British Journal of General Practice – review of Sick and Tired
Nick Read is, as the book jacket tells us, a ‘consultant physician and psychoanalytical psychotherapist who works to help people cope with illnesses that have no clear cause or pathology’. If either the subject or disciplinary background in the first sentence make you disinclined to read further, I suggest that you have identified both a personal bias and a learning need which is worth exploring a little more, given the increasing need for GPs to be able to deal effectively with complex multisystem problems. Dr Read has done a lifetime’s work in the field and has published over 500 articles during his academic career, of which he humbly references only three — while providing almost 60 pages of further notes and bibliography that will allow anyone to pursue his arguments through the rest of the relevant literature and key authors. The book itself is, however, very approachable in its writing style, with a blend of short case studies, personal insights, and narrative overview. Nine chapters cover the changing epidemiology of both illness and patterns of health care, with an increasing focus on those so-called ‘functional illnesses’ or patients with ‘medically unexplained symptoms’ (MUS); characterised (page 20) as:
‘… a variability of symptoms: the ability to mimic organic diseases: … gender predisposition for women: and … links with emotional disturbance and life events’.
There is a summary of how social experiences can affect body systems, repeated demonstration of our varying vulnerability as individuals to both life events and their unpredictable consequences, and a review of how illness experience is both culturally conditioned and (paradoxically) highly individualised in its outcomes.
This book does not specify its audience, but Dr Read seems to be writing for the literate patient or a nonspecialist health professional, perhaps in training. I am not sure that the bulk of my fellow GPs would be familiar with the evidence-based assertion that many cases of MUS are preceded by unresolved losses (page 33) or precipitated by excessive anxiety — ‘that inner sense of loss which can never be grieved and mourned because it has not yet happened’ (page 40). His arguments about the impacts and protective effects of stable and confident parenting were well known to me, but I teach, research, and have a longstanding clinical interest in the same field. The key underlying concepts are that it is ‘the episodes in life that challenge a person’s sense of their own identity which are most likely to result in an illness’ (page 47) and that some of the intriguing question as to why people are so different resides in the interaction of our own physiognomy and the hardwiring of the reactions of others in our earliest, ‘pre-conscious’ years.
Dr Read does not seek to oversimplify, but gives some key soundbites on his firm belief that the diagnostic approach must be narrative based and patient centred — that it is the constellation of events and feelings associated with startup, remission and relapse that will give both sufferer and clinician the most potent insights to an effective and holistic management plan:
‘It sees likely that many expressions of functional illness are bodily representations of what has happened to us … they convey a specific meaning, which our emotional brain has translated into the intimate and personal metaphor of our bodily feelings and physiological reactions. This is encrypted communication; its meaning can only be decoded by the life narrative of the individual …’ (page 127).
He also treads the tricky ground of exploring why illness may be a way of coping with apparently irreconcilable tensions, and expounding the potentially generalisable intervention of sharing distress and feelings with others, maximising healthy lifestyles including relaxation, and a certain amount of human pragmatism in the face of the inevitability of symptoms and ill health in us all.
Where I felt on less solid ground was chapter 7, where the author moves his arguments out from individual circumstances to broader societal issues, including rapid cultural change, media intrusion, loss of predictable community patterns, and social isolation. There is a lot packed into this chapter, including crosscultural perspectives on how distress is legitimated in different ways, and a brief history of medicine section on the concepts of hysteria and neurasthenia — all relevant and mind broadening, but under-developed for my taste. I was also a bit sceptical about the case studies, some of which seemed incredibly succinct, and which left me thinking ‘it can’t be that easy surely!’ This may be an editing issue, but more on how clinicians can sustain the ups and downs of working with these patients might be valuable. Referral guidelines or any specific exploration of pharmaceutical, psychological or behavioural therapeutics are also absent, beyond a general adage to avoid false hope and excessive investigation, or use of unproven therapies.
In summary, I thought this book a brave attempt to make a difficult and stigmatised subject mainstream; a very professional text, and well argued, but not pompous, and easy to read. The GP audience will find that it resonates with our understandings while gaining some new insights. I would also recommend it to certain patients, to my medical students, and to trainers and teachers in all levels of formal training. If it is a subject that ‘switches you off’, this book may not quite persuade you, but it certainly gives an informed and interesting debate.
Amanda Howe
published in the British Journal of General Practice, Vol 56 – February 2006
