, but every specialty has their own variants and favored terminologies (eg, chronic fatigue syndrome, fibromyalgia). The inadequate management of this segment of medicine represents a silent epidemic that is slowly eroding patient-physician relationships, perpetuating unnecessary disability, and straining health care resources.

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    8 Comments for this article
    Reflection on editorial
    Blake O'Lavin, M.D. | Mostly retired neurologist.
    It’s hard to call this an epidemic since it has been a “forever” in medicine. It’s sad that as we become smarter about brain function, we are plagued, even as brain doctors, with concluding that symptoms are somehow, made up by our patients. Even malingering is brain derived.
    It's All in Your Head, FYI
    David Elpern, M.D. | The Skin Clinic, Williamstown, MA. djelpern@gmail.com
    “It’s All in Your Head”— Medicine’s Silent Epidemic” by Matthew Burke is a necessary, succinct introduction to medically unexplained symptoms in neurology. It should have referenced the book, “Is It All In Your Head?” that won the prestigious Wellcome Book Prize in 2016 by the Irish dermatologist, Suzanne O’Sullivan (1). O’Sullivan’s volume was a practice changer for me, a dermatologist. Anyone who appreciates Dr. Burke’s article will find Dr. O’Sullivan’s book important and fascinating. I am cognizant that Viewpoint articles have strict limitations on the number of references, however, I feel that O’Sullivan’s work is more important than some of the other citations.


    1. O’Sullivan S. Is It All in Your Head?: True Stories of Imaginary Illness. Other Press. New York, 2016. (Originally published in the UK in 2015)
    Actually, everything is all in our head
    Richard Loewenstein, M.D., Clinical Professor | The Trauma Disorders Program, Sheppard Pratt Health System; Dept of Psychiatry, U of Maryland Medical School
    Dr. Burke is to be commended. As someone who worked in consultation-liaison psychiatry and neuropsychiatry, before my current specialty, I am only too familiar with the problems Dr. Burke describes. At the present time, I specialize in patients with severe complex trauma and dissociative disorders: precisely the patients studied by Charcot, Janet, Freud and others. These are exactly the "thick chart" patients who are treated with condescension by many physicians and also nursing staff and other allied health professionals. And, indeed, we are beginning to understand a profoundly fascinating neurobiology that underlies these patients' suffering. They are also a potentially important window into understanding the relationship among (simultaneous) mind-brain-body conundrums. Typically, I wind up with the person described by Dr. Burke, demoralized and humiliated by interactions with medical professionals. They tell me, "they said this is all in my head!" I say, that's true, it's all in your head. After they stare at me in disbelief, I point out, if we drop a rock on my foot, I only "know" this is occurring in "my head". My brain/mind is where this information is processed. Now we have the problem of figuring out where the information originates: in the periphery, in the brain/mind, or multi-directionally. We know that mental states - and even socio-cultural factors - influence the processing and presentation of symptoms and illnesses to practitioners. My complex trauma patients grew up in settings where, "if the bone wasn't sticking out of my arm, I got no help". Their illness behavior is either "shouting so loud no one can hear them", or numb and avoidant. So we begin to share the uncertainty of figuring out together what is going on. Thanks Dr. Burke.
    Non-organic, functional, psychogenic or unknown?
    Perminder Sachdev, MBBS, PhD, FRANZCP | Centre for Healthy Brain Ageing (CHeBA), University of New South Wales & Neuropsychiatric Institute, Prince of Wales Hospital, Sydney, Australia
    Dr Burke is to be commended for bringing attention to this important but underappreciated issue in medical practice. Physicians often feel threatened or inadequate when confronted with a problem they cannot adequately diagnose and treat. They are poorly trained to convey to patients the potential role of psychogenic factors, or are unable to devote the time needed for a proper evaluation and treatment of such patients. Their specialist training may also engender an incapacity to address the complexity of these cases. The remedy, as Dr Burke points out, is in better training and education, which should begin in medical school in integrated programs that do not separate mental health from physical illness.
    ME/CFS Patient experience, plus research proving pathophysiology
    Lesley Shure, MD, DPM |
    To get a realistic appreciation for the patient's perspective, watch the TED Talk by Harvard grad student Jennifer Brea (1).

    In the few short years since, Stanford and Open Medicine Foundation have maderesearch strides in understanding the pathophysiology of ME/CFS and are in the process of creating a clinically available, reliable and accurate lab test for it based on the unique biochemistry caused by that pathophysiology.

    And keep in mind that even diabetes mellitus existed before doctors had lab tests to prove it. Patients could have been considered malingering or psychosomatic on the grounds of polydipsia and

    1. https://www.ted.com/talks/jen_brea_what_happens_when_you_have_a_disease_doctors_can_t_diagnose?language=en
    It's not all in our head
    Ed Tobias, B.S. | Patient Columnist, "The MS Wire," www.multiplesclerosisnewstoday.com
    As someone with multiple sclerosis who also writes about my illness I frequently hear the lament “the doctors won’t believe me.” An MS patient arrives with a variety of, sometimes painful, symptoms at the office of his or her neurologist, or PCP or, worst of all, at the ER and is told “it’s all in your head.” Then, as Dr. Burke writes, some patients wind up searching for answers elsewhere – often from the dangerous Doctor Internet – and grasping at whatever solution is offered.

    Bravo to Dr. Burke for bringing this problem to the attention of other
    physicians. I can’t judge whether it’s an epidemic, but it’s certainly a significant problem in my MS world. It's comforting to know that this is understood by some in the medical world. It would be more comforting to know that this problem is being included in medical training, discussed at medical conferences and considered in the examining room.
    A Validating and Empowering Must Read for Patients and Doctors Alike
    Veronique Mead, MD, MA | Sharing the Science of How Adversity Affects Risk for Disease and Why It's Not Psychological on a blog Chronic Illness Trauma Studies
    Thank you for voicing this deeply disturbing ongoing problem in such a contemporary, articulate, validating and thoughtful way.

    I'm a family physician who left medical practice because my training and work in the medical system’s fast paced, non-emotional environment meant that I was frequently causing harm to my patients even as I didn’t fully understand why at the time. I also became gradually disabled by chronic fatigue syndrome (ME/CFS) and learned first hand how deeply shaming and traumatizing it can be to be disbelieved and told it's not real.

    As Dr. Burke so clearly
    states, this is among the many factors that is "eroding patient-physician relationships."

    There is a vast and growing body of evidence debunking the myth that any kind of symptom is "all in our heads" and medicine has yet to catch up with this information.

    I became a trauma therapist after learning how adverse life experiences interact with our genes to shape our physiology and influence risk for chronic physical diseases and emotional health conditions (and more).

    I blog about the science for other patients to gain more understanding of their symptoms, triggers and flares with chronic diseases of all kinds because research is showing just how deeply our physiologies are influenced by adversity and other environmental factors, as well as how plastic our brains and bodies are. The science is also explaining that we have more tools to offer than we have been taught in medical school.

    Although I knew this was an important problem when I was a physician, I never realized how pervasive it was until I started blogging. I have been shocked to learn from my readers just how many have been told it's all in their heads by at least one medical professional, regardless of their disease. This includes people in early and even late phases of autoimmune disorders of all kinds (RA, MS, SLE) and not just those with mystery illnesses.

    I recommend this article be made freely available to the general public as one small step to help mitigate this 100s-of-years-old issue pending the time it is taught in medical schools. It would support patients to keep learning, growing and healing despite the difficulties many encounter with our medical system. It would also provide the many physicians and other health care professionals who already work from this larger perspective another tool to support their work.
    Psychophysiologic Disorders
    David Clarke, M.D. | Psychophysiologic Disorders Association
    Excellent article, highly reminiscent of the paper by Francis Peabody published in JAMA in 1927. (The Care of the Patient, JAMA, 88, 877-882).
    30-40% of primary care patients suffer from medically unexplained symptoms, chronic functional syndromes or psychosocial factors linked to chronic pain. Collectively, my colleagues refer to these conditions as Psychophysiologic Disorders or PPD. A trauma-informed, evidence-based approach to diagnosis and treatment can transform these patients from among the most frustrating to the most rewarding and give them a far better chance for a full recovery. As one family physician who learned these concepts said: “It put the
    joy back into my practice.”
    CONFLICT OF INTEREST: Lead editor of textbook “Psychophysiologic Disorders"