by Derek Thompson
America is sicker than ever. That’s what the data say, anyway.
Psychological and psychiatric diagnoses have soared in the last few decades, including depression, anxiety, bipolar, PTSD, Tourette's, and eating disorders. Since the 1990s, the number of children diagnosed with ADHD has increased by a factor of seven, and autism has grown by a factor of sixty.
What accounts for this across-the-board upsurge? Maybe we are being poisoned by modern life—its food, its chemicals, its screen time. Maybe doctors are getting better at seeing what was always in front of their noses. For example, many new mothers experiencing severe mood disturbances were once dismissed as having trivial “baby blues,” but now psychologists recognize and treat postpartum depression with considerable success.
There is a third possibility. Perhaps the rise in diagnoses isn’t just about more illness or more symptoms. It’s about more diagnosis. It’s about a modern culture that has expanded its definition of illness and now pathologizes behavior that we used to consider normal. For many Americans, perhaps, what we used to call forgetfulness is now labeled ADHD. What we used to call a lack of motivation is now labeled depression. What we used to call nervousness is now clinical social anxiety. What we used to call awkwardness is now labeled autism. In this telling, it’s not our biology or our psychology that has changed. It’s our words.
The Age of Diagnosis
Several years ago, the Irish neurologist Suzanne O’Sullivan noticed young people arriving at her office who already had multiple chronic psychological conditions, including anxiety, PTSD, and autism. But rather than guide them toward better treatments, these labels seemed to trap her young patients in cycles of pain. “Medical diagnosis is supposed to identify a problem so that you can be supported [and] you can feel better,” she told me in this week’s episode of my podcast Plain English. “But instead, I'm seeing people accruing long lists of medical diagnoses, and they're not getting any better. The labels are not helping. We don't have happier, better-adjusted adults. We actually have worse mental health in adults.”
In her book The Age of Diagnosis, O’Sullivan argues that many of the psychiatric “epidemics” we talk about are not the result of more sickness. They’re the result of broadened definitions of sickness. Take autism, for example. The US Secretary of Health and Human Services, Robert F. Kennedy Jr, has insisted that the surge in autism in the last few decades could justify banning vaccines or other common chemicals. But as O’Sullivan points out, the number of people with profound autism has not increased. The clearest account for the rise in autism is that the medical field has broadened the definition of autism to include milder versions. “All of the diagnostic inflation has happened at the mild end of the spectrum,” O’Sullivan said. “There's nothing scientific about it. We made a societal decision to increase autism diagnoses.”
ADHD might be a similar story. I had long assumed that the rise of ADHD, like the surge in teen anxiety, might be significantly caused by phones and social media. O’Sullivan doesn’t entirely deny that possibility. But she also points out that when ADHD was first recognized, it applied almost exclusively to the most restless young boys. Over time, however, the definition was deliberately loosened in the DSM, the Bible of psychiatric diagnostics, and what began as a narrow label for the most severely affected children is now an umbrella under which millions of mostly well-functioning adults can plausibly fit. Today, she argues, ADHD has become not only a medical condition but also “a culturally acceptable way of expressing distress”—not to mention, a key that unlocks disability accommodations in schools and workplaces.
There are all sorts of ways you could present the Age of Diagnosis theory as straightforward bad-guy story. You could say psychiatrists are neurotic, and Big Pharma is a racket, and modern patients are wimps, and we live in a fallen society that blindly medicalizes every trivial moment of half-suffering. But O’Sullivan rejects the simplest interpretations, and I think she’s wise to do so. “We started out before the 1980s in a period with a lot of under-diagnosis, [where] people with special learning needs weren't recognized,” she said. “There was a deliberate decision on the part of the medical community to adjust diagnostic criteria to find milder sufferers.” The shift was well-intentioned, and it has surely given millions of people relief by giving them access to medicine and care or by attaching words to their once-inchoate suffering.
But what worries me about the age of diagnosis is that the words we use don’t just define us. They can also confine us. “There are stories that save us, and stories that trap us,” the author Rachel Aviv wrote Strangers to Ourselves, her book on the connection between diagnosis and identity. “In the midst of an illness it can be very hard to know which is which.” Decades ago, ADHD was considered a “recovery identity” for adolescents to grow out of, O’Sullivan said. Most of them did grow out of it. But today, as Ritalin prescriptions rise fastest among adults, ADHD is not just a recovery identity. It can be a grownup identity, a full-blown personality, even a predestination. “In order to get better, you have to believe that getting better is possible, and I fear that these over-biological explanations for [our] difficulties give [patients] the impression they have no control,” O’Sullivan said. But that’s wrong. “Actually, they have considerable control.”
The Age of Detection
At the same time that our diagnostic rules have broadened, our detection tools have sharpened. There has been a revolution in disease detection, including blood tests, biomarker panels, protein tests, and genetic screenings. We are better at finding and predicting illnesses as varied as cancer, hypertension, endometriosis, and heart disease.
The upsurge in detection technology is saving lives. Since colonoscopies were scaled up in the late 20th century, age-adjusted colorectal mortality in the U.S. has declined by 50 percent. That’s extraordinary. But the age of detection has also been an age of over-detection. We are finding more deathly disease, but we are also finding more abnormalities that will never lead to death. Many prostate tests, mammograms, and other screenings reveal “incidental” growths that cause no harm. Genetic screenings that uncover a predisposition to a certain deadly disease can prepare individuals for a lifetime of waiting around for a death sentence that never comes. In some cases, the price of longevity is a life of neurotic worry.
In their book Overdiagnosed, co-authors H. Gilbert Welch, Lisa Schwartz, and Steven Woloshin describe the way that over-detection can change the texture of life for otherwise healthy people. A healthy forty-something runner wakes at 5 a.m. daily to do finger-stick checks for blood sugar levels, which, after thousands of pricks, finds nothing. Another patient discovers a tiny adrenal mass and, after years of scans and surgeries, learns that it’s benign. “We’ve turned the pursuit of health into its own burden,” they write.
The science of detection could not be more personal for me. My parents both died of cancers that were untreatable by the time they were discovered. Both died within two years of the cancer diagnosis. By my mid-30s, I decided that I wanted to make early detection a pillar of my health plan, next to diet and exercise. I got a Prenuvo full-body MRI and went over the results with a counselor. I planned to get more preventive MRI scans every two years.
Around the time I was researching the merits of Prenuvo, I came across the story of Korea’s thyroid cancer campaign. In the early 2000s, Korea encouraged mass ultrasound screenings for its citizens, leading to a 15x increase in the national thyroid-cancer rate. But underlying mortality didn’t change. When it was clear the tests were just highlighting subclinical disease, the government ordered many of the machines to be taken away. Thyroid-cancer incidence plunged, and, again, the mortality rate didn’t change. Did the thyroid-cancer awareness campaign save some lives? Maybe. But it mostly made thousands and thousands of people think they had cancer that they didn’t actually have.
I haven’t decided what to do about my own full-body MRI screenings. I’ve read the research suggesting that the discovery of tiny nodules and cysts might drive me crazy without saving me one minute of life. I’ve read the stories about how random screenings—say, following a car accident—have discovered subtle cancerous growths whose early detection saved the patient’s lives. I haven’t made up my mind, yet. But there are millions and millions of people like me who, in this age of detection, face an existential question, whether or not they recognize it: When our ability to detect biological abnormality outruns our ability to understand and to treat it, how much detection is too much?
The Medicalization of Identity
Health is political these days, but the politics of over-diagnosis and over-detection cut in several directions.
Suzanne O’Sullivan’s argument has mostly caught flack from the left. Negative reviews of her book have argued that she’s wrong to question diagnoses of Long COVID and that shifting the culprit of rising anxiety toward diagnosticians downplays young people’s suffering. But her arguments also push back on the right. For example, the MAHA/MAGA/right-wing coalition seems certain that vaccines and chemicals are driving an “epidemic” in autism. Joe Rogan has mused that “one in every 12 kids who's a boy in California has autism now” because “California … has one of the strictest fucking vaccine policies.” But as O’Sullivan told me, we know “with a hundred percent certainty” that vaccines don't cause autism, because the question has been so exhaustively researched. RKF Jr. is trying to end a fake epidemic by banning vaccines that stop real epidemics.
But more than the politics, I am interested in the psychology of the age of diagnosis. The most famous motto in modern medicine is Primum non nocere, or first do no harm. But when doctors turn healthy people into patients, it’s not always clear if they’re reducing the risk of future disease or introducing anxiety and potentially harmful treatments to a patient who’s basically fine. There are no easy answers here, only tradeoffs:
Expanded ADHD diagnosis will put Ritalin in the pockets and medicine cabinets of millions of people, many of whom will find it helps them focus. It may also lock hundreds of thousands of people inside a medicalized identity that makes it harder for them to address the fundamental factors behind their restlessness.
As prostate cancer screens have expanded, more patient lives have been saved with early detection. But a significant number of tumors that pop up in these tests are benign or too small to ever cause symptoms or death, while unnecessary surgeries to remove them can result in impotence and incontinence.
At its best, diagnosis is a gift. There is a kind of magic in matching words to pain. When faced with life’s most profound questions—What is this hurt? Why have I lost control of my mind or body? What is my loved one suffering?—modern medicine can perform miracles when our remedies match our maladies. But O’Sullivan’s warning is that our maladies were never meant to be our identities. We used to get support and guidance from real-world communities, including church and institutions, O’Sullivan said. “Where do you go if you want to feel cared for? Where do you go if you want to feel supported?” O’Sullivan said. “Today, well, you go to your doctor.” With religion and community in retreat, we go to where the light is on to answer life's biggest questions. At the doctor’s office, the light is on.
https://www.derekthompson.org/p/the-age-of-diagnosis-how-the-over
