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Notes -
So, what are you reading?
I'm halfway through al-Ghazali's The Banes of the Tongue. In particular, this is a piece of wisdom which I ought to follow more:
It would be both amusing and dismaying to see what kind of trial I would receive if I was to be judged by what I have mentally said about many public figures in comparison to what they actually deserve.
It often seems like there is a part of my mind which can never shut up about its anger. But there's a common game that people play in bodycam videos where a suspect (who also seems incapable of shutting up) points in some random direction and says to the officer "don't you have better things to do, like arrest another [unspecified evil person, drug dealer, etc.]?" I imagine that mental anger, at least in some forms, plays a similar role: "look over there [and not at oneself]!"
Last week I finished The Age of Diagnosis by the Irish GP Suzanne O'Sullivan. Her thesis, in short, is that medical diagnosis is more of an art than a science, and that in recent decades medical institutions have begun to err on the side of too much diagnosis rather than too little. This overdiagnosis comes in two main forms:
Carrying out preemptive screenings and unnecessary tests on patients before they report any symptoms. Any oncologist will tell you that time is of the essence when it comes to treating cancer, and on paper the ability to identify and treat cancerous growths before the patient notices anything wrong sounds like a godsend. But O'Sullivan presents some disquieting statistics indicating that certain oncologists may not be as talented at distinguishing benign tumours from malignant as they claim to be, and that, as a consequence, many patients are being subjected to aggressive treatment regimens which deleteriously affect their quality of life for no good reason. Perhaps the most distressing example of this trend is women who undergo genetic testing to be told that they have an X% chance of developing breast cancer, and who undergo preemptive mastectomies before any tumours have been located (famous recipients of these procedures include Elizabeth Wurtzel and, most famously, Angelina Jolie). As O'Sullivan notes, while the margins of error on these breast cancer estimates have shrunk over time, they can never be zero; and even if they were, if you tell a large cohort of women they have an 87% chance of developing breast cancer in the future, the unavoidable conclusion is that some women have undergone mastectomies for literally no reason. We talk about medically unnecessary mastectomies a lot in this space, but it's sobering to be reminded that it's a topic of major concern even outside the domain of "gender-affirming care". O'Sullivan also cites some alarming statistics on the number of doctors who have admitted to ordering medical tests they did not think were necessary, purely to assuage a hypochondriac patient's worries (read: minimise the risk of a malpractice suit). This seems like a potentially under-discussed contributing factor both to lengthy hospital waiting lists and to Baumol's cost disease. When you hear that patients have to wait, say, 12 weeks to undergo an MRI, you can't help but wonder how many people ahead of them in the queue were not thought to be ill by anyone but themselves (not even by the doctor who ordered the scan).
Existing diagnostic categories loosening and distending over time, until they include people who in previous generations would have been considered completely healthy. This is the story we're more more familiar with. No one is merely "shy" or "socially awkward" any more: every such person is now "on the spectrum". No one is "easily distracted": they have ADHD. Sometimes these diagnostic categories stretch to the point of becoming contested illnesses (e.g. "chronic Lyme" disease, "long Covid"). O'Sullivan reserves particular ire for the concept of "masking", wherein "mildly" or "high-functioning" autistic people can supposedly learn to hide the outward symptoms of their condition and pretend to be neurotypical – which effectively turns being autistic into an unfalsifiable claim*. O'Sullivan argues that the excessive focus on people at the "high-functioning" end of the autistic spectrum has resulted in a highly skewed public impression of what autism entails and, consequently, social policies which demote the severely autistic in importance in favour of their "high-functioning" brethren (in other words, autism and other disabilities have become gentrified). O'Sullivan is clearly afraid of being misconstrued as a right-wing culture warrior sneering at Millennial snowflakes diagnosing themselves with ailments they don't have for clout, and is even-handed and sympathetic to a fault, hammering home that suffering is not any less real for being psychosomatic in etiology, and that the people who stand to suffer most from a medically unfounded diagnosis of autism or ADHD are the diagnosees themselves. But there are brief moments where the mask slips, and her exasperation with and contempt for these self-absorbed malingerers is on full display: when she notes that some residents of Australia have diagnosed themselves with "chronic Lyme", despite that country being inhospitable to the tick whose bites cause Lyme disease; when she describes what a high proportion of people diagnosed with ADHD are comorbid with one or more other psychological ailments; when she describes a list of dozens of potential "long Covid" symptoms (including "loneliness") circulated by a woman with a PhD in a non-medical discipline who consistently refers to herself with the "Dr." honorific; when she argues that, in some cases, a nonspecific medical diagnosis is a convenient coping mechanism for people whose life didn't turn out how they thought it ought to have; and the banger quote below (emphasis mine):
A fascinating and eye-opening book, but there were parts in which I wished O'Sullivan would be a little less equivocal and even-handed, more willing to take activists to task for their selfishness, more willing to openly discuss how destructive the "self-diagnosis" trend has been. I'd be fascinated to see the first draft and see how many of the hard edges got sanded down by successive rounds of editing.
*As drily noted by Hannah Spier, "masking" is basically synonymous with "emotional self-regulation", something every adult, to a greater or lesser extent, eventually has to learn how to do. Dare I say that the legitimately autistic are distinguished by a literal inability to "pretend" to be neurotypical? Indeed, that they don't even understand the concept of pretending to be neurotypical?
I saw that happen to an old university friend of mine. I don't suppose O'sullivan gives any advice for helping these people?
It depends on what is happening.
Most of these people fit into specific buckets, which bucket tells you what to do, for example -
-Motivated by secondary gain? (Ex: stimulant seeking). May become a drug addict, otherwise not too problematic since they are doing this to succeed and don't end up in the fail state.
-People who actually just have depression or anxiety and don't want to admit that? Get them treatment for what they actually have.
-People with "something else" many of these people have a personality disorder or something like a conversion disorder and they've found a way to excuse their psychology and experiences. If you can get them the treatment for what they have, do so. Many of these people were never going to flourish anyway.
Lots of people get shunted into all three buckets at higher rates because of modernity sucking.
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Not that I recall, sadly.
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