Elke Hausmann is a salaried GP in Derby
Suzanne O’Sullivan is a neurologist specialising in epilepsy who has come to prominence through her non-fiction books on psychosomatic illness. Her new book ‘The Age of Diagnosis‘ ostensibly makes the case for Long Covid being a (predominantly) psychosomatic condition.
She states that ‘…a variety of medical problems have been drawn under the single label of Long Covid…’, and she is not necessarily wrong in that. According to her, firstly, there are some people with a severe acute illness who had to be hospitalised who have ongoing physical symptoms stemming from that, secondly, some people will have developed a post-viral syndrome, and thirdly, some people were simply misdiagnosed by doctors who could not see patients face to face during the pandemic (which was not as long a period as people often imagine).
But the vast majority, she says, are people who are mistaking their physical symptoms for this condition, invented and described as Long Covid, with its huge array of symptoms which anybody alive could recognise themselves in, if they started monitoring the normal signals coming from their healthy living bodies, out of fear of being ill and/or because they have social problems in their lives that they cannot express other than through the acquisition of a medical diagnosis.
She is definitely right in that she is upsetting people. I’m a GP living with Long Covid. She is upsetting me, because this is so personal. But not for the reasons she gives.
She states that this argument is going to upset people, because her ‘truth’ is questioning their dearly held ideas about themselves, which they are intent on defending against the evidence.
She is definitely right in that she is upsetting people. I’m a GP living with Long Covid. She is upsetting me, because this is so personal. But not for the reasons she gives.
I disagree that she is speaking ‘the truth’. Listening closely to the episode on Long Covid in her book presentation on BBC Radio 4 (which is taken word for word from her book’s chapter ‘Lyme Disease and Long Covid’), her language is a give-away. She talks about ‘patient activists’, rather than ‘advocates’. ‘Activists’ conjures up the image of agitators, disruptors that need to be brought back into line. ‘Advocates’ are simply people who stand up for people who have no voice.
Her suspicion about the expertise of patients runs deep. She dismisses the idea that ‘patient experts’ should be central to research efforts, implying that they are not objective enough because they have skin in the game and would ignore any evidence that does not suit them. ‘Long Covid grew outside the control of the researchers’. She assumes that there are objective scientists on the one hand and subjective patients on the other.
The fact is that she could have found many people involved in pushing research in Long Covid forward, who are both medical doctors or medical researchers AND Long Covid patients. She argues that ‘science must take precedence’ and ignores the huge research literature that makes the case for Long Covid most definitely not being a psychosomatic condition, cherry picking some research that seems to support her view.
She makes much of the fact that for most Long Covid patients, tests are coming back as normal, and that this demonstrates that the condition must be psychosomatic. Curiously, she is actually contradicting herself when she talks about epilepsy, which is her field of expertise, when she states that negative tests are no obstacle to giving a diagnosis of epilepsy, as long as the patient describes their seizures as typical, since a good doctor takes into account the clinical presentation and does not put too much store on negative test results alone.
It is a real problem that we have no tests for Long Covid yet. Our understanding of Long Covid is still in its infancy, but slowly from the huge array of symptoms that patients have been describing since the outset, we are getting closer to understanding the many and varied manifestations of Long Covid – there are people with the cute label ‘brain fog’, which can actually now be better understood as a form of brain damage, we have patients with ‘post-exertional malaise’, a classic and core symptom of ME (which is another illness that is often misrepresented as psychosomatic), we have people with dysautonomia who may be diagnosed with POTS or orthostatic hypotension, which can lead to quite disabling symptoms, but for which we at least have some treatments that can really help patients, and we have patients with MCAS who find that antihistamines greatly improve some of their symptoms.
In my case, getting a diagnosis of POTS and starting ivabradine has made a definite improvement to some of my symptoms, even if I am still left with the (maybe even more) disabling exercise intolerance, which is driving the relapsing and remitting symptom complex described as post-exertional malaise, for which there are currently no treatments.
O’Sullivan suggests that people don’t like to be told that their physical symptoms might have an underlying psychological explanation. Her idea is that we simply ignore this possibility because mental health conditions are still stigmatised in society, and we don’t want to be seen through the lens of that stigma. Proponents of the psychosomatic explanation of Long Covid (and the same goes for ME), always make out as if we were really the ones stigmatising patients with mental health disorders, by inferring that mental health conditions are somehow lesser, when we represent our illness as ‘physical’.
In fact, rather than being resistant to psychological explanations and therapeutic interventions for Long Covid, we generally tend to be quite open to them. Until, that is, experience shows us that this route to a cure is a dead end.
O’Sullivan and others fail to recognise the likelyhood that most Long Covid patients will have already tried to improve their condition through psychological and behavioural approaches (pacing, breathing exercises, mindfulness and meditation, counselling and therapy), because in a situation where medicine is not able to give you any treatment that will cure your disease, the idea that there might be some underlying psychological or behavioural issues that, if addressed, could cure you, is the only thing we have left. So we try everything, only to find that none of it cures us. It might make us feel a bit better in ourselves and it might make it a bit easier to manage our condition, but we are still ill.
Now, it is not that O’Sullivan says that there are no patients who develop a post-viral syndrome following a Covid infection. My impression is that her response to me would probably be that my experience is not typical of Long Covid patients overall, because I am one of the minority with an actual post-viral syndrome. In contrast to that, I (together with the vast majority of people who keep themselves informed about ongoing research in this area) think that Long Covid fundamentally is a post-viral syndrome (maybe not necessarily even ‘post’, just ‘viral’), which is what the majority of Long Covid patients suffer from. When she talks about the majority of patients with Long Covid as having a psychosomatic condition, when she talks about Long Covid as fundamentally BEING a psychosomatic condition, with only few people experiencing ongoing problems after Covid infections that have different explanations, I think she is misrepresenting both the nature of Long Covid and our individual experience.
…in a situation where medicine is not able to give you any treatment that will cure your disease, the idea that there might be some underlying psychological or behavioural issues that, if addressed, could cure you, is the only thing we have left.
When she talks about Long Covid, she is talking about me. She characterises Long Covid as an invented and socially contagious condition, putting doubt into the minds of her readers and listeners about any patient who has Long Covid. As to whether their condition might not really be of psychosomatic origin, and yes, in our society that is still stigmatised (no matter how much she says that it should not be, and insinuates that we are just misunderstanding what psychosomatic conditions are).
What she says is not neutral. She is completely right in saying that mental health conditions should not be stigmatised, but the fact is that they are. Already, the central thesis of her book, ‘overdiagnosis’, has appeared in the media as a convenient way to minimise the extent of the problems that Long Covid and mental health conditions currently pose for our society, because when you say that the majority of Long Covid and mental health conditions are overdiagnosed, you can easily then justify putting less funding into those areas, for the support of individuals, and for research.
I don’t actually think that O’Sullivan would agree with her thesis being used like that; from what I understand she would favour a complete overhaul of medicine and society to give anybody who is struggling in whatever form the support that they need, without necessarily having to acquire a medical diagnosis. The trouble is, that’s not how these things work, and her thesis is may support the reduction of support for everybody, which is where we are headed in a world where ‘saving money’ is the core driving force in politics, not creating the conditions for people to thrive.
In conclusion, I don’t want to suggest that O’Sullivan has nothing important to say and that she is not right in some things, but I think that she is fundamentally wrong about the nature of Long Covid. Her book needn’t have included Long Covid as one of the topics she discusses. The fact that she felt that it needed to be included is in itself quite curious and will come down to some underlying assumptions of hers that we should be allowed to question (as people in positions like hers always like to question ours).
Featured book: Suzanne O’Sullivan, The Age of Diagnosis: Sickness, Health and Why Medicine Has Gone Too Far, Hodder, 320pp, £22
References
- All quotations taken from BBC Radio 4 18/3/25 at 11.45 – ‘The Age of Diagnosis by Suzanne O’Sullivan, 2. Long Covid’, available on BBC Sounds, https://www.bbc.co.uk/programmes/m002900d [accessed 27/3/25]
- See also the chapter ‘Lyme Disease and Long Covid’ in Suzanne O’Sullivan ‘The Age of Diagnosis’, Hodder Press 2025
Featured image by Angèle Kamp on Unsplash
As a GP with Long Covid impacting my health for 3 years, and as a clinician who is actively treating patients with Long Covid, I find Suzanne O’Sullivans comments around post covid conditions as psychosomatic illness to be highly offensive, scientifically inaccurate and clearly misleading to the public. Her comments reflect a lack of expertise and experience in this field and quite frankly she is not qualified to comment on this multi system post viral illness. Had she read any of the scientific research published in the last 5 years she would know that Covid virus causes brain damage and persistent neuroinflammation, damages the heart and blood vessels, damages the lungs, damages muscle and mitochondria and damages the kidneys in addition to causing dysregulation of the immune system. No wonder the patients have over 200 symptoms, there isn’t a single tissue or system that covid has not damaged.
Patients with Long Covid are sick because a virus has damaged their bodies, they are not making it up. It’s the arrogance of our profession to assume that because we, the physicians, do not recognise a new pattern of symptoms, the patient must be anxious or somatising. I thought that kind of attitude was defunct in medicine, paternalism seems to be alive and quite well in some quarters.
Her statement around the medical tests appearing “normal” in LC pointing to psychosomatic illness further reflects her ignorance of the scientific literature of Long Covid. The tests available to doctors in the NHS are incapable of detecting the damage covid causes on a cellular and molecular level.
A full blood count may come back “normal” because it only counts the numbers of each cell type. It does not look at the markers cells are expressing showing exhaustion of the adaptive immune system. It does not show you that the red cells have become inflexible and therefore worse at delivering oxygen. It does not show you the malfunctioning natural killer cells. Our test can’t detect the fibrinaloid microclots because we don’t have a test for them outside of research laboratories.
A routine CXR is incapable of showing the defects in gas exchange caused by covid, only detectable with research level equivalent. A routine MRI of the brain will look superficially normal but if you do fMRI with labelled glucose, brain metabolism is grossly abnormal, the brain stem is persistently inflamed, the hippocampus is abnormal in size, grey matter has been lost, to name a few. The brain in long covid secretes inflammatory markers similar to traumatic brain injury patients.
Even routine coronary angiography will appear superficially normal in the LC with angina like chest pains , but perform perfusion tests and significant defects in endothelial function become clear as the cause.
Nobody is somatising chest pains, it’s real and because of endothelial dysfunction. Nobody is somatising breathlessness, covid has damaged gas exchange on a cellular level. Nobody is somatising brain fog, the patients have neurological damage and inflammation caused by covid.
I suggest O’Sullivan removes her chapter on Long Covid until she has done some more homework on the subject. 2 million people in the UK have long covid, of which 110,000 are children and 10,000 are NHS staff who are still sick, and none of them are making it up. They are disabled, have lost their jobs , homes and life to this illness and O’Sullivan trivialises all of their suffering with her thoughtless comments.
I wonder, do their actions justify a complaint to the GMC for misinformation?
I absolutely agree with Dr Hausmann and Dr Shaw. I was working as a GP with long Covid, until I couldn’t. There are a great number of things I can no longer do. Of course I have tried to optimise my mental health, but it is the array of underlying physical issues, caused by Covid, that are limiting me. For a lot of clinicians I suspect, even those who are well read on the subject, the term post exertional malaise will not conjure an image that comes close to the reality of living with such a debilitating condition. Brain fog and fatigue likewise sound far less significant than they are. As clinicians if we don’t recognise that long Covid is a physical condition how will we ever find a treatment? Over diagnosis, even more worryingly, implies that the problem isn’t even as much of a problem to begin with, rather that it is less imperative to find an effective treatment, physical or otherwise.
The term psychosomatic is far too loaded and in my experience as an Adult Psychiatrist tends to lead to a medical cul de sac where the soma is ignored and the psyche is blamed. I prefer “biopsychosocial” as a concept as it places bio first and also includes social networks and functioning. To conceptualise Long covid we could compare to MS where vague symptoms occur in multiple sites in the body and fluctuate over time with different prognosis. Of course this is also missed as a somatic illness early on due to the pattern of variable symptoms in time and place. We need to do better. Immunological and autonomic dysfunction maybe a common root but end organ damage from inflammation can produce almost any other symptom. Always bio is first, then take into account the Psyche and Social impairments. That’s how I practiced Psychiatry and how I want to be treated as a patient.
But what happens when biological proof by way of test or scan results isn’t there but the patient is nonetheless suffering badly with pain or other symptoms and their psychosocial situation is plummeting as a result? Should a ‘bio’ approach be advanced then, regardless of what might be considered a lack of biological evidence, or should the patient be viewed as a ‘psychosomatic’ case instead with their care restricted to psychological/ behavioral and physiotherapeutic interventions? I suppose what I’m pondering is – to what extent should negative ‘bio’ test results rule out the use of medical or surgical interventions?
While ‘bio’ coming first sounds like good practice to me, what does it mean in reality for Long Covid sufferers if treatment/management decisions hinge on test results but patients aren’t being offered the tests that would reveal the presence of biological abnormalities (as described so well by another commenter)?
Reading this book, I was struck by how the author seemed to see different patient groups in completely different ways. I strongly sensed that Long Covid patients as a group were being characterized as clambering for diagnosis or overdiagnosis, while the portrayal of patients from families with Huntingdon’s disease came across to me as far more generous – with them seemingly having much greater wisdom/intelligence and alertness to the risks of overdiagnosis. It’s almost as if that group had been gifted with a gene that conferred additional wisdom/intelligence on them.
I very much doubt that a gene or familial predisposition for wisdom around healthcare seeking behaviour exists, rather that patients with harder-to-explain symptoms arising from poorly elucidated conditions are being viewed in a very different light to those with conditions that have been pretty well mapped out.
I believe that the psychosomatic/functional model could be having a disastrous effect on the UK economy now. It seems to me that the timing of a push/roll-out of teaching on MUS fits quite well with the steep rise in economic inactivity due to ill health that started in women (around 2014) several years before the covid pandemic began and that, as far as I know, hasn’t started to flatten out yet. A failing model that views being female as a risk factor could well explain why women are becoming sicker and are dropping out of work at a faster rate than men when such economic inactivity had previously declined in men and women at the same rate.
Having researched MUS for the last 10 years or so, I’d say that not all medical teaching can be trusted. Our leaders can get things badly wrong, and medicine is not exempt from that. GPs would be wise, I think, to sometimes challenge what they’re being taught, especially if it pushes a strategy or doctrine that could cut NHS costs. What exactly is the evidence that MUS misdiagnosis rates are low? Is prevalence of somatization as high as it’s been made out to be? What percentage of MUS patients are definitely somatising their symptoms? Do we know for sure that continuing to investigate and seek answers causes iatrogenic harm, or are MUS patients being seriously harmed by misdiagnosis and delayed diagnosis instead? Recent research is pointing to the latter for lupus and other autoimmune diseases.
I’m sure there’s a huge problem with the current approach to Long Covid, but I fear it extends much further than that.
So glad you found the energy to respond. After seven long years of being off work for “unknown and rare” side effects post cancer treatment, I was finally diagnosed with ME and POTS. With treatment I made it back to work part time – and I see now what I didn’t see before and was never taught – post viral illnesses such as Long Covid. Her approach is not new – I fired a neurologist I saw for similar thinking.
What the mind can do is alter the way we respond to our symptoms but not the actual syndrome. Once one improves enough with treatment of the underlying illness, then the mental response matters to reach maximal function at that moment in time – in my opinion. So sometimes the mind helps a lot, which is why they mistake it as the cause.
Thanks for responding to her book.
History is littered with the dismissal of symptoms as psychological but where does this come from? And why?
Why would a doctor who went to medical school to “help people” dismiss and not believe or listen to those very people? That is a question I have pondered even more since becoming ill and being at the receiving end of some serious gaslighting and dismissal.
I think there are 2 main factors, fear and institutional issues.
I think fear must be a key driver, imagine if you see a patient, a fellow doctor, me, who used to swim in the sea every week, work long shifts, and had a push scooter in their boot for home visits. Someone who was fit and well, took no medications, was happy, enjoying life and thriving in the challenges of work, loving their jobs. Someone who caught a virus at work and their life was turned upside down, then they had a vaccine which landed them in a wheelchair. Imagine knowing that that could happen to you! The next infection, the next vaccine, life could happen and suddenly you could be unable to get out of bed, crawl to the toilet and lay on the floor for 2 hrs. to recover enough to crawl back to bed.
It makes me wonder if there is something protective to the psyche of some doctors and institutionally, of making it psychological, the patients’ fault. It means that the doctor can convince themselves it wouldn’t happen to them. Because they are “strong.”
The institutional prejudice towards patients is sadly passed down through generations and from the top down with the current focus on those who are unable to work. Further enhanced in a system which is chronically underfunded with staff shortages and no time to look further into poorly understood conditions.
For me the low point was being told CBT and psychotherapy was the only “treatment” for my condition. I have PTSD from a particularly bad encounter that meant I nearly didn’t seek help when I collapsed in SVT. My friend took me into A and E and I was rushed into Resus, if she hadn’t of dragged me there I may have waited it out at home even died. Despite the crushing chest pain and racing heart I was worried I’d be told, again, it was “all in my head”! It turned out it was not and never had been. I’m a doctor and I was in a dark place, doubting myself, how would a “normal” person feel?
Now I’m stronger and that’s why I’m writing this. If people seem, anxious, low, its because fighting to be believed consumes energy and makes us desperate.
I struggle to understand what is happening to my body and explain it clearly. Going to out on a rare occasion. I put my best foot forward, washing my hair (which I’ve had shaved half off, and only wash with conditioner, or have to ask my kids to wash for me) for the first time in a month, putting deodorant over the top of deodorant because its too hard to shower, I put on a clean top and then go to an appointment where I’m asked “why are you using a wheelchair” or told “you look well”. Yes, I can look well for 30 mins or so, but I’m still in pain, yes, I can laugh, because why should I be miserable? I’m not depressed or anxious, but my life is carefully balanced, change one of my tablets and I could be back to being confined to bed.
I’ve met some amazing doctors, the ones who’ve believed me and listened. The difference they’ve made to my life is immense, and I will forever be grateful for those brave enough to admit they don’t know, that there is no cure, that the timeframe is uncertain. Those that are prepared to work with me to manage my symptoms the best way possible, those not afraid to try.
Why would a doctor/some doctors not believe or listen to patients or look further for answers? My guess is because they’ve been taught that they shouldn’t, that they may cause iatrogenic harm and waste valuable NHS/healthcare resources if they do; they’re simply being good little doctors and are doing what they’ve been told to do. That’s a problem with not having or taking the time to scrutinize the evidence. Look closely for yourself and you may reach the same conclusion as I did – that the evidence behind the whole MUS/functional construct that doctors have been taught to follow falls woefully short.