America in the Age of Diagnosis

Summary

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Podcast Summary: Plain English with Derek Thompson

Episode: America in the Age of Diagnosis

Date: September 9, 2025
Guest: Suzanne O’Sullivan, neurologist & author of "The Age of Diagnosis"

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Overview

In this episode, Derek Thompson sits down with neurologist Suzanne O’Sullivan to discuss the explosion of medical diagnoses in America and other western countries. The conversation explores why rates of autism, ADHD, depression, anxiety, and other medical conditions have soared—not necessarily because these conditions are more common, but because definitions and diagnostic criteria have broadened dramatically. The episode critically examines what O’Sullivan calls “the age of diagnosis”: the social, medical, and cultural forces driving overdiagnosis, the costs to individuals and society, and how this modern phenomenon affects our identities and perceptions of health.

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Key Discussion Points & Insights

The Rise of Diagnosis: Context and Trends

• Derek opens by citing rapidly increasing diagnoses in America:

  • Autism: up nearly 60-fold since the 1990s
  • Bipolar disorder: 40x increase among American youth (1990s-2000s)
  • ADHD: 7x more adolescent diagnoses since 1990
  • PTSD and depression: sharp recent rises ([02:19])

• Main Thesis: The increase in diagnoses often reflects not more disease, but more labeling of what used to be considered normal variation or mild issues ([04:55]).

  • “We used to be merely forgetful. Now we have ADHD. We used to lack motivation. Now we're depressed.” (Derek, [04:55])

Suzanne O’Sullivan’s Clinical Perspective

• Clinical change: O’Sullivan describes patients, especially young people, now arriving with multiple overlapping chronic diagnoses—ADHD, migraines, anxiety, depression, and more ([07:57]):

  • “What worries me... is that people are accruing kind of long lists of medical diagnoses, and they're not getting any better. Their lives don't seem to be being made easier. Their symptoms don't seem to be alleviated.” (O’Sullivan, [08:50])

• Questioning the purpose of diagnosis:

  • Medical diagnosis is meant to help and support, but over-medicalization may be failing to provide real benefit.

Diagnostic Inflation: ADHD & Autism

• ADHD Case Study ([09:40]):

  • Expansion from hyperactive children (1960s) to adults and milder forms over time.
  • The DSM (Diagnostic and Statistical Manual) regularly broadens ADHD criteria ([12:55]):
    • “Every time a new version of DSM comes out, it slightly tweaks what it means to have ADHD deliberately in order to make the diagnosis available to new sets of people.” (O’Sullivan, [12:55])
  • ADHD now serves as a “culturally acceptable way of expressing distress” and accessing support ([13:50]).

• Autism Case Study ([15:13]):

  • Growth in autism diagnosis is “all at the mild end of the spectrum.”
  • No objective marker for autism or ADHD; they are “collections of symptoms.”
  • Societal changes have systematically shifted diagnosis boundaries, especially via gendered reinterpretations (e.g., looking for autism in girls by retrofitting new behaviors into the definition).

The Age of Diagnosis: What Drives It?

1. Deliberate Broadening in Medicine ([19:12]):

   • Medical community’s well-intentioned aim to pick up milder forms of disease leads to increased diagnosis but not necessarily better outcomes.
   • “We have more and more diagnoses based on the assumption that we can help more people if we diagnose more people. But I'm afraid that assumption [is] proving to be wrong in many ways.” (O’Sullivan, [20:49])

2. Societal Demand for Explanations & Certainty:

   • People seek answers for everyday imperfection and distress (e.g., pain, sadness), pushing doctors to label more experiences as medical problems.
   • Derek: “We used to turn to priests for who we are. Now we turn to the DSM…” ([23:29])

3. Institutional and Parental Incentives:

   • Diagnoses can unlock accommodations and resources in schools, further fueling demand.

4. Role of Culture and Pharma ([24:21]):

   • O’Sullivan acknowledges some influence but pushes back against the idea it’s an orchestrated conspiracy: “We are begging for it. Also... technology and scientists and researchers and profit makers are responding to something that we are desperate for.” (O’Sullivan, [24:41])

Costs of Overdiagnosis

To the Body: Overcare and Overtreatment

• Cancer screening case studies ([25:55]):

  • Overdiagnosis during routine screenings leads to unnecessary interventions, biopsies, surgeries, anxiety, and sometimes harm.
  • Study cited: Screening millions for cancer generally did not reduce overall mortality except for colon cancer.
  • “You will help one individual and you will harm other individuals...” (O’Sullivan, [29:14])
  • Introduction of the term “incidentaloma” — accidental, often irrelevant findings in healthy people that lead to further tests and anxiety ([35:25]):
    • “I instruct patients quite blankly, not to have whole body scans, if the truth be known. … It’s almost impossible to get a completely normal array of test results back on someone once they get into middle age.” (O’Sullivan, [35:25])

• South Korea’s thyroid cancer screening ([32:26]):

  • Incidence skyrocketed, but mortality did not change, later plummeting after reducing screening rates.

To Identity and Agency

• Diagnosis as Destiny:
  • Diagnoses, once “recovery identities,” now become lifelong labels that can limit self-esteem and agency, especially in youth ([39:39]):
    • “If you explain problems that people are having through medical illness, you potentially make those problems concrete... It can become a sort of self-fulfilling prophecy that stops people from getting better.” (O’Sullivan, [40:04])
  • Risks of forming communities based on medical identity, which disincentivizes recovery.

Counterpoints & Nuance

• What if “the Age of Sickness” is real? ([43:13])

  • Derek challenges O’Sullivan: Could it be that diagnosis is merely catching up to rising rates of sickness caused by modern life?
  • O’Sullivan replies that actual symptoms (like for ADHD) have not risen in tandem with diagnosis rates, often due to increased self-monitoring and awareness, not true prevalence.

• Potential Psychological Benefits of Diagnosis ([46:57]):

  • O’Sullivan agrees some people are empowered by diagnoses (feel validated, treat themselves more kindly), but questions if medicalization is the best or only way to provide that validation or support.
  • “You were never a terrible person. We need to create a society where we’re a little bit kinder to ourselves without the need for medical explanation.” (O’Sullivan, [48:30])
  • Warns overdiagnosis diverts resources and trivializes serious disorders.

Politics of Diagnosis

• Both left and right have interests in the diagnosis debate:
  • Left often defends the expansion of neurodivergent or Long Covid diagnoses; right has promoted conspiracy theories about vaccines causing autism ([50:40]).
  • O’Sullivan: “If there’s one thing we know with 100% certainty, it’s that vaccines don’t cause autism.” ([52:14])
  • The social contagion of diagnostic seeking may reflect unmet needs, not necessarily a medical reality.

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Memorable Quotes & Moments

• On the nature of diagnosis:

  • “We are not getting sicker. We are attributing more to sickness.” — Derek ([04:47])
  • “There is no single brain scan abnormality [that] will tell you that somebody has ADHD or autism. There is no test you can do. ... They are collections of symptoms.” — O’Sullivan ([15:31])

• On the societal quest for a diagnosis:

  • “We used to go to priests to know how we fit into a community, and now we go to doctors to learn how we fit into diagnoses.” — Derek ([06:21])

• On overtreatment:

  • “You do enough blood tests, you do enough scans, you’ll find lots of little incidental findings.” — O’Sullivan ([36:20])

• On the trade-off of longevity and anxiety:

  • “Is a good life one in which you live to 100 but for the last 20 years of it you are on multiple different tablets and having endless, endless amounts of tablets, tests?... We should be aiming to be as well as possible for as long as possible, but live a full life rather than a long life.” — O’Sullivan ([55:18])

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Notable Segment Timestamps

• [02:19] — Framing the age of diagnosis: rising labels, not necessarily rising disease.
• [07:57] — O’Sullivan’s clinical worries: “tsunami” of diagnoses, overlapping, not alleviating suffering.
• [09:40] — ADHD as an evolving, inflationary diagnosis in both US and UK.
• [15:13] — Autism: all recent diagnostic expansion is at the milder end, powered by shifting social definitions.
• [19:12] — The deliberate medical and social expansion of diagnostic categories.
• [25:55] — Costs of overdiagnosis: breast/prostate cancer screenings and iatrogenic harm.
• [32:26] — South Korea’s thyroid cancer screening experiment—incidence up, mortality flat.
• [39:39] — Identity and agency under threat: diagnoses as lifelong markers not paths to recovery.
• [46:57] — The psychological upside of diagnosis, but at what collective cost?
• [50:40] — Diagnosis and politics: left and right, anti-vax, and the culture war.
• [53:21] — Philosophy of diagnosis: The trade-off between anxiety and longevity, "priests versus doctors."

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Tone

The conversation is clear, inquisitive, and thoughtful. O’Sullivan is measured, deeply informed, and careful not to diminish legitimate suffering, while Derek brings a journalistic curiosity and a willingness to challenge both guest and listener to consider all sides of a controversial issue.

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Closing Reflection

O’Sullivan and Thompson close by reflecting on what makes a good life in the age of diagnosis. They agree that living longer should not come at the cost of living perpetually as medical patients, anxious and overly medically managed. The conversation urges listeners to balance our desire for answers and certainty with an appreciation of normal human variation, and to ask whether medical labels are always the best—or only—path to relief, support, or a sense of self.

Transcript

[A]

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[B]

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[C]

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[B]

Today Sickness and Identity in the Age of Diagnosis I've been thinking a lot recently about health and language, the illnesses we have and the words we use to describe them. Robert F. Kennedy, Jr. Has been fixated for decades on the rise of autism in America. Since becoming health secretary, he's made it a priority to discover the environmental causes behind autism, which by one account has grown nearly 60 fold since the 1990s. This increase in autism could be the result of several things. It could be a real epidemic caused by vaccines or environmental factors, the chemicals in our food and drugs. This is the bet that Kennedy himself is making. Last week, the Wall Street Journal reported that Kennedy is set to release a report that suggests a link between Tylenol use during pregnancy and autism. But scientists have looked into this for decades, and it's been very, very difficult for any solid study to identify a correlation between autism and vaccines or pollutants or Tylenol. Another explanation is that the rise in autism is mostly about an explosion in diagnosis. Here, the evidence is much stronger. Several studies from around the world suggest there's been no meaningful increase in the symptoms of autism, while rates themselves have surged. In other words, autism itself might not be increasing. It's just our diagnoses of autism that are rising by a factor of 60. In July, the New York Times writer David Wallace Wells pointed out that autism is far from the only diagnosis experiencing hyperinflation in America and throughout the Western world. Between the 1990s and the mid 2000s, bipolar disorder among American youth grew by about 40 fold. Since 1990, the number of adolescents diagnosed with ADHD has increased by a factor of seven. Since 2017, rates of PTSD among college students have doubled. And since 2015, Americans report 50% higher rates of depression and anxiety. As with autism, several things can be true here, and maybe several of them are true at the same time. Maybe Americans are sicker than they used to be. Maybe in previous decades, doctors were missing millions of cases of psychological illness that we're now catching. Or perhaps, as David writes, borderline medical problems are becoming ironclad diagnoses and normal differences are being pathologized. These statistics could indicate that ordinary life experiences, bodily imperfections, sadness, and social anxiety are being subsumed into the category of mental disorder. In other words, we are not getting sicker. We are attributing more to sickness. We used to be merely forgetful. Now we have adhd. We used to lack motivation. Now we're depressed. We used to be introverted, and now we experience social anxiety. We used to feel awkward. Now we call it autism. Today's guest is Suzanne o', Sullivan, a neurologist and the author of the Age of How Our Obsession with Medical Labels Is Making Us Sicker. O' Sullivan argues that too many doctors today are pathologizing common symptoms in a way that's changing the experience of the body for the worse. 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. Rather than see this age of diagnosis as something all good or all bad, a mitzvah or a new disease, I want to see it as a social phenomenon, something that is good and bad and all around us. As o' Sullivan says, we used to go to priests to know how we fit into a community, and now we go to doctors to learn how we fit into diagnoses. While this shift might in some cases help us forestall death, she says it can also keep us from living a fuller life. I'm Derek Thompson. This is plain English. Suzanne o'. Sullivan. Welcome to the show.

[D]

Thanks for having me.

[B]

I am so excited to have you here. This is a conversation I've wanted to have, a podcast I've wanted to produce for a long, long time. I want to start with your very personal experience. You've been a doctor for more than 30 years. You've been a neurologist for 25 years. And in your book, you write that something has changed in those decades. There's been a startling rise in people arriving at your office who have already been diagnosed with four, sometimes five chronic conditions. We're talking about autism, Tourette's, adhd, migraines, depression, eating disorders, anxiety. Before we get into theory, before we even begin to try to explain what's going on here, I'd love you to just tell me as a clinician, what have you seen? How would you describe this tsunami of diagnosis?

[D]

Yeah, I mean, it is precisely because of my experience and the work I do with patients that I'm really worried about this. So, as you say, you know, I qualified in Medicine in 1991. I've seen a lot of patients. I'm in full time clinical practice, and I've seen this sort of trend that is really, really worrying me. And it's really peaking over the last 10 years. And that's where you have often very, very young people coming to see you. And they already have an ex kind of list of two or three medical diagnoses. And oftentimes those diagnoses have very overlapping symptoms. So oftentimes it even feels like people are getting multiple different diagnoses for the same problem. And what worries me more about that trend is, you know, what is the purpose of diagnosis? Well, medical diagnosis is supposed to identify a problem so that you can be supported to make your life easier, or you can be cured, or you can meet a group of people who will make you feel supported through, through their shared experience, et cetera. And all of this should be making people feel better, but instead, what I'm seeing is people getting accruing kind of long lists of medical diagnoses, and they're not getting any Better. Their lives don't seem to be being made easier. Their symptoms don't seem to be being alleviated. So I feel like we're falling into medicalization that's potentially not necessarily labeling people who are not suffering, but those labels are not helping. And that's the problem with over medicalization and over diagnosis. It is not to say that a person isn't suffering. It is not to say that a person doesn't need support. It asks the questions whether medical labels and medical treatment is the right kind of support.

[B]

Let's zoom in on a really specific example here. Adhd. You've seen patients with ADHD for decades, but in the uk, as in the us, there's been a huge increase in diagnosis. I think the UK, I read, has seen a 400% increase in adults seeking an ADHD diagnosis just in the last few years. Now, one possibility is that actual ADHD is skyrocketing. Another possibility is that underlying conditions are essentially flat and we are surging not the underlying phenomenon, but our diagnoses sticking with adhd. First, before we begin to broaden this theory, what do you think is going on here?

[D]

Okay, well, let's look at the trajectory of ADHD to try and understand it a little bit. So when I qualified as a doctor, ADHD only was diagnosed in children and it was predominantly manifested as hyperactivity. It was first kind of conceptualized as a disorder in the 1960s, late 1960s, it was called hyperkinetic reaction of children. It causes restlessness that tended to go away in adolescence. Now, what happens with a medical diagnosis when you create it is first it identifies the most typical sufferers and usually the most severe sufferers. In those 1960s 70s ADHD children, it wasn't called that then, but those children were very hyperkinetic, very hyperactive. You know, they could not settle at all. And they would have been evidently hyperactive to anybody who met them. Now, what happens when you create a diagnosis like that is that people say, okay, well, maybe this comes in milder forms. And that's pretty much what's been happening over the last 50 years, is that doctors have been redefining what it means to have ADHD in order to find people with milder forms of it. And this is like a really well meaning, well intentioned thing. So you assume that, you know, you in the first instance are only helping really severely disabled children, but maybe if you can find moderately disabled children, they will benefit as well. And then you say, well, maybe if you can find even milder symptoms and you help them they will benefit even more. So, quite literally, ADHD has been renamed and redefined with the deliberate attempt of finding people with milder forms of that disorder. And the way you read it, find these things, is begin with quite extreme symptoms and they have to be present in a child who's under a certain age. And then you say, well, maybe it happens to older children, let's move that age upwards. And maybe the symptoms aren't all hyperactivity, maybe you just have attentional difficulties. So you keep just massaging the symptoms, raising the age at which the diagnosis can be made. And every time. I'm sure people are familiar with the Diagnostic and Statistical Manual of Mental Health Disorders, which is where disorders like ADHD are defined and everything.

[B]

We have lots of listeners in lots of different areas. But I'll just say very quickly, by means of definition, the DSM 5 is like the bible of psychological diagnosis, right? It's the bible that tells doctors in the English speaking world, or maybe just throughout the industrialized world. It's everywhere. So I just want to make sure that people are on the same page there.

[D]

It's essentially a cyclopedia, that encyclopedia that describes what symptoms you need to have to have a mental health diagnosis. And there's a new version of it every few years. And every time a new version of DSM comes out, it slightly tweaks what it means to have ADHD deliberately in order to make the diagnosis available to new sets of people. So I would say that's why we have seen this explosion in the number of people with ADHD is because the change in definition in the DSM has allowed the diagnosis in greater groups of people. But also in recent times there's been a particular explosion. And that's because it has become a culturally acceptable way of expressing distress and saying you're struggling and asking for help. And because it has become such an ill defined and kind of woolly defined condition, it has become an explanation through which people can get support in a lot of schools now in order to get extra time or things that you feel you need, you need a medical diagnosis to get those things. So it's sort of combination of a medical, which was well intentioned, on which the kind of society has jumped to sort of amplify that through awareness campaigns and through help seeking, through this as a sort of means of getting help.

[B]

You put your finger on something I have found so interesting for a while, which is diagnostic inflation, this idea that we're expanding the definition of a disease to not only account for more people as in the case of adhd, not just children, but also adults, but also to include forms of a disease so mild that they begin to approach the category of actually practically normal. And I want to expand this conversation away from ADHD right now to talk about another diagnosis that you look at, which is autism, which is similar in some ways. There's been staggering increases in the number of people diagnosed with autism in the last few decades. But I read from your work that most of that growth is on the milder end of the spectrum. So maybe tell us a bit about how the autism story and the ADHD story fit together in a way that might build up toward a larger thesis here.

[D]

So let's imagine that. So we all can are aware that autism. There is a great many more people with autism in the world than there used to be, because most of us didn't know many people with autism, and now I think most of us know many people with this diagnosis. So we can see the growth is there. So the first possibility is that autism itself is becoming more common. Common for whatever reason. I don't believe there's any good evidence to say that the actual set of symptoms that are autism. We're talking about woolly things here. We've got to remember, because there's no objective evidence that ADHD or autism are discrete disorders. There's no single brain scan abnormality will tell you that somebody has ADHD or autism. There is no test you can do. It's really. They are collections of symptoms. So we're dealing with things that are hard to define to start with. But if we really had a substantial increase in the number of people with autism, we would expect people with profound autism, with severe autism, with profound needs. So we're talking about people that have very substantial behavioral problems that anybody could see without needing to be a doctor or needing to do an assessment. Those people have not increased in number. All of the diagnostic inflation happens at the mild end of the spectrum. And this is where we're trying to. To draw the line between what is normal and what isn't. And let's face it, nobody can draw that line. You know, where does normal begin and end? Nobody knows. But the line has been gradually shifting to draw in more and more people who would 10 years ago, unequivocally not have been diagnosed as autistic. And this is a really conscious thing that happens. You know, there's nothing sort of very scientific about it. It's more of a societal decision that we think we're not making enough diagnos. This set of people. So let's tweak the diagnosis to allow us to do that. So let's, for example, think about how the diagnosis has changed in women, for example. So 1940s autism was a very severe communication disorder that mostly happened in people with learning disabilities. In the 1960s, somebody said, hey, maybe there's more milder versions. So let's call it a spectrum disorder. So there's severe and mild versions. Then over the next 20 years, people adjusted the age to allow the diagnosis in older and older people. And now what's happening is people saying, hey, we're making this diagnosis a lot in men, but we're not making it enough in women. We must be missing women. So then they apply the existing diagnostic criteria to women, and they find, oh, well, they don't seem to have a lot of autism according to these criteria. Maybe we find a few extra people that way, but not a lot of extra people. So then they say, okay, so maybe autism looks different in women. So then it's literally a case of looking at young women or girls and saying, well, you know, I noticed the girls flit from group to group in a playground. Perhaps that's how autism manifests in women. Maybe instead of having deep friendships, they flip between groups. So it's literally. It's a bizarre kind of process of looking at behavior and retrofitting it to the diagnosis. There's nothing scientific going on here. So there is a theory that women have a different type of autism, and then a group of scientists create what that different kind of autism is based on looking at female behavior, and then they find a whole new group with autism. It's not based on we went out and did a bunch of scans, or we applied the previous criteria. We found lots of people. You know, criteria are deliberately changed in order to allow us to make more diagnoses.

[B]

You call the phenomenon that we're living through, the age of diagnosis. The name of your book is the age of diagnosis. Sickness, Health, and why Medicine has gone too Far. What is the age of diagnosis? What is in the air that you're trying to put your finger on here?

[D]

Well, I think that basically what we. I often think so. Very often, when people look at diagnostic inflation, they think there's some sort of subterfuge happening. Pharmaceutical companies are out to get us, Researchers, private doctors are trying to make money from us and so forth. I'm not saying that neither of those two things are true, but I think we started out with a period, say, pre1980s. Pre1970s where there was a lot of under diagnosis. People with special learning needs weren't recognized. People with diabetes, you know, they were blind before they got to the doctor and discovered they had diabetes. People were having strokes before anyone tested their blood pressure, et cetera. So things were being under mild suffering or hard to explain suffering was not being diagnosed. People were going to the doctor too late. So we thought, let's work harder at trying to find more and more diagnosis. And that's been a big driver of this. So this is why way more people have hypertension, way more people have pre diabetes, way more people have autism, adhd. Because there was a deliberate decision on part of the medical community to adjust diagnostic criteria to find milder sufferers. And that's well intentioned and it sounds terribly sensible because it does seem to make sense. If somebody will benefit from the treatment at this end of the spectrum, then surely the person at the milder end of the spectrum might benefit even more. I'm afraid those assumptions though, are not held up by reality. If we go back to the ADHD and autism example, the theory is you find these milder and milder and milder and milder forms and you recognize them and you give them the diagnosis and you help them. Well, what's the purpose of that? The purpose of that is that now you have happier, better adjusted adults. We don't have happier, better adjusted adults. We actually have worse mental health in adults, you know, so this, we have more and more diagnosis based on the assumption that we can help more people if we diagnose more people. But I'm afraid that assumption proving to be wrong in many ways. I also think the diagnosis has increasingly grown because we, our society, we like explanations for things. You know, we like to know why, what is this? What is this pain? Why do I feel this way? As we age, our bodies, you know, betray us all the time. We like to know answers. And you know what? 50 years ago, if you came to me with a headache, you know, I could do one test probably. Now if you come to me with a headache, I can do a whole range of tests. So you're looking for answers. I have a huge number of things I can do to try and help you get answers. So I think it's a really multifactorial thing. It's a kind of a. Science is advancing, technology is advancing, society is desperate for answers. Society is perfectionist. Why am I not able to do the thing I'd like to do? And science is responding to that as well. So it's really society is kind of mixing together with our technical abilities to create this age of diagnosis. I would say I wonder how you.

[B]

Would edit this attempt to explain some of the drivers of the age of diagnosis. And this is cobbled together both from my reading your book and just listening to right now as I was editing some of my notes. Number one, psychologists, well intentioned and even humane changes to the DSM have broadened these definitions and that has pulled in a lot more diagnoses. Number two, parents. I think with the politics of accommodation, for example, it's easier to get your children certain accommodations, extensions, longer times to take tests if you get that diagnosis for ADHD or if you get that diagnosis for some other hyperactive diagnosis. Number three, the medical community. Maybe there's financial incentives to overmedicate and they might be driving some of the urge to expand diagnoses. And number four, I love that you put your finger on this, even though I think it's a little bit touchy feely. I do think we live in a culture that prizes a certain kind of certainty about identity. Right. Who am I? These are questions that we used to turn to priests for or philosophers for. And now we can turn to the dsm, we can turn to a psychiatrist, we can turn to our doctors and they can tell us who you are is not a confused and scared person who can't name their underlying symptoms. You are adhd, you are autistic, you are someone who suffers from generalized anxiety disorder. And for many people, I think these terms provide a sense of clarity that might come with certain risks that we'll talk about in a bit, but also come with this beautiful aesthetic. Aha. Oh, that's who I am. That's why I have suffered. So in thinking about the drivers of the age of diagnosis, we've got psychologists on the table, parents, the medical community, culture. Any big thing I've missed here?

[D]

No, I think you've covered it quite well. But what I always want to emphasize is because I often feel like people feel like the diagnosis is something that is being done to us. Whereas I think as a society it's very important we understand that we are begging for it. Also there are people, technology and scientists and researchers and profit makers are responding to something that we are desperate for. But I think you've covered all the main drivers, but obviously we also include a little bit of that. Pharmaceutical companies do have to play a little bit of a role in that, but I don't think they have as big a role as people think they do.

[B]

Let's talk about the Costs of overdiagnosis. Because there wouldn't be any reason really to have this conversation if there were no downsides to this phenomenon. I want to break this part of the discussion into two categories. One is the cost to our bodies when we combine over diagnosis with over medication. And the other is the cost to something harder to put our finger on, like our identities or ourselves. So let's start with the first. For certain conditions you write in your book, the cost of overdiagnosis is measured in over care. Perhaps one third of breast cancer treatments are unnecessary, which means those patients are incurring risks that they simply don't have to incur. There's evidence that prostate cancer screening programs have saved relatively few lives, but incurred many unnecessary surgeries. How would you fill out this story of the cost to our bodies of over diagnosis and over medication?

[D]

Yeah. So if we think about cancer screening now, I always like to be super clear. The difference between a cancer found on screening and a symptomatic cancer. So symptomatic cancer means you found a lump, there's blood, there's pain, had a symptom that led to your diagnosis, that type of cancer that always needs to be treated urgently. But the type of cancer that is subject to over diagnosis is cancer that's found in a perfectly healthy person because you screen them. So let's say mammography for breast cancer for women or PSA tests for the prostate in men. There is over diagnosis built into every one of these kind of screening programs. So let's say that you screen 1000 men for prostate cancer using the PSA test, you may, by some people's measure save one life. Some people would say you save no lives by doing this. But what you will do is for sure is find in the region of 200, 250 men who have an elevated PSA. And now the minute that happens, they won't all have cancer. But the minute you found that test, okay, now what are you going to do with it? So now you're going to have to investigate them further to see whether that elevated PSA is due to something innocent. You know, prostates can be enlarged for non cancerous reasons, for example. So now you've got a test you've got to pursue. A percentage of those 250, not all of them, but a percentage of them will be suspected to have cancer and they'll have to have biopsies. I'm not a man. I have never had a prostate biopsy. But it certainly is not a pleasant investigation. It comes with complications like Bleeding and infection, which can occasionally be serious. So that's a deeply unpleasant test. A proportion of those 250 will ultimately be diagnosed with cancer. But cancer's so small and so slow growing, it doesn't need to be treated. But now they're living with cancer and they will have to have that screened regularly over a period of time. A percentage of that 250 will be told they have cancer and they will need an operation and radiotherapy. All of those 250 men have been subject to all of that to perhaps save one life from cancer. So that's a lot of tests and that's a lot of psychological anxiety and that's a lot of negative impact in the body through unnecessary tests and treatment. And it's quite interesting. There was a study, I think now I'm going to forget where it was published. I think it was Journal of American Medical association in 2023. And they looked at millions of people that had been subject to cancer screening programs for various cancers like colon, prostate, breast, et cetera. And they looked to see if they had reduced all cause mortality. So the theory would be you screen all these people for cancer, you must be saving some lives. And what they found in that study was with the exception of colon cancer, they didn't save any lives. Colon cancer, they may have prolonged life by three months, but in the other groups they didn't prolong life. And the way you explain that is that yes, they will have saved somebody. There will be somebody in there who had a cancer that would have killed them if they hadn't found it. But that life saved has been offset by the 20 people who had cancer treatment, who didn't need it, and how that negatively affected their lives. So you will help one individual and you will harm other individuals. And again, I probably need to explain that a little also as we age, we all have abnormal cells in our body. And we know now from autopsy studies, et cetera, and we know from MRI studies that lots of us, abnormal cancer cells that never grow or progress or lead to anything. We only know that now because we have the technology to know that. It's always been the case. But now that we have the technology to find these abnormal cells, we feel compelled to act on them. And that's where all this over diagnosis is arising from. We're finding things that people used to die not knowing they had, and we're treating them.

[B]

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[E]

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[B]

Just to put a fine point on the last thing you said, you're saying we now have the ability to cut into cadavers and essentially find cysts and little growths that a perfect full body MRI machine might have caught at the age of 45 or 50 and said, oh, this person has cancer. But if that machine could somehow see into the future, it would recognize that the patient would die having experienced no symptoms of that cyst or that minor growth that was caught in the full body MRI machine. So I want to make this a little bit personal for me, which is that I find this subject so Interesting and so rich because both my parents died of cancer in my 20s. My mom died of pancreatic cancer, and then my father just a few years later died of a very rare vascular cancer. And both examples were cancers that, if they had been caught earlier, would have been treatable. So in my mid-30s, I did one of those pre nouveau whole body MRI machine scans where it looks for cancer and other disease screening things. It didn't find anything, but I'm the kind of person who is alert to wanting to find some detection of early cancer in my body. And I was in this period of researching how I should do this. But I came across an example of something I know you know about, which is South Korea's famous experience with ultrasounds to catch thyroid cancers between the late 1990s and early 2010s. And this is an amazing story for those who don't know it. I'll give my summary and you can tell me where it's wrong. South Korea, the government in the 1990s sends these ultrasound screening booths all throughout the country. They're popping up in shopping malls, they're in workplaces, and lo and behold, what does the government find when they essentially make it incredibly easy to screen for thyroid cancer? The age adjusted thyroid cancer incidence rate increases by a factor of 15 in the small country of Korea, the steepest increase ever recorded for that cancer in, I think, the history of the world. But the mortality curve was flat during this period. There were no actual increases in deaths. And then the Korean government runs a counter campaign to reduce screening because they say, look, maybe we're over detecting. And again, the cancer incidence rate plunges by 40% in two or three years, and there's no change in mortality. So here you have a classic signature of over detection, right? The rates of diagnosis are surging up and then surging down, and there's no underlying change in mortality. It seems like you couldn't find a clearer case of over detection than the story of Korean ultrasounds. Sorry for that little monologue, but I guess knowing that there must be thousands, millions of people who have a psychological disposition toward life like I do, who want to know how they're going to get sick, how they're going to die before they die. How do you as a clinician think about instructing patients on this?

[D]

Well, I mean, I instruct patients quite blankly, not to have whole body scans, if the truth be known. I tell you what I usually say to people is we did not know what the inside of a healthy body looked like until quite recently. Really if you think about it, MRI scanners, they first came into kind of regular clinical use in the 1990s. But the original MRI scanners that we had were, you know, they were like the original mobile phones, you know, that sort of comparison in terms of how sensitive they were and the kind of pictures they produced. So really, the kind of incredible, detailed pictures of the inner body that we can get now in an MRI scan has only been around for 10 or 20 years. So we are only now learning what the inside of a healthy person looks like. And we are only now learning how many of us have cysts and blood vessels abnormalities and little blood flow abnormalities and so many other things. We are just learning about those things now. And having a test for no good reason has a really high chance of turning up what doctors call an incidentaloma. So if you do an MRI brain scan of somebody, say, in their 50s or 60s, you've got a 50, 50 chance probably that you'll get a result back that finds some, you know, and I'm gonna put this in verted commas, you know, abnormality, but something, and sometimes it can be quite something quite worrying. You know, 1 to 3% of us have an aneurysm. So an abnormality in a blood vessel in the brain, which is potentially very dangerous, but it's not dangerous for everybody. The minute you do a scan and you find the aneurysm or you find that, the cyst that you didn't know, you have, ask yourself how you're going to deal with it. So that's kind of more. I think a person who's going to go for one of these tests needs to understand the kind of person they are and how they will respond to it. They need firstly to know that it's almost impossible to get a completely normal array of test results back on someone once they get into middle age. You do enough blood tests, you do enough scans, you'll find lots of little incidental findings. So you need to know that they exist. I only do tests to answer clinical questions that are raised in my consultation with the patient. So they have this symptom. This test is done to identify the cause of that symptom. I would never do a test as a kind of mining exercise. You know, let's see what turns up, because that's when you get an incidental finding and you don't know what to do about it. I would suggest to people, if they still feel compelled to have the test, to be aware of these incidental findings, know what kind of person they are Are you the kind of person who, when you get that test result back, will spend the next 30 years being overshadowed by the fear of what that test result means? Or will you be someone who's able to engage with your doctor in a conversation, who will be able to accept reassurance if the doctor feels that reassurance is enough? So it's really about understanding the potential negative outcomes and deciding if you are the type of person who can compute that and deal with that.

[B]

We talked about the cost of over medication. I want to talk about the costs to agency. I was really taken by this observation that you made in your book that ADHD used to be a diagnosis for young people, which meant it was a recovery identity. It was something that you grew out of. It was something to look forward to growing out of. And I think some studies have found that, that in the recent past, ADHD had a remission of something like 60, 70%. But now ADHD diagnoses are rising fastest among adults. It is not a recovery identity. It is not something to grow out of. It is an identity identity. It is an excuse. It is an accommodation. It is a predestination. It is a this is who I am. This is my lot. And I wonder, I wonder how you would frame the cost to agency or to esteem from this shift that we've seen in diagnosis.

[D]

Yeah, I mean, this is the thing that worries me a great deal. Especially I work with patients who have neurological problems, but many of them are very young and carry a long list of these diagnoses. And when I spoke earlier about saying, we've got this new population of young people with ADHD and autism, but we also have a bunch of young adults who have the worst kind of mental health health or more mental health diagnosis than any generation that's gone before. I think this adult mental health crisis is a direct result of the way we are conceptualizing difficulties in adolescence. So the difficulty is what happens to a child if they're having some difficulties in school. And you conceptualize that as a brain development disorder, and you explain it to them through the language of neurochemicals and brain connections. You are potentially saying to that child that there is something innately wrong with you that cannot necessarily be overcome. You know, adolescence is the time of great change, and there's an awful lot of maturation happens between the teen years and the early 20s. But if you explain problems that people are having through medical illness, you potentially make those problems concrete. That child then becomes the child who is not good at the this, and they Focus their attention on the thing they are not good at. And that can potentially make the thing they are not good at worse instead of better. They might lower their expectations for themselves because their difficulty has been explained by this kind of brain neurological explanation, this kind of biological way of explaining things. Other people will expect less of them. It can become a sort of self fulfilling prophecy that stops people from getting better. If you describe their difficulties in this way, I always say to people, you know, we all, most of us had a teacher in school or a person in our lives who said we were the sort of badly behaved one, or we were the stupid one, or we weren't very good at this, or we weren't very good at that. And we can remember the impact that had on us. We're now doing that to children and combining it with an explanation that says, and that's because your brain hasn't developed normally, which is not something a person can overcome. We are then encouraging people to take these disorders on as an identity. In some groups it has even become sort of insulting to say that you should try to master some of the difficulties you have. Instead, it's encouraged that you be your more authentic, neurodivergent self. So we're not only saying you're going through a difficult time which you might mature out of. We are saying be your moral, authentic, neurodivergent self which is reinforcing the symptoms. We are also creating communities of people based on their difficulties, on the things they cannot do. That's a real problem. Because if your community is based on a medical diagnosis, then what happens if you get better? Well, you won't be part of a community anymore. It can prevent you getting better because you are disincentivized from improving, because you will lose this tribe that you have found. And because we now have this very strong adult identity of neurodivergence. We are creating the impression that these things cannot be recovered from. In order to get better, you have to believe that getting better is possible. And I fear that these really over biological explanations for a child's difficulties gives them the impression they have no control, when actually they have considerable control.

[B]

I have a couple questions that push against the narrative that you're presenting. One, is this the name of your book is the Age of Diagnosis. I could imagine someone looking at all the data that you're looking at writing the opposite book. It's called the Age of Sickness. Right. They say screens are giving us adult adhd. Social media is giving us anxiety and depression. Pollutants are giving us More autism. The news is giving us more, I don't know, social anxiety, our food system is giving us more pre diabetes, on and on and on. All of these things that you're talking about as being inflected by over diagnosis. No, this is about the modern world making us sick and our tools of diagnosis accurately capturing just how sick the modern world is making us. What is your pushback against that book, the Age of Sickness?

[D]

Well, if we take the example of sort of adhd, for example. So in the UK there has been quite a huge spike in people seeking diagnosis for ADHD since the pandemic. So since about 2020, it was already growing before that, but now there's been a particular spike. A recent study has looked at the symptomatology of the community to see whether the that spike in people seeking diagnosis is reflected in a spike in symptoms. And in fact it isn't, you know, that more people are looking for a diagnosis, but there's only small amounts of evidence here and there that people are actually more symptomatic than they were. And even where people are more symptomatic, for the moment, I'm talking about more the mental health side of things. There's so many other explanations for that. Are more people symptomatic? Because we are, are really sort of intent on encouraging people to examine themselves for symptoms. Are they truly more symptomatic or are they paying more attention to themselves? So I think even where the evidence is that there are actually more mental health symptoms, one can say, well, is that because we keep telling people to worry about these things. And there was another interesting study, again, a UK based report from the Department of Education. They went into two different school groups of teenagers and they gave one group mental health awareness training and they gave the other group no mental health awareness training. The group who had the mental health awareness training 12 months in were worse off than the group who didn't. And these sort of bits of evidence, of course you'll find evidence to the contrary, but these bits of evidence suggest really that it's more about how we are instructing people to think about the negative aspects of their experiences rather than the negative experiences getting worse. Also, I think, you know, some of this, you know, the rates of autism have gone from 1 in 2,500 children, let's say, you know, 50 years ago, to 1 in 36 children in the US, 1 in 20 children in northern Ireland. Does that really reflect our experience of the world? Do we really believe that we have had explosions of autism at that rate? I Think that social media is very often blamed for this and mobile phones blamed for it. I know that's something that you've covered, but I remind people that the escalating numbers of people being diagnosed with various things began when the definition changes began in the 1990s. They didn't begin when we all got smarter phones.

[B]

Another pushback might be that maybe diagnosis inhibits agency and inhibits freedom. But maybe for some patients, or for many patients, being able to put a name on a set of inchoate feelings actually makes people feel more free. Right. Maybe the autism diagnosis for someone with very, very mild symptoms lowers their self esteem. Or maybe it removes an anxiety from their lives that they've worried about and worried about and worried about. And now a certain box is checked and their self esteem rises. And I wonder if you've seen cases where a diagnosis might have been dubious, but its dubiousness brought great psychological relief to the patient. And so in that respect, you could almost think of it like a placebo. Right. So how do you feel about the possibility that over diagnosis might have many benefits for some patients?

[D]

I 100% think it does. You know, I'm sure that the, you know, a very common story in the neurodivergence conversation is for people to say they do feel validated by their diagnosis. And I've heard many stories of people who perhaps they, because of their diagnosis, they kind of were able to, they, they looked at themselves and they examined things differently and it empowered them to make life changes that they would not have been able to make without the diagnosis. So I don't want to imply that I don't think anybody benefits from this diagnosis. I think people do. I think it empowers people to be kinder to themselves and it empowers people to make changes that they found difficult to make before the diagnosis. But then I have to ask myself, yes, there are people who are benefiting, that's for sure. And I don't want anyone to listen to anything I'm saying. And if they have found their diagnosis beneficial to feel threatened in any way, if your diagnosis benefits you, then that's all that's important. But I want to consider what we are losing by using this method of making people better. First of all, I ask the question, why do we need a medical diagnosis to be kind to ourselves? You are the same person before and after your diagnosis. And I hear a lot of, of people say, well, you know, now I understand, you know, I'm not a terrible person. I'm a person with this diagnosis. You were never a terrible person. We need to create a society where we're a little bit kinder to ourselves without the need for medical explanation. I think we need to consider the harms of over diagnosis, which is as we diagnose milder and milder cases of much more high functioning people, we're directing resources away from the people who really need it. And we are trivializing these disorders for people, people who really need them. So, you know, autism in a severe form exists. And if anyone has ever seen anyone with severe autism and how difficult it is for them and for their families, they would understand that it is a very serious condition to live with. It's trivialized by a conversation in which autism is diagnosed in such mild forms that it almost isn't apparent at all. The conversation about autism is really taking away from the people who need that diagnosis, both in terms of trivializing their disorder and taking resources away. We also have to ask ourselves, what is the health service for? I don't object to people getting relief from a diagnosis or relief from an explanation, but I do feel that we need to understand that, that medical diagnosis and health services serve a purpose, and that purpose is greater than giving people a diagnosis to validate them.

[B]

The politics of this work seems to cut in a number of interesting directions. So for example, I'd expect that folks on the left are the loudest critiques of the claim that, for example, we're over diagnosing Long Covid, or that it's wrong for young people to lean into neurodivergence. I am not prepared for or. Or am going to start a conversation about trans politics. But the question of over diagnosis hangs over a lot of trans politics as well. So that's one place where I would expect most of your critics to be concentrated on the left. However, RFK Jr. America's Secretary of Health and Human Services, has very loudly entertained the idea that America's rising rates of autism are the result of vaccines. And your approach has us consider the possibility that autism diagnoses are rising not because our children are being poisoned by shots, but rather because we very simply broaden the definition of autism, which has pulled in more children for qualifying under that broadened definition. So there's a case in which your work seems to push back quite explicitly against the maga. Right. I wonder, just as a personal matter, in an era where health has become political, how do you make sense of the politics of this thesis of overdiagnosis?

[D]

Yeah, I think it's a real problem for science and for medicine. How caught up it is in social pressures and in sociocultural influences. We need to get medicine back to science so that we've got scientists being experts in medicine and not politicians and not members of the public and so forth. I think, I think that if there's one thing we know with 100% certainty, it's that vaccines don't cause autism. I heard somebody say recently that, you know, that's been the most. We know that with more certainty than anything else that could possibly be known because it has been researched more than anything else because of the controversy around it. So we know that is not the cause. I think there is a much more well meaning cause which is that we, you know, we've tried our hardest to help in more and more children and now they are caught up in a sort of situation, social contagion, of explaining their difficulties through these kind of lenses. And that may be because we're not helping them in ways that we should be helping them. It may be that we're, you know, people need help. And when you need help, you ask for it in a way that is socially appropriate in the culture in which you live. So perhaps what we should be doing is listening to these young people and hearing that they're suffering and finding a better way to help them. Them.

[B]

I want to close by thinking about the philosophy of this because I find it really profound. I wonder if the age of diagnosis incurs this trade off between anxiety and longevity where we live longer, but the substance of our life, the texture of our life, is meaningfully changed because we survive as patients rather than, in some cases, live more freely as patients, people. And our identities, which we once took from priests and from religion and from our parents, are now something that doesn't emerge from within us, but is handed to us by a doctor, by a piece of paper, by a diagnostician. And that's strange and interesting to me that there's this trade off that's baked into this modern age of diagnosis, which is longer life, more anxiety, and an identity that comes not organically from within us, but rather is handed down by the new priests who are diagnostic doctors. How do you feel about that as a sort of gloss of your work and the fact that the age of diagnosis is not all evil or all beneficial, but rather this really messy trade off?

[D]

Yeah, there's so much in there I agree with, really. I mean, I think that first of all, with regard to religion and things. So it used to be that we lived in a society where everyone, generations, all were much closer to each other. We lived in Houses full of people. We had religious institutions that supported us more. We used to get our support and our guidance from different people. And now we are much more kind of independent and much less likely to take our guidance from religious institutions. And you know, if you can, you go to help to, when you need help, you go to where the help is available. And medical institutions are always available and they are increasingly available. So it makes sense for us to ask for help in a way that is culturally appropriate at a point in time, depending on what kind of help is available. And I think that, that, you know, more so in the uk, perhaps in the us, where religion for us is much less central. So where do you go if you want to feel cared for? Where do you go if you want to feel supported while you go to your doctor? So that's an institution that always exists if you're having difficulties. I think we also have to start questioning, look, what does a good life look like? Is a good life one in which you live to 100 but for the last 20 years of it you are on multiple different tablets and having endless, endless amounts of tablets, tests? I think we don't really know what a good life looks like and we don't appreciate that basically living forever isn't necessarily what we should be aiming for. We should be aiming to be as well as possible for as long as possible, but live a full life rather than a long life. I think that we're intolerant of aging and we're intolerant of the realities of our existence, which is, you know, the minute you hit your 50s, I hate to tell people, anyone under the age of 50 that things will ache and things will pain and things will wrinkle and you know, our bodies start, our brains actually start deteriorating in our 30s and our bodies start deteriorating shortly after that. We're intolerant of that. We, we want modern medicine to solve that. So I don't really feel like the age of diagnosis has arisen out of any kind of malicious thing. I think it's a kind of a collusion of scientific abilities along with society having a lack of support structures for people and people needing help and wanting perfection.

[B]

It's a profound idea and a really profound book. Suzanne o', Sullivan, thank you so much for talking about it with me.

[D]

Thank you for having me.

[B]

Thank you for listening. Plain English is produced by Devin Beroldi and we are back to our twice a week schedule. We'll talk to you soon.

[F]

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