Is It All In Your Head?

All In Your Head Graphic

Neurologist Suzanne O’Sullivan, M.D., was the winner of the 2016 Wellcome Book Prize for her dazzling contribution titled “Is It All In Your Head?”  It is a brilliantly conceived presentation about the evolution of psychosomatic illness, and chapter 5 features Yvonne as the face of Visual Conversion Reaction (VCR) in which “the patient sees nothing and the doctors sees nothing”, but not because of a conventional neurological disorder.

I was reminded of VCR last week when my sister-in-law’s seven year-old granddaughter came into the office for examination.  She was having unanticipated difficulties with reading in school, and my Resident – Dr. Kristen Vicnent – was conducting the evaluation.  We wanted to administer the Readalyzer, but the child (we’ll call her “VC”) insisted she couldn’t see any of the words.  We tried to administer the King-Devick test, but VC reported that she couldn’t see any of the numbers.  Our plans to administer the TOSWRF had to be abandoned when VC claimed she couldn’t see any of the letters.  Recognizing the difficulty that VC was presenting, Dr. Vincent consulted with me on differentiating malingering from VCR, the type of assessment that can only be done when one has experienced a number of these cases.  As Dr. Simon Barnard has noted, Visual Conversion Reaction often centers around stress, and has numerous equivalent names, one of which is Amblyopic School Girl Syndrome.  There are intriguing questions of how well the umbrella term “non-organic visual loss in children” can be applied.  From an optometric perspective, there has always been somewhat of a debate about the extent to which Streff Syndrome is a form of psychogenic bilateral amblyopia.  An Rx with appropriate low plus lens power and/or prism may alleviate VCR or Streff Syndrome in children, as in some cases may optometric vision therapy.  In other instances, reassurance that vision will come back to normal on its own is equally successful in time.

help me

The greater conundrum occurs in how to present the diagnosis to the child and the parents.  In some cases reassurance is key, in other instances taking advantage of the placebo effect is in order and in other cases addressing the underlying stressor is paramount.  In my experience, while referral to a mental health professional may be indicated, how one presents this to the child or parents is paramount.  Accusation and confrontation, particularly when the patient’s motives for subjective visual loss are suspect, rarely accomplishes anything positive.  Empathy rules the day, and that is a strong message in Dr. O’Sullivan’s book.

Is It All In Your Head - Cover

Back to Yvonne and Chapter 5.  “Whatever else you do, give people the benefit of the doubt.  The moment you say to that woman that you think she can see you have lost her,” was the advice that Dr. O’Sullivan received from her mentor.  As Yvonne was being discharged, she handed Dr. O’Sullivan a card that she had drawn.  Even with her mentor’s warning ringing in her ears, Dr. O’Sullivan found herself saying: “But if you can’t see, how could you draw a picture“?

Dr. O’Sullivan notes that an appreciation of conversion disorders comes as a practitioner learns to see patients differently in time, and is part of the maturation of a professional.  Simply because tests do not pinpoint the cause of a problem does not mean that the problem is any less real or in some cases any less debilitating.  It would help if medical students (and I’ll add to that optometric students) were taught about conversion disorders as more than a footnote in the curriculum.  She concludes: “I was a fool to question Yvonne’s motive and insight because she had, consciously or unconsciously, answered my question on the day she was discharged from the hospital.  Yvonne had told me how things were when she handed me the card she had made.  A woman who wishes to lie and fake and deceive wears dark glasses and carries a cane and stumbles about.  That woman certainly does not draw a picture.  Yvonne’s drawing was not evidence of guilt but of innocence.  At the moment she handed it to me, it was I who could not see.”

One thought on “Is It All In Your Head?

  1. When the patient sees nothing and the doctor sees less is it all in the patient’s head or the doctor’s head? Once the doctor has ruled out knowing what is going on, then the road to the patient’s enhancement is no longer blocked.

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