Suzanne O'Sullivan (on over diagnosis)

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Welcome, welcome, welcome to Armchair Expert Experts on Experts on Experts on Experts. Whoa, so many.
I'm caught in a loop still because we just did a personality test that seemed to be a loop. I feel like we answered the same five questions six or seven times.
It's meant to throw you. Yeah, it did a good job.
Today we have a guest on a fascinating topic that I think a lot of us talk about all the time. Oh, yeah.
Are we getting over-diagnosed? Are we medicalizing everything? Is everything a pathology? This episode was really interesting because we talk a lot about overdiagnosis, but also about kind of psychosomatic contagions. Yes, yes, yes, yes, yes.
This is across the board fascinating because she's here to talk about her new book. Well, first of all, Dr.
Susan O'Sullivan. She's an award-winning writer and neurologist.
And her new book, which we're going to talk about a lot, is The Age of Diagnoses, How Our Obsession with Medical Labels is Making Us Sicker. But her previous few books are also fascinating.
We get into those and that's about psychosomatic illnesses and contagious illnesses. All of it is so I told a lot of people about this.
Me too. So interesting.
And so funny too, because we just immediately contradict ourselves and then we get another expert on and learn about a new pathology. It's good for us to have all the information.
To hold two conflicting ideas in the head at one time is a sign of intelligence. Please enjoy our ever charming guest from Ireland, Dr.
Suzanne O'Sullivan. This episode is supported by FX's Dying for Sex, starring Michelle Williams and

Jenny Slate. Inspired by a true story, this series follows Molly, who after receiving a

terminal cancer diagnosis, decides to leave her husband to explore the full breadth of her sexual

desires. She gets the courage and support to go on this sex quest from her best friend Nikki,

who stays by her side through it all. FX's Dying for sex.
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Terms and more at AppleCard.com. So you've been here since Friday.
Did you do anything fun? I was the absolute ultimate tourist. Oh, God.
I did everything that you'd expected tourists to do. First, I did the Universal Studios tour.
Okay, great. I was very surprised.
So because I'm only here for a brief period, I paid for like the most expensive tour, and it was six hours around the studios. What I thought.
I didn't realize it was a theme park. I didn't know that.
Oh, you didn't even know. You thought you were just going to see the sound stages and the lot.
I did for six hours. And the very first thing that happened was they put me on the Harry Potter ride.
Oh, yeah. How was that? The effects and everything are amazing, but it was just very disorientating when you were expecting something entirely different.
Now, are you wearing green as a nod to your Irish heritage or do you always find yourself in green? I wear a lot of green, but I do identify very strongly as Irish. I mean, I'm from Ireland.
You have the most Irish last name. You got a Sullivan and an Owen.
Yeah, exactly. It's 100% Irish, but I've lived in England for a long time.
Well, you've written maybe more, but I'm aware of three books. And I would love to just tap dance lightly through some of them before we get to the new book.
Because I do think there's definitely going to be concepts in the new one that were laid out and built on the back of these other ones. And this is going to get Monica so excited.
I think we should first talk about, you're a neurologist. You know, so I've got a master's in creative writing, which is impressive, but you specialize in epilepsy.
I have epilepsy. Oh, do you? Well, let's find out.
Let's find out. The first book is All in Your Head, True Stories of Imaginary Illnesses.
So let's just start with some actual data, which is your guesstimation, and you acknowledge it's an estimate, but of all the people that come in that have had seizures, a symptom of epilepsy, 30% of them are not epileptic. Correct.
And then you found also that's largely true for cardiologists when people come in with chest pains. It's common for people with heart palpitations.
That about a third of people that are experiencing symptoms, often it doesn't align with the actual underlying disease. Yeah, so I run seizure clinics and most people who are referred to me, they've been having a variety of different kind of convulsions or other types of seizures.
Usually they come to me with a pre-existing diagnosis of epilepsy. And in the best week or the best year, a fifth of those do not have epilepsy.
The seizures they're having have a purely psychological cause. So their brains are shutting down for a purely psychological reason.
And that's something that we as neurologists see all the time. That is so common.
As I always explain to patients, our brains shut down in certain overwhelming situations all the time. You know that sort of you're really overloaded with information, you're listening to the radio, you're trying to hear a sports result or a particular thing and you miss it like 10 times and you keep rewinding and rewinding and rewinding and missing the same thing multiple times.
That's dissociation. That's what our brains do to protect us in moments of being overwhelmed.
It's like everything in the body. Some people have too much hair, people have too little hair.
Everything goes a bit wrong in some way. And this thing called dissociation, which is designed to just help us to control the overwhelming amount of information in our environments, sometimes goes wrong.
And when it goes wrong, it can cause people to faint. It can cause people to collapse.
It can cause people to have convulsions. And it's so common that this would be part of the bread and butter of a neurologist's job.
How do you distinguish those seizures from epileptic seizures? For a neurologist who deals with seizures, it's phenomenally easy because they don't look anything alike and they don't behave in the same way. I won't go into the small details, but epileptic seizures tend to be incredibly brief.
They last a few seconds or a minute. They behave in a certain way, whereas these seizures that you get for psychological reasons tend to last for much longer and have a sort of different pattern of behavior.
I think it's very difficult for a non-specialist doctor to tell the difference. But if you've heard people describing epileptic seizures enough times, you can tell the difference very easily.
If we were to observe the brain with an fMRI, maybe it's already been done. Do we see any difference in how it plays out electrically? Absolutely.
First of all, if you do a brainwave test where you just put the stickers on the head where you're measuring the brainwaves, an epileptic seizure is caused by a burst of unwanted electrical activity. You will see that electrical burst when the person has a seizure.
If you do an EEG and someone having these psychosomatic seizures called dissociative seizures, even when they're unconscious and completely unresponsive, you see a normal waking brainwave pattern. So the brain's very busy in some quadrant.
It looks awake, but for some reason, people are not able to access that awake part of the brain. So they're like maximum disassociated.
Absolutely. If you look to the brainwaves of someone in one of those seizures, they look normal.
If you look at the brain in a different way, so you mentioned fMRI. So that's where you look at blood flow activity in the brain.
If you look at that, you will see slightly different patterns of activation of people having these seizures to otherwise healthy people because you will see increased connectivity, say, between the emotional parts of the brain and the motor parts of the brain. So something is going on that shouldn't be, but it's not necessarily a brain disease per se, but rather this emotional part of the brain is connecting in some way to the motor part of the brain to produce these symptoms in a way that it shouldn't.
So you're seeing 30% of the people come in or 20% on a great year where these are psychosomatic. And I think we have a paradigm which is very dismissive of psychosomatic.
In the same way that people are dismissive of placebo effect, people have this association that placebo effect is not real. Of course, it's real.
It doesn't have the causality we thought it had. So do you think that by writing a book about psychosomatic disorders, you ran the risk or you would be afraid people were thinking you're dismissing them as opposed to, I like what you say, which is the symptoms are the symptoms.
They're the same. Why do we have compassion for one cause of the symptoms and not the other? The purpose of writing the book was very often this something affects really young people.
And I was seeing these young people who were having hundreds of seizures every week. And I would explain to them what was wrong with them.
And it was like I was reinventing the wheel or something. I'm seeing it every day, but they can't even believe that such a thing exists in the world.
Do you feel like they felt invalidated by that? Absolutely. Well, I always say to people, imagine your next door neighbor is in a wheelchair.
You understand that they've got multiple sclerosis or motor neurone disease. And obviously, you've got a huge amount of sympathy for that and support for that.
And then next week, someone tells you, well, actually, their nervous system is normal. This has a purely psychological cause.
Even the most caring and understanding of person, there's something in us that kind of says, oh. None of us like feeling bad.
It's an emotion that's uncomfortable. So if we can say it's your fault, I think it relieves us of that responsibility to be compassionate and understanding.
It's like, well, they're choosing to be this way or it's their fault. I think a lot of it's like they need attention.
I think it relieves us of that responsibility to be compassionate and understanding. It's like, well, they're choosing to be this way.
I think a lot of it's like they need attention. I think that's where the problem arises is that people think that they need attention.
Even though you can tell people it's not consciously generated, people secretly think that people are doing it on purpose and that they're doing it for attention. And they know they're doing it.
And they could stop doing it if they wanted to. And again, I say to my patients, so many analogies in life for this.
Imagine something terribly frightening has just happened to you. Your heart rate goes up to 120 beats per minute.
It's really happening. You're not doing it on purpose.
If I told you snap out of it, slow your heart down, you wouldn't be able to do it. So it's the same with these sort of seizures.
When my heart races because I'm frightened, it's not because I have a heart disease, but neither am I doing it on purpose and neither could I stop it. And it has a self-perpetuating physiology, right? Which is once my heart rate is so high, I'm actually going to be in my amygdala whether I want to or not.
I can't bring on my frontal cortex, really. And that's how these things get worse.
It happens once. And then the next time you face a similar situation, you become really focused on your body and thinking, I hope that awful thing that happened to me before doesn't happen again.
And it's all feeding back into itself. So I think that's another thing that people misunderstand is they think that psychosomatic conditions are less serious than others.
In fact, they can be in many ways more serious. Say a fairly average patient with epilepsy, this is a huge range of differences, but let's say they might have a seizure every month if they're quite bad or once a year if things aren't so bad or once every 10 years if they're pretty good.
A person with non-epileptic or dissociative seizures can have 100 a day and yet because they have a psychological origin, we kind of think that's less serious. You can't put the latter patient on Keppra or a medicine that would help them.
It may work as a placebo. It could be a placebo.
Yeah, so often I will find a stumbling block for them is someone has told them it's epilepsy. They go on the epilepsy drug and the seizures stop for three months, say.
But the epilepsy drugs won't solve the problem if it's not epilepsy. So then generally the seizures will come back.
Okay. You want me to, should we? Yeah, absolutely.
Dead honest with you, I don't think one thing or another. I do think both sides should be explored passionately.
I agree. Okay, so you can tell me.
First of all, I'm very unlikely to tell you because I would have to ask so many deep personal questions that I wouldn't ask. But we do that.
You probably already said them out loud. Yeah, that's what we do here.
Because we're not going to force you to try to diagnose one of us. We know that's unethical.
Sure, you don't have to diagnose one. But I had a seizure nocturnal.
I woke up. I was sleeping by myself.
I didn't know, but I was like, I feel crazy. I peed in the bed.
You had a lot of muscle sore. Really bad muscle soreness.
I thought maybe I had a kidney issue. So I went to the doctor.
They took a urine test and they're like, nothing's wrong with your kidneys. We don't know what it is.
He gave me a steroid shot for the muscle pain. That was that.
I'm just going to stop you there. So the bottom line was you woke up, you'd wet the bed, and you had aches and pains.
Did you suspect a seizure then? No, I was very disoriented. That was chalked up to a mystery for a year.
A year goes by and then I'm on vacation with girlfriends and I have another seizure in sleep again. And they're there.
So they see what happened. Then I go to the hospital.
They do an MRI. It's all fine.
And then when I got back home, I saw a neurologist. He looked at the scans and he said, based on the fact that they were a year apart, they were at night, it's epilepsy.
And I've been on Keppra ever since. That was in 2020.
For five years. I've been on it for five years.
I haven't had one. That's epilepsy, yeah.
Okay. Yeah, it's just no doubt in my mind.
That's nice, right? I always knew it. Oh, yeah, yeah.
Again, I didn't not know it. The better question is, why did you doubt it? I am a hypochondriac.
I feel fair to say that. Yeah, I wouldn't say that a lot, but yeah, I think she has a bit of hypochondria.
I didn't doubt it. I just am curious.
Well, now that we know that it could maybe not be. It was a fair question.
Typical of how epilepsy behaves and seizures in sleep. But I think the important thing is that this is the conversation I would like people to have.
Because very often the conversations I'm having with patients are they're saying, but it must be epilepsy, but it must be epilepsy because it feels so impossible to them that the brain could do this without a disease. And what I would love, you know, it's much like if you're deciding, does someone have migraine or do they have something else? You just have a conversation about it could be this, it could be this, and people are fine with the alternatives.
But most of the conversations I have are people are almost begging to have epilepsy because they know how stigmatized the alternative is. So this is exactly what I would like to see happening is you've got two possibilities and both are equally respected so that either can be considered.
Right. There's no shame in one of the diagnoses.
Exactly. Yeah.
So, well, I guess what I'm curious about is do we understand the mechanisms that can create symptoms psychosomatically? Talk about Matthew maybe from the book. We don't fully understand.
When I was studying training as a neurologist, so let's say in the 1990s, we didn't have a clue about this stuff, but we are beginning to develop theories. But they are only theories.
But an awful lot of it really is around the concept of what we call predictive coding so how your brain processes information it isn't absorbing information as if we were video recorders or something our bodies behave as we expected to behave in the case of Matthew I'm going back a bit now with remembering the story 2015 I'm asking you to go back a decade yeah I can hardly remember what I had for my breakfast so Matthew had some tingling I think in think, in his legs. I've forgotten exactly how it started, but it started with some disturbed sensation in his legs.
And then he was reassured by his doctor who didn't find anything wrong with him, but he wasn't really reassured. And he felt that he had a more serious problem than that.
that tingling in his legs then progressed into a feeling that he wasn't coordinating or using his

legs correctly and that then progressed further until he got to the point where he wasn't able to

walk. his legs then progressed into a feeling that he wasn't coordinating or using his legs correctly and that then progressed further until he got to the point where he wasn't able to walk and he was completely wheelchair bound.
Now as a neurologist when you examine someone who cannot move their legs at all there is a big distinction between what you find when you examine someone who's got say a spinal cord disease or brain disease and something psychosomatic because the nervous system is arranged in a very complex way. And when you can't move your legs because you've got a brain disease, it looks one way.
If it's a spinal disease, it looks another way. So when I saw Matthew, it was very obvious to me.
His reflexes were normal. Lots of things were normal.
And yet he couldn't move his legs. And MS specifically, if I remember right, the myelin sheath is eroding around the nerves is the issue.
So can we observe the myelin sheath? First of all, you can tell from the history how multiple sclerosis behaves, it's flitting symptoms that move around the body. And then basically you would be able to see certain signs in the legs, such as a particular kind of spasticity or stiffness in the muscles, reflexes that are very brisk, patterns of sensory loss that fit with the brain.
And then when you do brain imaging, MRI, you can kind of see the result of the loss of myelin rather than the loss of myelin itself. In Matthew, none of these kind of abnormal signs when you examined him, apart from not being able to move his legs, everything was normal and brain imaging,

et cetera, was all normal. It was very obvious that this had a psychological cause.
So the

question Matthew would have for me is how could I not be able to move my legs? You were telling me

my nervous system is healthy. Why can't I move my legs? Oh, it must be another layer of anguish

on top of everything else. Well, I think it's very unbelievable for people.
Yeah. There are kind of, again, analogies for this in life.

If you think about your foot or your feet for even a moment,

they feel different than if you're not thinking about them

because our bodies are awash with all of these sensations at all times

that we could feel if we paid attention to them.

But because our brains can only handle so much information,

we just eradicate that white noise so we can pay attention to the conversation we're having or important things in the room. So first of all, it takes very, very little for your body to feel different.
All you have to do is pay attention to it and you will notice stuff. It's like when you start thinking about your heartbeat.
You can almost immediately give yourself a palpitation just by considering it. If you're starting to have a panic attack, if you start thinking about having a, it gets so exacerbated.
Because these things are supposed to be automatic. You've been learning them your whole life.
But Matthew became aware there was something wrong with his feet. So the minute he pays attention to his feet, they feel strange.
And then what does that do? It makes him pay even more attention to his feet. It becomes a kind of a looping thing that gets out of control.
So that's how you change the sensation in your body. But then think about motor activity.
So I always give examples like sports people. So only some sports people can take penalty tries.
You might be brilliant at something when no one's looking at you, but the scrutiny of the crowd completely affects your ability to coordinate your muscles.

Or I give examples like walking on a cliff path somewhere. Any other day you just walk, you don't think about it.
But if you're walking somewhere where there's jeopardy. If someone's asked you to walk along a six inch line on the ground, you could do that to eternity and never misstep.
Exactly. We can change the quality of both our movements and how our body feels by the scrutiny that we pay to our bodies.

Very often these things happen because we are paying so much attention to the body and then we expect the body to behave in a certain way and therefore it does. So it's not actually that unusual for people to have problems a little bit like Matthews.
That's an extreme example, but for a neurologist dealing with these kind of issues, it's also a common example. A depressing side of this is that in the folks you work with, 30% of which are having psychosomatic seizures, only 30% of those people will have success treating it with CBT, which is our best option currently.
If you talk about dissociative seizures, people think, oh, that's less serious than epilepsy. 70% of people with epilepsy will become completely free on medication, but only 30% of people with dissociative seizures will get better.
It is phenomenally hard to make people with these problems completely better. And I think a little bit of that is because it's been such a neglected area of medicine.
There are great scientists working on it now, but during my training period, there was nobody. As soon as the doctor has decided it's in their head, they're kind of off their plate.
Go see someone else. I only know how to prescribe you these medicines or send you to this physical therapist.
There's no tools on the table for a doctor. Exactly.
As a neurologist, so I've told you how often I see these kind of seizures, but I'm in no way trained to treat them. If it's such a big part of my day job, I should be better trained to treat them.
But there would be a real expectation for many neurologists that if you see someone and you rule out a brain disease, then it's sort of like, that's fine. Then you can discharge that person.
And that's a big part of the reason why I became interested in it because I was a young woman and a lot of the patients were young women my age. I was finding myself in a position of potentially sending people home, having lots of seizures.
Is it gendered? It is more common in women. So about two thirds of the patients who develop psychosomatic conditions, seizures in particular, are women.
So the part I still would love to know the mechanics of is if I wanted with all my might to give myself a seizure, I don't think I could replicate the level of seizure you're seeing. What happens in the brain? Do we know? I don't think we really understand it.
We can liken it to things in daily life, but do we really know how that is possible? Well, I don't know is the answer to that question. I mean, with regards to some of these things, we talk about how predictive coding.
So predictive coding is how we process information. So if I show you this object, you've never seen it before and I tell you what it is, then you recognize it.
But the next time you see this, you will be able to manipulate it in your brain. So the next time you see it from this angle, you don't have to have learned what this looks like from this angle in order to recognize it.
So our brains aren't just... They're modeling machines.
Exactly. And they're manipulating everything that comes in to try and make sense of it.
We're making sense of the world according to our experience. So this kind of prediction machine that is the brain is making a best guess at what the body should do in this situation and how the world should look in this situation.
And you know what? It makes mistakes. That's the bottom line.
And these are some sort of mistakes that come out of these faulty predictions or prediction errors. I mean, is anti-anxiety pharmaceuticals ever tried for this? Other than in a placebo way, medication doesn't really work for this.
What can often work is much simpler than that. This probably will shock you a little bit, but I have seen patients who are having 100 seizures a day and one conversation in which you explain what is happening will stop the seizures there dead on the spot.
Oh, wow. Because what you've done then is you've broken the pattern of the expectation.
Actually, the one thing that can make these better very quickly for some people, as long as they haven't been there for that long, is just for them to understand what's happening, to be less frightened of it and then distract themselves. Because often it's a kind of a snowball.
So you feel the dizziness and then you think, oh, what comes after the dizziness? I don't mean this in a conscious way, unconsciously. So I just say to patients, you feel the dizziness.
So next time you feel the dizziness, look for everything in the room that is green or list all your favorite football teams. Just do something that breaks the pattern.
Okay, so the third book, The Sleeping Beauties and Other Stories of Mystery Illness, you have a story in there about contagious seizures and schoolgirls in Colombia. Yeah.
This is a story that could have begun anywhere in the world, actually, but it happens to be set in Colombia. So I visited this little town in Colombia, beautiful town near Cartagena about 2012 in a school in Colombia.
It was a very hot classroom. The windows were closed.
It was overcrowded. A girl collapsed.
We presume she fainted. And following that, multiple people in the class collapsed all over the school.
They heard the commotion coming from this classroom. So suddenly, you know, everyone's rushing out into the corridors.
You can imagine what a heightened situation this was. In that single day, in that one classroom, there were multiple people fainting, collapsing, having convulsions, rushed to the hospital.
Those stories are a dime a dozen. You will find similar examples to that exact story happening in the US, happening in England, on a semi-regular basis throughout the world.
Usually, that stops very quickly. So it's a very frightening situation.
What's likely happened is that one person has fainted and then other people have sort of collapses in sympathy really with that person's sudden emotional overwrought situation. Well, if you were uncomfortable with the heat and the lack of air and then you witness it take someone else out, now a new reality is on the table, which is I might pass out from this.
Other people may simply have fainted also. Young people who have low blood pressure, especially girls, because they have lower blood pressure, sudden fright, your blood pressure drops, you faint.
So probably the first person fainted, maybe the second person fainted. Eventually it was more of an emotional contagion, more likely.
We call that poison. Well, it was correlation, not causation.
Exactly. And then that rumor then spread around the town.
I spoke to some of them who had even recovered completely. You know how you make these things better is you're positive.
So I'm saying to these young women, you look great. You're better.
Isn't that wonderful? And they would say, but I know the poison is still inside me, this sort of attitude.

And there was a real malign influence moved to the town.

There are anti-vax people.

And if they get a whiff of somewhere where they can recruit new members to the anti-vax movement, people from all over the world heard of these seizures and went to the town and stoked the fear.

So something which should have been gone in 24 hours, it was still ongoing years later. Wow, because it became weaponized by the anti-vax movement.

Thank you. and went to the town and stoked the fear.
So something which should have been gone in 24 hours, it was still ongoing years later. Wow, because it became weaponized by the anti-vax movement.
Wow. And these poor girls, they were so terrified.
Let's say you got some doctor from Germany, America, wherever, coming into your town and saying you've been poisoned, and you come from this kind of deprived area in Colombia. Who are you to believe? Also, you're in a country where perhaps you trust this outsider more than you trust your local government.
I'll give you another one, which is the belief in the sonic weapon. Somebody who's clearly intelligent and educated and works for a embassy in Cuba, hears a noise in the middle of the night and develops symptoms with hearing loss and dizziness and ringing in the ears and believes that they have been targeted by some sort of weapon, which was actually perfectly reasonable in some regards because the embassy had been closed in Cuba for a long time and these sort of things do happen.
And they were a Russian proxy. Exactly.
I think the sort of Russian spies, I don't have the terminology for all of this stuff, but they do have a reputation for going into people's houses, moving things around to mess with people's heads and so forth. I mean, it was perfectly reasonable for this person to think that something had happened to them.
The difficulty again was the idea that there was such a thing as a sonic weapon took off within the embassy community. It's exactly where these mass psychogenic illnesses happen in these contained communities potentially under threat that are quite insular.
So people really began to believe in this concept that there could be a sonic weapon that were being directed at individuals. The problem is that scientifically it makes no sense because sound doesn't damage the brain in that way.
You know, if you've got a big explosion that's big enough for everyone to hear it and to displace your whole body, well then sure, your brain could be damaged and so could the rest of your body. But sound cannot be directed at a brain to damage it.
Sound just travels along nerves into the brain. So scientifically, it made zero sense whatsoever.
But unfortunately, people really bought into it. 60 Minutes even did a segment on it.
I was very disappointed. I love 60 Minutes.
My bigger issue was, and this is disrespectful to the people suffering from whatever it is they're suffering from, but I was like, okay, so Russia has this crazy weapon and they deployed it on you. Not to be mean, but truly, if we made a hierarchy of who would be most advantageous for them to cripple, we wouldn't start with the ambassador in Cuba.
It just also was illogical in the motivation. The whole thing was so illogical.
You got to feel for these people's position because I think Marco Rubio was saying things about this weapon. They were being called in and they were being told by the highest forces in their country to hide behind walls and to be frightened.
Oh, they're trying to retrofit embassies. Yeah, it really took off.
What is the Tourette's-like syndrome that was spreading through New York high schools? Do you know about that? I've heard of this. You've heard about this? Yeah.
Oh, I know nothing about it. These are the TikTok tics, essentially.
So there were a few quite active people on TikTok who were demonstrating their Tourette's syndrome. It led essentially to an outbreak of not exactly Tourette's, but Tourette's-like syndrome throughout the world.
So young people began presenting to doctors with Tourette's-like symptoms. But they obviously didn't have Tourette's because often these psychosomatic conditions, they are your idea of what a seizure would be like, or they are your idea of what Tourette's syndrome is like more than they are like the actual thing that swept the world.
But the problem with these things is that most people will be fine because most people, this will be a passing thing. It'll happen to them and it'll disappear.
But vulnerable people will go to doctors and have tests and this can all get very out of control. So for a small number of people, it's probably been a persistent problem.
And we didn't delineate, but I want to now, because I'm now remembering, even Monica, so you draw a very hard distinction between a hypochondriac and someone with a psychosomatic condition. A hypochondriac is worrying about getting things, but they don't have the symptoms.
And a psychosomatic person has got a big plate of symptoms. I wonder if, because I often say this, I'm like, yes, I'm a hypochondriac.
It's not like I'm like, ah, this hurts. You're a lazy hypochondriac.
I got to go to the doctor and get tests. Don't you think a real hypochondriac is in the doctor all the time? Yeah.
That's a good question. Again, that's coming back to my current theme of overdiagnosis, which is when does worrying about your health become hypochondriac? It's when it stops you living a normal life and it disables you.
So it's perfectly okay to worry about your health and to be a person who thinks, what's that, what's that? We all have a different kind of personalities and we all have different foibles and so forth. If it isn't disabling you, I wouldn't call it hypochondria.
Oh, I love this. This has been a very validating, yeah.
You're getting a clean bill of health from this whole thing. Okay, that makes sense.
No real consequences. That's precisely the thing, isn't it? We're really into using medical words to describe our personalities and the way we feel now.
It's a trend. And then once you start using the medical words, then suddenly you find yourself potentially being diagnosed with something.
But the line in the sand has got to be disability and impairment. And that's something I think people need to think about when they're kind of using medical terms in a casual way.

Yeah.

Great.

So that's next.

Before we get to the new book, I just want to know about the sleeping sickness in Kazakhstan.

What was that?

This little town in Kazakhstan called Krasnogorsk,

it's literally in the middle of nowhere.

Really hard place to get to.

In, again, about 2012, 2010,

a woman working in the market there, she couldn't be woken up. They noticed that she appeared to be asleep or unconscious.
Her name was Lyubov. The other people in the market tried to wake her up.
They couldn't. They took her to the hospital.
Nobody could understand what it was. Although it was a small town, it had good healthcare facilities.
So they did all the usual kind of scans and stuff and everything was fine. They said maybe you've had a stroke, which to be honest, wasn't a great diagnosis because stroke wouldn't really present like that.
This is now she has woken up. Yeah, she's woken up.
They say, you probably had a stroke, go home. No sweat, you've had a stroke at home.
Exactly. That's what they do.
I should have applied. They had done as much as they could do.
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What they really don't want to say is we don't know. I think a lot of doctors don't want to say that.
See, I'm not sure that's what they don't want to say. I think that saying you don't know when you don't know isn't that hard.
So if someone comes to you and says, I've got a pain in my toe and you don't know, there's not really any recriminations from saying, you know, I'm sorry, I've looked at everything I can. I don't know what that is.
Patients don't get angry at that. I think the thing people don't want to say is what they think they do know, which is that perhaps it has a psychosomatic cause.
This is in your head. A lot easier to say you don't know than to say that.
So I don't know what her doctors actually thought, but they said possibly a stroke. They did do lots of tests.
I was a bit casual in saying they sent her away, but they did care for her. But shortly after, the nurse were affected.
And as it spread, the symptoms changed. And that's kind of what happens with these things.
It spread from older people to children. And when it went to children, they started having different symptoms like hallucinations and things.
Oh my goodness. I mean, this town, I read about this in the newspaper and you should have seen the pictures of this town.
Imagine the most depressing town in the middle of the Kazakhstani steppe, sort of dilapidated buildings, and all of the people were pictured beside rusty swing sets. Oh, God.
I have an exact image of what the scene is. Adonishingly depressing.
When the sleeping sickness happened, it was a big mystery for the country. The government did loads of investigations.
They sent engineers and people to the town. It was a uranium mining town.
So they thought maybe a toxin was coming from the uranium mine and really went into overdrive investigating this. But also loads of foreign journalists came.
So this town went from being a town of 300 people to being a town that was kind of awake with activity of all these people visiting it. So when I read about it, I just thought, well, I would fall asleep in that town.
It looks terrible. I sort of assumed that this happened because it was such a depressing place to live.
I want someone to do work on this, and maybe they already have, but someone in the social scientist needs to think about the impact of 40 years ago, you could be in this Kazakhstan town and you wouldn't really know it was that bleak. The only swing sets you had seen were rusty.
Maybe you saw some movies from the West. I wonder what the impact of being aware of what everyone else is living like on planet Earth with the internet, where some of these symptoms might be a result of that.
It's like, what are we doing here? And this is miserable and I'm going to just not wake up. Yeah, because the world is so small now.
And you're very aware of what you don't have now, whereas I don't think you were in the past. Let me tell you the end of that story because then I visited the town.
So I'd seen how depressing it looked. And I thought, well, I'll go and interview the people and see if I can kind of understand this a little bit better.
And I met the people who'd been in the sleeping sickness. And the first woman I met, lovely lady Tamara, beautiful, well into her seventies, but had kind of bleach blonde hair and she was really making an effort.
She was lovely. And she basically was telling me that this town was paradise to live in.
What? It really was not paradise. It went down to something like minus 50 in the winter and they had no running water, most of them.
The town had been dying slowly. They had no electricity.
I visited the hospital and there was a bath full of water where they could come and get a bucket of water if they needed it kind of thing. This town was not paradise.
And I just thought, this is bizarre. But then the more people I met, the more I realized that I was not understanding the story, which was that this town once upon a time actually had been paradise for these people.
So basically, it was a secret uranium mining town for the Russians during the Soviet era. These people came from Russia and they were basically mining families and they had been put on a bus one day in somewhere like Siberia and told you're going to Kazakhstan.
They didn't have much choice in it and they got on this bus and they drove to Kazakhstan. I don't know how long that took.
They stopped in multiple bleak places and thought, oh God, I hope this isn't it. And eventually they came to this actual paradise town in Kazakhstan where they had built brand new apartment blocks.
They had a brand new hospital. They had a facility for looking after the children.
There was fruit and vegetables in the shop that nobody in the Soviet Union ever saw. And the reason it was set up that way is because they wanted to keep this mining town secret.
They wanted these people to stay in the town. They wanted these people to be happy.
So I had thought the people were delusional when they said this town was paradise, but actually it had been. Relative to where they came from.
Oh yeah. And then what happened was the Soviet Union broke up and the uranium mine shut down.
And one by one, all these amazing facilities they had were lost. Most people left the town.
There had been thousands living there, but this stall worth 300 stayed. And I think they stayed kind of thinking,

this was once paradise. I raised my children here.
This place means a lot to me. They told me stories about having picnics by the riverside and it was all very beautiful.
They thought that it would eventually go back to being paradise. But instead what was happening was it was just becoming more and more decrepit.
What happened when you got the sleeping sickness, the only way to cure you was to leave the town.

I think it was just a really phenomenally sophisticated way of making that really hard decision. In the end, I thought it was a kind of a love story for this town.
You know, it meant so much to them and leaving it was so painful. Sometimes these psychosomatic disorders, we think of them as illnesses, but sometimes they are a way of our brains helping us through a problem.
There's survival mechanisms in some way. Our subconscious seems to have a genius about saving us.
Dissociative seizures, very often they happen for the first time at a time of great stress. There's only so much you can handle, and this is your brain protecting you from the thing you can't handle.
Then it all goes a little bit awry. Or your body will make your back hurt so much you can no longer do the job that's killing you mentally.
The body will somehow protect itself. Absolutely.
Okay, so the new book, The Age of Diagnosis, How Our Obsession with Medical Labels is Making Us Sicker. Now, I sought out an expert like you because you'd have to be asleep to have missed this wave of self-diagnosis that we all are giving ourselves.
The current one, and we'll just put an earmark in it, is every single person I know, and I've convinced myself of it maybe, has ADHD. Right now, that's the one.
We'll get to it, but let's walk through why this felt like a natural progression in the books you were writing and why you felt like it's time to shine a light on this. Yeah, everything I write comes from the patients I care for.
I'm in full-time NHS practice. I'm seeing patients every day.
And the patients I'm seeing have changed over the decades. A lot of my patients are very young.
I will see people in their 20s and they're coming to see me now and they will have a list of nine, 10 different diagnoses. But they've given themselves or they've accumulated from medical...
No, they've accumulated. This is a kind of a collusion between

society and the scientific world and the medical world. The doctors live in the same culture that

has its powerful impact on us. 100%.
And we are responding to the needs of the culture in which

we live. So it's a kind of collusion of multiple different sections of society.
But basically,

I'm going to go ahead and get started. powerful impact on us.
100%. And we are responding to the needs of the culture in which we live.

So it's a kind of collusion of multiple different sections of society.

But basically, I see these young women, I always say women, but it's not only women,

but it is slightly more women.

And I think perhaps I became interested in because I could kind of relate to these people in this situation being dismissed.

They'll come and they'll have ADHD, autism, a condition which people may or may not know

called POTS, postural orthostatic tachycardia syndrome.

We can see. the situation being dismissed, they'll come and they'll have ADHD, autism, a condition which people may or may not know called POTS, Postural Orthostatic Tachycardia Syndrome.
If you haven't heard of it, you will soon. It's best you don't.
No, it's coming. It might be best you never hear it and then you can't get it.
Then you won't get it. You can't get what you don't know.
I'll stop listing them. They'll have 10 diagnoses that often come in a little batch together.
What's really noteworthy, I was chatting about this with a colleague recently, is basically we didn't see people with this constellation of diagnoses 10 years ago, but we also didn't see these people with a constellation of undiagnosed symptoms that fit with these diagnoses 10 years ago. So it's not like you can say that 10 years ago or 20 years ago or 30 years ago, there were loads of people suffering in this way and no one knew what it was.
And now there are names for it. People are developing groups of symptoms that people didn't have 30, 40 years ago.
And we're giving it names. Right.
So you say like worldwide, 537 million people are living with diabetes. That's incredible.
That's half a billion. 783 million are predicted to be affected by 2045 with diabetes.
Oh my God. We kind of have three explanations on the table that would make sense.
One is we're sicker. A second explanation would be we are just finally able to diagnose all these people because we now have the language and it's in the DSM and it's in these other places.
And maybe we're getting healthier because now we're getting treatment. And you're offering a third explanation.
When you talk about medical overdiagnosis or you say you're writing a book about medical overdiagnosis, everyone thinks of the autism, ADHD things, but you've already raised diabetes. This actually overdiagnosis kind of epidemic applies to both physical and mental health problems.
So it applies to cancer, it applies to diabetes. It applies to asthma.
It applies to high blood pressure, high cholesterol, as much as it does depression, ADHD. Yeah, I was shocked to read in your book that asthma diagnoses have gone up 48%.
That's freaking Teddy Roosevelt had asthma. This isn't a new diagnosis.
There's different ways that this happens. The two main ways that it happens is one, you are kind of diagnosing things that don't need to be diagnosed.
So if we take diabetes as an example, we now have this state of pre-diabetes. So you don't have diabetes yet, but you're almost getting it.
It's not really a diagnosis in itself, but it's becoming one. Everyone I know is panicked about their pre-diabetic.
Basically, the way these things come about is that we as doctors and scientists are encouraged to make sure we keep as many people healthy as possible and therefore to find as many people who might be at risk of disease as possible and treat them. So we are incentivized to find as many people who might get diabetes as we can and an absolutely religious belief in the assumption that finding diagnosis early and treating it is the right thing to do so what we'll do is we'll say okay to be pre-diabetic used to mean that you had to have a fasting blood sugar of six but you know what i think that's too high we might be missing some people so we expert committee get together and we say let's change that parameter and say you can have pre-diabetes at 5.6.
Nothing has changed in science. Nothing has changed in our bodies or in society.
The only thing that has changed is that in order to make sure we are missing as few people at risk of diabetes as possible, we are going to change the number at which you can be diagnosed. And the then is obviously you identify all these extra people with pre-diabetes and that particular change if applied to the entire population of China would have meant that 50 percent of men in China were pre-diabetic and something like a third of people in the US would be pre-diabetic so these thresholds are being set phenomenally sensitively the thing we're not great at is proving that that actually is making people healthier.
And there isn't an awful lot of evidence to suggest that by adjusting thresholds in order to identify prediabetes at an earlier stage, you're actually preventing lots of people from getting sick further down the road. Well, actually probably aren't.
And we tend to move these goalposts and consider success to be how many new sick people can we find rather than the more important end point which is what difference has that made to these people's long-term health what we very often don't do say in the case of cancer we'll say well we screened a thousand women for cancer and we saved one life but we potentially treated 10 people for cancer who didn't need to be treated. And what was the impact of that? What was the impact emotionally, physically, psychologically, everything? We're very good at capturing more and more disease, but we're not terribly good at measuring the implications of that down the road.
Yeah, how successful that was. Yeah, let's talk about diabetes a bit further.
I guess when I was growing up, if you were suffering from the condition of diabetes, you were having amputations, you were dying quite prematurely. Have we reduced the amount of people getting amputations or dying prematurely? I don't know specifically about amputations, but have we reduced the number of people who are ultimately developing diabetes? No, diabetes is still rising.
And that's always my issue with these things is now we've got this whole new population with pre-diabetes, which isn't really a disease state, but a kind of a warning. And if identifying those people and then giving them advice really worked, we should ultimately have fewer people with diabetes and fewer people with serious diabetes, but we don't.
So what are we doing? Why are we doing it? And what has been the impact for those people newly labeled pre-diabetic? Yeah, you say many of the diagnosis aren't what they seem. The quest for certainty turns borderline medical problems into ironclad diagnosis, pathologizes the normal and hurt those who are most vulnerable.
In other words, we are not getting sicker, we are attributing more to sickness. Break that down a little bit.
Autism was developed as a concept in 1943. And when it was developed, the people who were affected by autism had very severe communication problems.
So severe that they would have no interest in people at all. So there were very, very disabled young people.
And it began in infancy. It began at a very young age.
It was obvious from an early age. And the people who had it could not function normally in the world.
Now, at some point in the 1960s, Lorna Wing, a scientist, she said, well, I think perhaps this thing called autism, we're probably missing cases of it. We can see these really severely affected children.
You don't have to look very hard to see them. But I think if we look in these schools, we can see there are other children who are being poorly served by society because perhaps they have a milder version of this.
And I think that's really valid because when I was in school in the 1980s, there was no people with special learning needs. There must have been people who were being neglected.
Oh, certainly. You kind of go back in your mind and you go like, oh, right.
Yeah, that kid was ADHD and that kid was this. We had no terms for any of it.
Exactly. And there was no support systems.
And imagine how differently those young people's lives could have gone if people had realized they just learned differently. It's such a complex issue.
I'll add that I just interviewed Bill Gates two days ago

and I said to him, he knows everything.

He was consuming all things.

He read all 21 volumes of the encyclopedia

at nine years old.

I'm like, when did you first hear autism

and did you connect with that concept?

And he said, I was aware of it,

but at that time they were such extreme examples that I would have never put myself in that bucket. Because again, these were people who were nonverbal.
Does he put himself in it now? Yes. He says recently, and that's what's interesting, is he recognizes he is on the spectrum of it.
And then the natural question is, would he have been served with that title or not? That's the big unknowable.

This is the difficulty. So let's say someone realized that some children were not being properly supported and they changed the diagnostic criteria so that slightly subtler signs are sufficient to make the diagnosis.
The problem we have now is that has continued since into, I would say, to a certain degree, going to be a little bit harsh, the realms of the ridiculous, because you've got to the point now where you not only are looking for signs that are so subtle that they are barely perceptible, we are also including something which people are calling masking. And masking is you don't appear in any way autistic, but you feel autistic on the inside.
This concept of masking or camouflaging made complete sense for people with severe autism. There's a program on TV, I don't know if you've seen it, it's called Love on the Spectrum.
Yes. And I was resistant to watching it at first because I thought it would be kind of mocking or something.
That's how I felt, yeah. But it's beautiful.
There's really lovely examples of masking in that where you you kind of see that the people are being taught, when you go on this date, have back and forth conversations, you can see them masking in the sense that they're learning the social rules and applying them. But it doesn't really look completely natural ever.
The masking is obvious. One I like to add is when the movie Rain Man came out, the man it was based on was interviewed with his father.
And Leslie Stahl did the interview from 60 Minutes. And this was in the 80s.
And he was very hard to conduct an interview with. He also memorized every book in the Salt Lake City library.
And he could read with his eyes separated both pages at the same time. So she did a follow-up story on him like 10 years ago, went and revisited him.
He's still at the library reading and the dad's still there. And he greets her and he's making eye contact with her and he's interacting in all these ways.
And when he's not there, Leslie says to the dad, he seems to have improved a lot. Has there been some treatment? And he said, well, make no mistake.
He's exactly the same. He has just learned more tricks over the years.
He knows to force himself to look at you and he knows to say, yes, Leslie. And so that's all that's happened.
You haven't seen an improvement in the condition. That's sort of masking or camelizing.
That's real masking. Yes, that's learning the social rules and applying them.
But often it's hard to sustain. It can be exhausting for people who have autism and it often is very difficult.
But these concepts like masking have been taken to the point now where someone can be masked all the time so that they never look like they have social communication problems. And that still qualifies as a diagnosis.
So we're being asked to make diagnosis in people who don't show the typical features of autism, but the self-reporting of it. Yes, more people needed to be diagnosed for sure.
And there were children who needed help who were not getting help and who benefited from the relaxing of the diagnostic criteria. But now the diagnostic criteria are relaxed to a point that it's not fair to the very, very mild people who are being labeled.
I'm not worried about Bill Gates at all. He seems to be doing fine for himself.
I'm worried about children. So you got a 16 year old child who perhaps has some social communication problems, but they're quite mild and they're able to compensate and they're able to mask to the degree that they can function normally, albeit maybe they're nervous and they don't enjoy things and they're exhausted afterwards, but they can function.
What happens to a person like that when you tell them that they have autism? You're essentially telling them that they're neurodevelopmentally abnormal, that there are things they can't do because their brain's not normal. That is a self-fulfilling prophecy for a child.
We've all gone through those difficult periods and we've had to learn to overcome our shortcomings. But if you tell a child that they have a neurodevelopmentally abnormal brain, you're really running the risk that you have this labeling effect where you concentrate on the things you can't do.
You become the thing that you've been labeled as. It's so nuanced because what's interesting is I think the diagnosis of autism is almost more for all of us neurotypical people, in quotes, it does do and I've witnessed it around me and I myself know I'm guilty of it if someone says this dude's autistic when you meet him just know he's autistic I can go into all these other things that might trigger me when I'm interacting with them and I have a level of compassion now that I didn't have which is just a shortcoming of my own own.
Monica and I have talked before. It's like really the end goal for all this would be to be compassionate to everyone with all their idiosyncrasies.
But that label helps us. It helps us write off stuff that would otherwise irk us.
It's like they can't help it. You can't help anything about your personality.
But it is a complimentary situation because now I have lower expectations of you and you have lower expectations of you. Exactly.
So it can be also a self-perpetuating. And it also isn't as straightforward as to say you can't help that.
Part of maturing is learning to adapt. You know, I was a very shy child.
You would never imagine that I would be sitting here in the future. What if my shyness had been pathologized? It disincentifies people from trying to overcome their difficulties.
It reinforces symptoms instead of helping people to kind of get over their problems. And I know that you're saying if someone tells you that they're autistic, you think, OK, well, I understand you a little better now.
But I don't think that's everybody's attitude. I think there's also people who, if they that someone's autistic in the mild range I should say that when I'm talking about this I'm really talking about people who are in that borderline zone.
There's always value to being diagnosed if you have significant problems. I'm talking about the value of being diagnosed if you're in that borderline zone.
Some people might be understanding but other people will be quite judgmental of that. It's also very worrying that the milder and milder the diagnosis get, the more we're trivializing this disorder for people who are really disabled by it.
People with mild autism, again, this very borderline area of autism, have very loud voices now because we see there's a lot of people in the public eye who have these diagnosis and it gives people the idea that they know what these things are. I doubt they've seen many people who have what I would call significant moderate to severe autism because they don't get to be on telly and they don't get to be on podcast.
They're often nonverbal. Yeah.
It is so ubiquitous. You almost have to delineate.
There's that new podcast telepathy tapes and it is about nonverbal autistic children. But you have to say, oh, it's about autism, but you know, really extreme.
You have to say that as opposed to just before. That's what it meant.
And the sort of tone of conversation sometimes can be quite difficult for people in that severe category because there is a sort of conversation that says it's okay to have these mild autistic traits. You shouldn't them you should embrace them be your most authentic autistic self but I've talked to the families of people with severe autism if they didn't help the children in the family to overcome their difficult behaviors they would be institutionalized they would not be safe in the world and they find it really quite disparaging to have people going, be your more authentic autistic self, because really what their children need is a lot of support and to learn to control the sort of outbursts that they can sometimes have.
I don't want to say to people, well, I don't truly believe that in the very, very mild category, everyone diagnosed with autism really is autistic. I'm not absolutely convinced.
However, I don't think that's the most important question that I need to answer I think the question needs to be answered is is it benefiting them to be labeled because no one can say where the line between being autistic and not autistic is there is no such line so it will always be difficult I want to ask people who support the more inclusive diagnosis is it helping people? Because as far as I can see, it's not helping people at all. If it was helping people, we've been expanding the concept of autism since the 1990s.
So we're now like a good 30 years into this. And the story I'm being sold is that, you know, if we can recognize children and give them these diagnosis and give them support, then we'll be creating happier, better adjusted adults.
Are we, as far as I know, mental health problems are rising significantly and there is no evidence at all that giving people with a very borderline diagnosis and medical label is actually helping anybody. I think, as you said earlier, this is a collusion of many, many facets.
And so one that I can immediately see is parents whose children exhibit behavior that is embarrassing to them in their own ego because they're an extension of your identity. I think they themselves are comforted by some medical diagnosis as opposed to just living with the embarrassment that, yeah, sometimes your kids are really embarrassing.
That's part of the fucking ride. It's not you.
You don't need to go find some diagnosis so you can tell everyone she's this, he's that. And then you alleviated yourself of that.
I think that's a bit harsh. You do? Yeah, I do.
Oh, I see so many peers excitedly sharing the diagnosis their kid just got. I think it's a little bit more that everyone's desperate for their children to do as well as possible.
And they're desperate to do the best for their children. And this at the moment is perceived as a way of doing everything you can for your child because they'll get the maximum amount of help and support possible.
First of all, our society is too perfectionist. You know, this kind of concept that we'll all succeed.
Well, we can't all succeed. It's simply not realistic.
And the idea that if you try really hard, you will ultimately get the thing you want. Well, it doesn't actually work that way.
You have better odds of getting what you want if you try really hard. Yeah, you need to try really hard.
But I was shy. I worked to overcome it.
But maybe I might not have managed that at some point. And that's the point you need to recognize.
The things you can overcome and the things you can't overcome. And I think we still have this expectation of our children are struggling in school.
That if we get them the maximum amount of help and if we push them hard enough, that they will become the person we believe they can be. And maybe we'd be kinder to our children if we accepted that sometimes children are mediocre at certain things.
And instead of concentrating on that thing. Funnels into one of the topics of your thing is this kind of false notion of the norm.
I think that's the message that needs to get across to parents is irrespective of what their motivation may be. I think that people perceive diagnosis as at the least something that will help their child.
What people are not understanding is that diagnosis is not inert. You don't just diagnose someone and then it's all rainbows and sunshine from then on in.
There'll just be help and nothing bad comes with it. There are substantial harms with giving people a medical label.
Other people expect less of them, as you've said, so underestimate them. They underestimate themselves.
They become more aware of the symptoms. Like no one ever said to me, you're very shy.
I was just aware of it. But perhaps if you have these things pointed out to you and pathologized, you become more aware of it and kind of dig into it.
So I think a parent may be well meaning. We as a society must find a way of supporting children without labels.
And parents who seek out labels for the children must understand what a dangerous thing that is to do to label your child at such a young age. What's happening with Huntington's disease? I just think this is a really powerful story to teach us about how your experience of your body is altered about beliefs about your health.

So Huntington's disease is a degenerative condition.

It's very, very unpleasant.

It usually begins in someone's 30s or 40s with psychiatric symptoms and behavioral changes.

It's a neurodegenerative condition.

So you get frontal lobe symptoms like impulse control and then you start getting involuntary movements. They're called choreoform movements, like funny writhing movements.
And then ultimately you lose control of your speech and of your swallow. So you have both a psychiatric decline and you have a physical decline.
It's an inherited condition. And they discovered the gene for Huntington's in 1994, I think it was.
If your parent has a Huntington's disease gene, then you have a 50-50 chance of getting it. I think this is a fascinating concept because there are people walking around knowing that they have a 50-50 chance of getting this disease and knowing that there is a test that they can get that will tell them whether they have it or they don't have it.
And of all those people who could have that test, only about 10 or 20% of people actually have the test. Oh, interesting.
They have this opportunity to know this enormous part of their health future and they don't take it up. I spoke to a lady called Valentina.
Her mother was adopted, so didn't know this was in the family. Valentina was 28 and pregnant when she discovered her mom had Huntington's disease.
So the minute she discovered that, she knew she had a 50-50 chance of getting it. And she knew that her unborn child had a 25% chance of getting it.
Obviously, it was devastating. She had siblings who had children.
The family were very anxious and their first impulse was to think they would be tested. They met genetic counsellors and then it was pointed out to them that the minute you test your whole life changes if it's positive and it's a devastating diagnosis so they put it off.
Now what happened to Valentin in the following years is although she hadn't tested she became absolutely convinced she had Huntington's disease. She could just tell she had it.
Organization problems and anxiety and anger outbursts are common at the beginning of Huntington's disease. She began having arguments with her husband or if she went to the airport, she couldn't organize her documents.
If she was walking, she'd walk into walls. So she was aware that her symptoms were accruing, but she was frightened to have the test to have it confirmed because the minute it was confirmed for her, her children were at a much higher risk and she just couldn't face the idea of looking at her children and thinking i'm gonna die and you've got a 50 50 chance of going the same way so she actually waited about 20 years to have the test and she only had the test when she was so disabled by these symptoms that she realized she just had to have it confirmed and when she went went and had the test, it was negative.
She didn't have it. Oh, my God.
Oh, my God. She didn't have it.
Oh, well, in that case, I wish she had had the test. Oh, obviously, yeah.
But you see, that works both ways. But that's how strong it is.
It works both ways. You see, because all of her little symptoms didn't all go away.
She still got flustered in airports, but it didn't get out of control. And that was what was happening is she's noticing little things.
And because she thought she has Huntington's, then she was examining her body and thinking, what's going to happen? Because she's seen her mom get sick. She knew exactly what was going to happen next.
So she was really focused. But imagine if 20 years ago she had the test and it was positive.
then every one of those symptoms, none of which were due to Huntington's, would have persisted. That's the difficulty with knowing you're at risk of a disease that might not happen for 20 years.
The symptoms will start long before the disease starts. And every ordinary thing that happens to you, that happens to all of us, every time you lose your keys, every time you trip over a paving stone.
Yeah, it's confirmation bias. You're excluding a ton of data and focusing on a very tiny bit of data to validate what you already have a hunch is true.
Exactly. And it shows the power of thinking you have a disease.
And that's why it's so important to this discussion about pre-diabetes or autism or ADHD, if you think you have the disease,

some people will display the features of the disease and that can be really hard to overcome.

Stay tuned for more Armchair Expert, if you dare. well even when i see on, because it's everywhere, ADHD is the thing.
And I see these videos, and of course, it's like astrology. Like, if you say enough adjectives about me, you're going to find some that are fitting.
So I'll see the couple things that are identical to me. Like, if I start brushing my teeth, I've got to immediately do something else.
There's no way I can stand there and just brush my teeth. And I'll see that one, oh yeah, that's me.
But I've also ignored the six they said that I have no connection to whatsoever. And also we're back to something we said at the start about when does worrying about your health become hypochondria? It becomes a medical problem if you're impaired or disabled.
And these are the subtleties of diagnosis that people don't really understand. I could look a list of ADHD symptoms and have them all, but they have to obey certain parameters for me to have an actual medical problem.
And the parameters they have to obey is they have to be there in every environment. You're not just autistic in school, you're autistic at home, you're autistic in every environment.
And they have to be there to a degree that you are are disabled by them we've become very casual about this sort of like i'm on the spectrum or i have adhd well listen we all have some of the traits of these things but we do not have a medical problem unless we are impaired and it's the impairment that makes it a medical diagnosis and that's what everyone in tiktok is really failing to appreciate, I can't remember whether it was ADHD or autism, but there was something like 11 billion TikTok videos about, I think, autism. And when they scrutinized top 133, 27% of them provided accurate information and the other 73% were just full of inaccuracies.
But that's interesting too, because those inaccuracies are seeding themselves into medical culture as well. Well, it's funny when I see the ADHD clips, which I see all the time, it triggers something that happens a lot in AA, which is I'll be listening to someone share in AA and they'll say like, this, this and this, my alcoholism.
And I often go like, no, that's your humanism. You're being a human right now.
And similarly with ADHD, I'll go, that's just being a human in a highly stimulating world. Yes, you have that.
I don't deny that. But that's normal and natural.
And we all have some degree of that. Exactly.
And I think we're just getting worse and worse at drawing the line between what's a normal amount of it and what is an abnormal amount of it. Do you think part of the problem is with social media? I feel like people want a thing that makes them specific.
They want a thing that makes them special. They want something to be able to talk about, be an expert in.
I wonder if the uptick... I think they want to excuse some of their shitty, unappealing behavior.
Like, yeah, I always am interrupting, but I have ADHD. Don't you also think they want an excuse for some stuff? Yeah, I'm sure that's part of it.
But I also think there is this like inclination to have a thing now to present to the world. Like you don't even have a personality if you don't have a thing.
Exactly. I struggle a little bit with that because I'm seeing people who are, I'm the 15th doctor they've seen and they've got 10 different diagnoses and I'm seeing a slightly different population than the TikTok population.
Right, that's what I'm talking about. And I think it's difficult because you can make generalizations about what's happening in TikTok and then I assume the people who come to me are suffering and perhaps I don't agree with the labels and perhaps I don't agree with specific diagnosis but I do appreciate that if they've made it all the way my clinic, then they're not well and there's a problem.
You know, it can be very difficult for them to hear us saying things about looking for attention. There is something nice about being part of an illness group.
It makes you feel validated. Communities.
They feel validated. Seen.
Yeah. But the distinction you're making is great.
Of all the people I'm seeing on Instagram declaring themselves, my guess that I feel strong about is like 90% of those people have never seen a doctor for it. And they have no program of treating it.
They don't want to treat. That's my whole point.
They don't want anything to change necessarily. They just want to say, I have this or I'm this.
Most of them in that sort of category, next year there'll be something else on TikTok. These social trends occur on social media.
But the difficult thing is that a small proportion of people, these diagnoses will stick and that becomes really problematic. What's going on with chronic Lyme and long COVID? Oh God, yeah.
Lyme disease is caused by a bacteria, which you get from a tick when the ticks come from deer. Lyme disease is just essentially an infectious illness, but there is a subset of Lyme disease called chronic Lyme disease.
I think they're called the National Institute of Allergies and Infectious Diseases would define chronic Lyme disease as a set of symptoms that has nothing at all to do with a Borrelia bacterial infection and nothing at all to do with Lyme disease. There's a large number of people throughout the world who have been labeled as having a form of Lyme disease called chronic Lyme disease, which probably is not an infectious illness.
Now, the difficulty is that Lyme disease can cause symptoms that we all get, like fatigue, aches and and pains and things like that which quite frankly are symptoms of everything. What happens in society is when people are suffering with those kind of symptoms and they're struggling to get a diagnosis they will take the diagnosis that's salient at a moment in time and chronic Lyme disease is a very salient diagnosis at the moment.
It's for people who are struggling without a diagnosis, it can explain a lot and it allows people enter a community where they can get support and they can get treatment with antibiotics, which don't work, but gives them the sense that they are being treated. Lyme disease is a very good example of how medicine is an art.
You know, it's not a matter of someone comes to see you and you think they have a bacterial infection. So you do a blood test and they either have it or they don't.
Tests are so much more sophisticated and hard to interpret than that. You know, every single blood test we do, every single brain scan we do comes with 100 caveats.
If you live in a Lyme disease area, there was a study in the UK in a place called the New Forest where there's loads of Lyme disease and foresters who work there, something like 25% of them will test positive for Lyme disease if you test them. It doesn't mean they have Lyme disease, it just means they've been in this area for a long time.
You have these kind of variables and this is a problem in Lyme disease. If I wanted to make a lot of money, I could diagnose a lot of people with Lyme disease by doing that blood test and telling them you've got an abnormal blood test and therefore you have Lyme disease.
So some people have Lyme disease and really no symptoms. Well, it's not they have Lyme disease.
They've been exposed to the bacteria. They've had an immune reaction and antibodies and they never got sick and therefore they fought it off.
Perhaps they had a really mild case they didn't notice. People are kind of aware that perhaps mental health problems and things may be a little overdiagnosed now, but they don't think quite so much about how the parameters of physical diseases have changed and led to overdiagnosis.
It's fine that we do what we do as long as people are able to go to their doctor and ask the right questions and understand the issues. Long COVID.
This is one that I just intuitively, when I hear it, I'm a little skeptical of. How it came about is so interesting, really, because as a hashtag, it appeared on Twitter.

An Italian woman tweeted hashtag long COVID on the 20th of May 2020,

raising awareness about chronic symptoms after COVID infection for the mildly affected.

You say March of 2020?

May.

May.

Okay, it's only three months in.

Well, that's precisely, you know, we're already predicting disability for millions,

and we haven't even had time really for chronic illness to develop.

But this concept that a mild illness could lead to chronic disability took off after that hashtag.

It was shared throughout the world.

And this story spread the concept that the mildly affected could develop long-term symptoms.

You know, it went from Twitter to mainstream news to medical newspapers with phenomenal speed.

We're going to have a out to ever actually declare something long COVID. There was so much that was counterintuitive to this being related.
Let's just say that, of course, there are people who have chronic symptoms. If they were hospitalized, I volunteered in ITU during the pandemic.
I saw how bad things were. You would not be surprised a very sick person would have chronic symptoms.
Also, all viral illnesses cause chronic symptoms in a small proportion of people. There is really good evidence that most people, however, long COVID probably didn't get it related to the virus, but rather to the kind of idea of long COVID.
Firstly, it's a different population. So people in hospital were older people with diabetes, they were mostly men.
People with long COVID were younger people, healthier people, and mostly women. And studies that have emerged have been very interesting, like loneliness is a precursor for long COVID.
A study in Germany followed health care workers from the beginning of the pandemic and people who had an expectation of symptom severity developed long COVID. So if you expected to get it, you got it.
Depression. I kept hearing brain fog.
I'm like, we're in a pandemic. Our brains are foggy.
Yeah, we've knocked out 80% of the stimuli we're used to. And that point is so important because what they were doing in the studies at the beginning on long COVID is they were surveying people.
They were self-diagnosed and a self-diagnosed person is more likely to get long COVID. And they all had huge constellations of symptoms, but there was no control group.
And later when they'd had time to do the science properly and they were now comparing people with long COVID with people who were in the pandemic who didn't get COVID, they also had hundreds of symptoms. Exactly.
Of course, it was a crazy time psychologically. So science of long COVID was very poor at the beginning.
And the general public was scared witless by this concept that they could get chronically ill, even if they weren't hospitalized. And much like other people I've described, like the lady with Huntington's disease, if you think you're going to get chronically ill, then a small proportion of us will get chronically ill.
I don't want to be dismissive of it because it served a very important purpose. There were people dying and that was terrible and there were people losing loved ones and that was terrible and there were people losing jobs and that was terrible but there were also a lot of other people who were suffering and there was no space for them where did they go people at home alone with nobody to talk to who weren't necessarily physically very ill long covid gave them a voice it gave them a group it gave them a place to go and it gave them a name for their suffering that other people gave more respect to than just we're all in a pandemic and I'm having a horrible time.
Nobody had any sympathy for that. So it served an important social purpose.
How do we correct? How do we keep all the upside of figuring out a lot of these diseases and providing help for people? And how do we shave off this large group that's also shouldn't be seen as having a pathological disease? I think it's kind of a multifactorial. Lots of people have to change a lot of things that they're doing.
First of all, as a medical community, we need to really challenge this assumption that early diagnosis works because we've been diagnosing cancer, blood pressure, diabetes earlier. We're not making anyone any better.
I think we do need, and this might sound a bit strange, to dial back on some of the mental health campaign awareness work that we're doing because there was a very interesting study out recently that showed that raising mental health awareness in schools actually added to emotional distress rather than subtracting from it. We perhaps would do better to teach people what normal looks like and learn how to support children without labeling them.
Why can't we recognize that a child is struggling a bit in school and can do with learning differently without calling them neurodevelopmentally abnormal? So I think maybe we change the names. Support people without labels would be really useful.
Yeah, you get into the structural and logistical issues there. It's like there are X amount of resources given to those added hours of teaching and test taking.
And then it's kind of the same way the insurance reimbursement works. We've got to get this one thing so we can get this other thing we need.
I mean, you're right. I don't think it's very simple.
It would require a huge overhaul of systems in order to allow us to support people without medicalizing them. Right.
Also, we've got no support systems outside of medical institutions. Where do people go who are suffering? A doctor is a place you can still go.
Perhaps we need better support systems for people that are not surrounding medical institutions. Yeah.
They don't feel the need to be labeled to belong to a group and to get support. Yeah, if there was just a place you could go to that was funded, that was like, I feel shitty.
Therapy or is that still to? I think that's still sort of medicalized. People just want to belong to a community.
And the UK, the church isn't quite so prominent. It's slightly different in the US.
In the UK, that system of being supported by your church has really been lost. But, you know, I'm not advocating for that idea, but there is something to be said.
We want church without all the collateral charges that came with it. Without God, without priests, without pedophiles.
I love this topic and I think it's actually kind of brave, But I do think you do it with a ton of compassion, even tackling psychosomatic disorders in the way that you have with compassion and actually a call to treatment for the people. It's difficult for people to hear some of the things that I'm saying, and I do understand that.
It'll be threatening to a lot of people's identity. You know, I think that a lot of people in the world are aware that something isn't going right.
Mental health problems, something like one in five people in the world now has a mental health diagnosis, and there is something definitely wrong there. Sometimes it can be frightening to be honest about what you think is going wrong, but I think a lot of people have a lot of suspicions that aren't being voiced, and we do need to have these discussions more openly.
Well, Dr. O'Sullivan, this has been wonderful.
I'm so grateful that you made the long trip to be in rain and be at Harry Potter. I was absolutely thrilled and delighted to be here.
I'm honored. So thank you so much.
Oh, yeah. Everyone check out The Age of Diagnosis.
Incredible book, incredible message. Thank you.
Hi there. This is Hermian Permian.
If you like that, you're going to love the fact check of Miss Malka. It's a little chilly.
Wow. Talk about a reversal reversal.
Double reverse. This is a reverse back.
Oh my God. Reverse back.
Because last fact check, I was in a sweatshirt. You were in a T-shirt.
You were not cold. Yeah.
Now you're freezing. I'm in a tank top.
I know. And I'm hot.
I had walked yesterday. Oh, and you didn't walk today.
No, I didn't. And I just exercised with resistance training.
The aliens would be really confused by weightlifting. Oh, yeah.
Because initially they'd be like, oh, that monkey has to get that thing up and he's going to move it. So no, he's setting it down.
Or maybe it was too heavy. No, he's picking it back up again.
Where's he going to take it? No, he's setting it. Yeah, they don't get it.
Just repetition, useless movement. Do you think the aliens have to worry about bone density? No.
There's zero gravity. They just goo.
They don't even need really muscles. So jealous.
Yeah. Speaking of, well, this episode, which is for Dr.
Susanna Sullivan. Dr.
Seuss. Yes.
It's connected to this episode, but it's also a ding, ding, ding for a future episode. I'm starting to panic that I have something.

Oh.

And it might be psychosomatic.

Yeah, I would have thought your conclusion after Dr. Suzanne O'Sullivan would have been,

I'm not going to ignore that, all that stuff,

but you're saying it got worse?

Well, it didn't.

It didn't get worse.

I was like, oh, yeah, I'm fine. Nothing's like really getting in my way, you know.
Yeah, yeah. But then we have another expert coming up, Easter egg.
And there is something brought up in that episode. I'm as lost as a listener.
Oh, perimenopause.

Well, I want to kind of.

Yeah, yeah.

No.

We've been saying we're going to have one for a long time.

That's okay.

I know, but I don't want to get into the details because it's not, I think I have perimenopause.

It's, I think I am getting frozen shoulder.

Oh.

You're probably just shoulder hurts.

Maybe.

Can you trace it to any activity?

If I must.

Okay.

What would be your guess?

Thank you. You're probably just shoulder hurts.
Maybe. Can you trace it to any activity? If I must.
Okay, what would be your guess? I mean, sometimes I do some little lifting. Some lifting? Yeah.
Did you lift weights? Yeah, sometimes I do. And then your shoulder hurts? Well, no, it also happened when I was home.
In Georgia? Yeah. But you don't call that home anymore.
Oh, God. It's so confusing.
It happened when I was home. Something happened when I was home that made me think, oh, gosh, I might have this thing that my mom had and my grandmother had.
Yeah, but what age did your mom have at? Let me ask. I think it's Relly.
Okay. Let me ask.
I have a crazy sim. Okay.
It's bad. Like, I feel bad saying it.
Okay. And I think people might be mad at me for saying it, but I have to.
This is wild. You must get it off your desk.
So, because of the SAG Awards, there was a bit in there about Gossip Girl that I wrote. And because of it, I was mimicking the opening of the pilot.
So I started the pilot to hear the voiceover to write it. The Gossip Girl pilot.
Yes. And so it was just on.
OG original Gossip Girl or the reboot? Original. Okay, great.
With Kristen. Great.
So then when I listened, I just kind of had it, I kept it going. Yeah.
So I've been watching it at night. Oh, wow.
You're in. I'm back in.
I've just. Had you watched it when it was airing? Yeah.
Oh, you did? Uh-huh. That was one of your shows.
Mm-hmm. Okay.
So I was doing a little rewatch, casual rewatch, which was nice and nostalgic, liked that. And I just got to this part with Michelle Trachtenberg.
Oh, wow. Okay.

And I was watching,

she was on, you know, a bunch of episodes,

but this was her first time on it. And I was, and I thought,

whoa, I haven't, like,

seen her in a while.

And she has a really

great

part on that show, and she plays

a horrible villain who is scary and manipulative and scary. And so I've been thinking a lot about her.
And even yesterday I said to Jess, I said, I'm rewatching Gossip Girl. And did you see it? Michelle Trachtenberg has such an interesting part in it.
Yeah. And then she passed away today.
Yeah, that is weird. It's really sad.
I mean, I don't know any of the details. Nor do I.
By the time this is out, maybe there will be some details. Yeah.
But I just go through a checklist in my mind because I, like everyone else, or I think, we all want to make sense of the world. It's like...
I know. If it's nonsensical, it's very scary.

Exactly.

If it makes some kind of sense, I can deal with it.

And so I...

Yeah, I just go 39 is too young to die of all the other things.

Yeah.

And then I just start doing like probabilistic guesses.

I know, me too.

We all do, I think.

And I mean, when things are ruled out like a car accident or things like that, yeah,

we start making... But I remember people, we were pretty early, or I was—or I felt no tension for me personally to guess that Matthew Perry had OD'd.
But people were really mad at me about that. Well, you knew him.
I mean, that's fair. I knew him, and it's just—it's my disease.
Yeah. Like, I know— She did have a liver transplant.
Oh, she did. Ugh.
It was really sad. So tragic.
And what? That's so weird. Oh, yeah, yeah, yeah, yeah, yeah.
I mean, I haven't thought about her in a really long time. And then yesterday I said it, said her name out loud for the first time.
I don't. Oh, my God.
Be careful. My ring's back.
That's what Jess said. He says, you really need to be careful.
You need to be a little more careful. What am I supposed to do? Just watch new stuff.
I'm so powerful. Just watch new stuff.
Oh, my. I'm rewatching something too.
I started something over again. What? Which I don't really do.
I've done Patriot three or four times. Sure.
But I'm unsatisfied with the amount of Goggins I'm getting in White Lotus. Oh.
It's like it's a tease hit of Goggins. I'm not caught up.
Okay. Did you watch the first episode? Yeah.
There's only two. Yeah.
So it's like, you know, it's like when someone would offer me one Vicodin. I'm like, I would just go, I would pass.
I would go, well, do you have four? Interesting. And if they say no, I go, oh, okay, thanks for the offer.
But I don't want a hint of the feeling I'm going for. I'll just get really agitated.
I understand that. This is no knock on White Lotus.
It's great. It's just an ensemble.
Of course. And I just want some Gagin.
So you wish he wasn't even in it? No. No, no.
I'm not going to put him on. I'm not going to fully map on the Vicodin analogy, but I did start Fallout over again.
Oh, nice. Last night.
I'm like, I need to see him for like 17 minutes with no nose, tons of dialogue, making moves. Yeah.
Yeah. And it's, and I watched it recently, but I'm, it's, it's great.
O'Sullivan has come up a lot in my life since we interviewed her. Me too.
Yeah. I loved this episode, but I loved what it made me start thinking about and questioning.
And I think everyone is overdiagnosed. I think everyone's overdiagnosed.
And then also, I'm glad she asked this second round of questioning about psychosomatic disorders. because I think I was, I kind of, I think I would have guessed about the number she said.
Like it wasn't shocking to me that 30% of all neurological seizures are psychosomatic or that 30% of. Really? That was shocking to me.
No, I know so many people who go to the, personally, I know a lot of people who've gone to the doctor having a heart attack and it's not that. It's anxiety.
Yeah. But a seizure is so, I mean.
Yeah, you would think, like, you can't trick it. But then, again, I don't, I've never thought they were tricking them.
That's Munchausen, where you're faking something. I've thought, no, people are experiencing this.
I don't doubt that. Right.
But I didn't go this step further, which I like that she did, which is like, yes, they're psychosomatic. They're not, the cause of them aren't this other thing.
Yeah. But the results and the symptoms are actually the same symptoms.
They're just as serious. And in fact, more so in epilepsy.
As she said, an epileptic would probably have one seizure a year or maybe one a month would be a lot. Well, medication will help.
And these people can have 100 seizures a day. No medication.
Yeah, her going. I think I was in the past like, yeah, that's psychosomatic.
You can't do anything about that. Yeah.
Like it's in your head. Yeah.
So what would we do? But the notion that she's really screaming, we need treatment for psychosomatic illnesses.

I know.

It's the same experience.

Exactly.

Yeah.

Well, she said for some people it helps to know that that's what's happening.

And that makes sense.

That's almost like a DBT.

CBT, DBT.

Yeah.

BBT, BBD.

Uh-huh.

Poison Man.

BBD.

A&W.

Belle Viv DeVoe. But it only works 30% of the time.
I know. Which is a bummer.
But again, the same with recovery for addicts. Yeah.
Nothing's above 30%. Yeah.
But for me, I'm at least going to go try the thing that I have a 30% chance at. And for me, it worked.
So I think people should still pursue it, whether it's 30%. I agree.
I wonder how many neurologists know. I mean, do you think they all know this? They must because as she said, she would start talking to other specialists, asking the pulmonologist, asking the cardiovascular, asking the the...
Yeah. And they immediately were like, oh yeah, it's like 30% that aren't actually having the thing.
So weird. Because like I had not heard that at all.
And I had gone to an... It's not like he said, well, let me see if they're psychosomatic.
Like that was not a thing. Right.
At all. But what is unfortunate, and it probably, I'm surprised this didn't come up, because you can delineate the difference.
So you can observe the brain having an epileptic seizure versus a psychosomatic seizure, and there's a clear difference. Same with the heart stuff.
Same with the breathing stuff. All of it.
The mental stuff is not observable. Yeah.
We cannot tell the difference between whether you have psychosomatic depression or any of these disorders. Yeah.
We can't tell if you have some base biology or biochemistry or anything. Yeah.
So what do we do about those? Like the overdiagnosis of ADHD. You could have all the symptoms of ADHD.
It would be weird to me that this tracks almost perfectly across all of the different medical conditions, and then it would stop at ADHD. No.
Right? Yeah. It is.
So I would argue probably conceivably 30% of people with ADHD, they definitely have the symptoms of ADHD. Sure.
But they don't have ADHD as we think of it. Yeah, but also because we just decided what that was.
Yeah. Like, it's not, I mean.
Yeah, what level are you distracted? Epilepsy and diabetes are like clinical and medical. And ADHD is, but now we've diluted it into that like everyone has it.
Right. And that's just personality traits.
I'm going to get in so much trouble for saying that. But I think a lot of it is us taking personality traits that are like— And making them disorders.
Yeah, that are our favorite personality traits and calling it a disorder. Yes, but she was quick to acknowledge too, even the markers in the hard, let's call them the hard sciences of biology, like taking a blood sugar level.
Yeah. That's a metric.
Yeah. But even if they set it at three or 9 or 23 or, that is arbitrary to some degree.

They've all decided like, when do we think this really tips into something very destructive for the body?

And they set a number.

Then you get into like, okay, attention deficit.

What level of fragmented attention is before we get to a pathology. The bar should be that it's disabling.
Yes, disabling. Unless you're going to separate identical twins and raise one with a label and one without a label.
And I say this in total good faith. I just want to know what the best outcome is.
I agree. I'm not really against or for any of it, really.
I just would like to know what's the best outcome. I mean, I think also, unfortunately, that's nebulous.
It's for one person having a diagnosis is probably very helpful. For another, it could get in their way.
I mean, it's hard to know. The risk I think I'm most afraid of is that you inadvertently limit someone's potential.
Yeah. Because you accept that this condition has these limits.
I agree. And just setting a limit before it's really discovered is just a little precarious and dangerous.
It's so personality-driven. I mean, I saw my brother last night, which was really nice.
Yeah, how was it? What did you get? Did you guys go out to eat? Went to dinner. Where? All time.
It was really nice. Yeah.
But we talked a little bit about this. I think he felt like he wasn't good at school.
Uh-huh. And then, so then he, I think, subconsciously, and he was like, maybe even a little consciously, just said, fuck it.
Yeah. Like, if I can't do it.
You're probably in the mix of that equation, I think. I think he's also going, I'm not going to be Monica.

Yeah.

So.

Maybe.

I'm not even going to try to be Monica.

Yeah.

Because I've decided I've given up on that. And to even try to improve myself would be seemingly like trying to be her, and I can't be her.

That's possible.

I mean, he's, yes, he's so different from me.

He made many different choices.

I have fucked up my younger sister in lots of ways I wish I hadn't.

Yeah, and I... It's possible.
I mean, he's, yes, he's so different from me. He made many different choices.

I have fucked up my younger sister in lots of ways I wish I hadn't.

Yeah, and I don't need, is it fucking them up or just making them?

It might just make them have their own, like really feel the need to define themselves.

But like Nikki's life was hugely impacted by having a sister 18 months younger than her that was being told she was beautiful everywhere they went. Like, that just fucked her up.
It's not the younger sister's fault. Of course not, no.
But I think living in immediate proximity to somebody is, you know. I guess so.
I mean, I think my brother was spared a lot of it because of the eight-year gap. Like, I was out by the time he was 10, you know? Yeah, but he certainly knew.
I'm sure your parents said, Monica got these grades or she... They might.
Well, they definitely were shocked at what was going on. Yeah, yeah.
By things that weren't, shouldn't have been shocking. Yeah.
So, yes, I do think maybe the bar was set. Do you think they just, because I would have just gone like, yeah, he's a boy.

I said that.

You did, yeah.

I was like, it's going to be fine.

It was building on itself.

Like, the more he felt like he wasn't doing the right thing, then he would do something else that was not the right thing and something else and something else.

Like, it was, it's, yeah.

But you know what's also funny is they were so worried, of course, and he's doing great. Just got a promotion.
Like he's great. It all is fine.
Everything's fine. This is like, you know, I have a few different friends in my life who, and one just totally admittedly, and I fucking love him.
And his honesty in saying is like,

he's hell-bent on getting his kid out of one school into this other school.

And the kid's evaluated, and the other school's like,

I think he needs more time at this school,

and he's taking that personally.

And, you know, at a certain point,

he had the sobriety to go, I want this.

My son doesn't want this.

Yeah.

I'm will run riot.

I'm trying to control everything in the world.

And it's so true.

It's like, you don't have to end up in these places.

You don't have to end up in the fucking school

and you don't have to end up with good grades.

I know.

It's just one version of how you can go through life.

I know.

And I know people have done every version version of how you can go through life. I know.
And I know people

have done every version

and it has no prediction

on their happiness

or their fulfillment

or their sense of purpose.

I know.

I agree.

And that's also

a ding, ding, ding

to this episode

because that's sort of

what she was saying.

She's like,

the expectation

is that everyone's supposed

to hit 100 at everything.

She's like,

it's not realistic.

Yeah.

And then we say

there's a disorder

that's causing them

to not reach you know, reach the highest potential. And it's just like, that's just life.
Two of our best friends, I mean, two of us friends are, we'll tell you at the drop of a hat, admittedly, they hardly got through school. They both would be like, we can't, we didn't know anything at school.
And they are, I would list, and all the people I've met in my life,

they're among the most successful humans I've ever met.

I agree.

They have more friends than anyone I know.

They have more fun.

They're better parents.

They've totally made a great living and have a great life.

A hundred percent.

And who gives a flying fuck?

They had a bunch of people we know,

much smarter, did way better academically,

and they're not having nearly as big of a life.

No, I know. I know.
I agree. When he and your dad have a drink, what do they have? They don't really.
I mean, if we're all at dinner, my dad will get beer. I will get wine normally.
My mom sometimes will get a cocktail, like a sugary cocktail. Sure, like some kind of paradise.
Yeah, exactly.

Sangria.

Yeah.

Loves the sangria.

And my brother will get like a tequila soda or a whiskey something.

But you and your dad are the drinkers.

Yes.

Yeah.

And will you and your dad ever get kind of drunk?

Yeah.

Yeah.

Well, he does.

And so I guess I am.

I'm sure I am too.

Not drunk.

Not drunk.

But like loose.

Yeah, yeah.

Loose.

Yeah.

But my mom, I'm so critical of my mom.

Yeah, that's standard.

And he's so critical of my dad.

Yeah, very standard.

I know it was funny because Jess was there and he was like,

Thank you. of my mom.
Yeah, that's standard. And he's so critical of my dad.
Yeah, very standard. I know it was funny because Jess was there and he was like, oh, a daddy's girl and a mama's boy? Like, duh, classic.
Textbook. And my brother was like, oh, yeah, I guess it is.
It's not special. But yeah, it is.
It's a lot easier to project onto the same gender. Yes.
Yeah. It's tough.
Yeah, my mom, you know, Carly will give my mom a good run. I would give my father the hardest of runs.
Yeah. Oh, I don't know how he loved me.
It's hard. I mean, my mom and dad are on a cruise right now.
Oh, they are. Where are they going? Oh, I forget.
Oh, who cares? In the water. That's where they're going.
And they sent a picture. My mom took a picture and sent it to my brother and I on the group chain.
And then I woke up to this. And all I saw was my brother say, why aren't you smiling? And then he had like laughing emojis and I looked and then, yes, my mom had taken like a selfie of her and my dad.
Yeah. My dad is smiling and she looks.
She's probably nervous about taking the picture. So yes, I do think that's what it is.
Yeah, yeah, yeah. She had a lot on her plate.
Of course, my brother is laughing and I'm like, yeah, why can't you just, why aren't you smiling? Oh, you had the same reaction. Yeah.
I had the same reaction, but his is like, he can, he's like, that's silly. Yeah, yeah, yeah.
But I am like, oh, mom, why? Come on, mom. I know.
Yeah, I would have thought and gone like, oh yeah, Nermie's nervous about having to take this selfie. I know, which is exactly what it is.
And she said, oh, I wasn't paying attention. And I was like, yes, what do you mean? Like then you said, of course you were paying attention because you took the picture.
That's not- Well, she was paying attention on how to operate the camera. I know, I know.
Not how to pose in a picture, yeah. She forgot she was in the picture because she was taking it.
They sent another one yesterday and everyone was smiling. Smile, forced smile.
Yeah. Because you're doing to her what they do to women historically.
I know.

Smile more.

I don't even smile more.

You know, you should smile more.

I know.

I feel bad.

But you know what?

This is the way it goes.

It's true, though.

That's good advice for everybody.

Not just women.

Everyone should smile more.

I agree.

Yeah.

It's infectious.

It can work the outside in.

Right.

But yeah, so I felt bad about that.

But what can we do?

Yeah. We got to try to do our best.

We're all just really doing our best.

Stay tuned for more Armchair Expert, if you dare.

That was nice to spend some time.

And he's off to Big Bear.

He's off to Big Bear with some friends.

And did you find out if they're going to ski?

They're going to ski.

They are going to ski.

Yeah.

And your brother has as well?

No.

So, okay, this is another thing.

I'm like, why?

Why do we do this? Why did we fall into these roles? So it's so exhausting. It's so exhausting to be like, I'm nervous about him skiing.
I'm nervous about him getting to Big Bear at night. Oh, you have all these fears for him? Yes, because he's my eight year old young.
he's my little brother like it's never going away and we all and we

he You have all these fears for him. Yes, because he's my eight-year-old young, he's my little brother.

Like, it's never going away. And we all, and he mentioned it too at dinner.
He said, you still think of me like that. And I said, well, when you're around me, you still act like that.
Oh, boy. Okay.
It was a good conversation. We were like smiling, unlike my mom.
but because even when he was trying to park,

he like called,

things he wouldn't do if he was meeting somebody else, he reverted too. We're all reverting.
I think for Carly and I, it's really interesting because I have such a clear role in our family when we're all together. And that's not the role I wanted in life.
Yeah. And I have purposely become a much different person than I am when I'm fulfilling my role.
And so we were just all together like a week ago in San Francisco. Yeah.
And Carly has done a very good job at joining me in my new role. She doesn't force me to be the old role.
Right. And what's the old role? The old role is depressurizing every situation.
Lowering the temperature at all times. Intercepting criticisms of different people.
Got it different people and making jokes and really just trying to distract the right person who's having a thing you know yeah um that makes my i hope doesn't sound like i'm throwing my family under the bus but whatever that that's my role and i find it quite exhausting it's not me. I want to be the person that's deciding how I want to feel.
You want other people to depressurize you. Sure.
Yeah, that would be preferred. I don't think I require that too much.
But at any rate, I think Carly's done a really good job of recognizing what my role is outside of the main family, adjusting to that. And she herself has her own role, right? I think she was the baby of the family, comparison sickness.
Yep. My oldest brother was my mom's partner, business partner.
They built this incredible business together. I'm like at UCLA doing great or whatever and then getting on TV.
It's a lot. Yeah.
So I think in her own life, she's been able to be the star of her life, which is fantastic. And I try to make her the star of our life as much as I can when we're together.
But when we go back, we both snap right in. And we had snapped right in for three days.
And then we got home and both of us were inordinately exhausted. Like she took a five hourhour nap, was up for two hours, and then slept the entire night through.

I, too, was exhausted.

Yeah.

And then the following day, I said to her, man, I get exhausted.

I'm out of shape for my role.

And when I have to do it, it's just very exciting.

She's like, oh, my God, yes, same.

I was like the baby of the family all over again. And, you know, vying for attention and all the.
Oh, interesting. Yeah.
All the things. Yeah.
It's a lot. It's a lot.
You're not on, you've only watched one episode of White Lotus. Yeah.
You know, this one family on the show is just vomitous, right? They're just. The North Carolinians? Yes.
They're repugnant. And.
But they're funny. Well, so far.
They're funny. Yeah.
The next episode you'll see, you're like, oh, my God, you got to spend your whole life in that dynamic. Right.
I flash forward to like, man, if you have shit kids and you did a bad job raising them and they're assholes and you're an asshole, you deal with that. It doesn't go away.
And just you stay in this little cancerous puddle of shit talking and fighting and bickering. I'm like, oh, my God, I would hate if that.
But they, I don't think they hate it. Because if it came from, if it comes from the top down.
Well, it's just normal for them. Right, exactly.
So, yeah, I don't even think they're so aware of how yucky this situation is. But it's like every kid's grossed up by the other one and judgmental by the other one.
I'm excited to see where this goes, but I'm also confused. It's very weird.
Yeah, it's only getting weirder. Oh, my God.
Yeah. Yeah, we just, it's just normal.
It's normal. And you can kind of become numb to it.
You have to exit it for a while for me.

Yeah. I wouldn't have been able to describe what my role was until I moved to California.
Exactly. Yeah.
And I returned home and I'm like, oh, right. Yes.
My brother's getting a little heated. I got to get in there with some magic sauce.
I know. I think the same thing.
I would have never been able to pinpoint unless I, without leaving, that like, oh, I'm just making, I feel like I need to make sure everyone is safe. Yeah, yeah.
I would never have been able to put two and two together about that. Right.
Without. So you feel yourself.
Wapping in it. Yeah.
It's also a great gift, I'll add. Yeah.
Because I think of how much my relationship with my brother has played out in my professional life. Like, Ashton's a great example.
Bill Gates is a great example. There's been these folks that I can weirdly be beta because it's implicit that I'm beta with my older brother.

Like I grew up that way.

Yep.

I'm a bit like Delta though.

I'm also kind of a fight.

Like are you beta?

Let's just say I've learned how to flatter people that are above me.

Yeah.

And honor them and be deferential to them.

And then come in and still be out of the role with my comedy. If that makes any sense.
Yeah. Like very deferential, but then weird zinger that like a beta wouldn't try.
Oh, I see. Yeah.
That ends up allowing me to rise up a bit and join them more as a peer. Like I'd have these moments with my brother, of course, as any younger brother probably has.
It's like there would be peership quite often. Yeah.
Often we're both racing go-karts and it's equally as fun and it's the thing. And then there's another dynamic where he's the older brother and I'm annoying and I got to shut up.
But I could break through and we'd have very peer-to-peer moments. Yeah.
And I got good at manufacturing those or instigating them. Yep.
And so I was thinking when I was with Bill, it's like I have this weird thing where I revere him so much and I couldn't be more deferential. I'll also tease him.
Yeah. Right? And so I got that from practice with my brother.
Yeah.

That's so, now that you're saying it like that,

I think, because, you know, you do, I mean,

anthropology and all of these reasons,

there's a million reasons why, but you pay attention a lot to status and alpha, beta,

all these things.

It's very much on your mind a lot. and in the way you think about the world.
And can I add really quick why? My dream is to be peer to peer with everyone. Yeah.
I don't want to be silencing myself because I don't have the status to be myself. Yeah.
So it's like, yes, I'm in a race to be able to just be myself. Yeah.
No, yeah. Yeah.
But I think that's weirdly because you are a younger sibling. Like, I don't have that.
Yeah, you were built in alpha. Right.
But I don't think, I'm not thinking about that ever though right and i'm never thinking like oh i'm in i'm never i just it's not even a part of the my processes but can i say one thing i can observe about you yeah when you aren't yeah when you're in a very rigid status structure and you're not equal, it really rubs you the wrong way. That's an interesting question.
So I don't know if you know why it's so uncomfortable to you, but I think that's why. As you just had baseline, you were the alpha, you were older, and then you get in these situations where people have much higher status than you, and you're like, oh, what the fuck is this?? But, well, depends because it might, I mean, I don't know what you're referring to, but you can tell me.
I'm happy to hear it. But I think what I'm allergic to is people feeling like they are above because I'm like, for me, I'm like, I don't understand what that is.
We should all be peers. Like, I don't feel like that around Bill Gates.
I wasn't like, oh God, I'm like uncomfortable talking to him or that didn't, that doesn't scare me. Well, no.
I guess I'm also not trying to get his like approval. I don't think, it's not about being scared to talk to him.
You recognize he has earned the right to take up the most space. If we're sitting in and we're talking about biology, literally any topic in the world.
Well, no, see, that's where I disagree with you. I don't think literally any topic in the world, he has the right to talk the most.
On so many topics he does because he has an expertise there. But I'm not in a room with somebody and think just because they have done X, Y, and Z or become this or famous or— Well, that's not a real thing.
But knowledge is. So if me and Neil deGrasse Tyson, the three of us are hanging out.
Yeah. I shouldn't take up any amount of the time talking about astrophysics.
It's ridiculous. Because that's his thing.
That's his thing. And Bill, uniquely, you and I can't cover it.
There's maybe one or two topics. 100% of him and I are talking about his tie that was on the floor, his Tom Ford tie.
Yeah. I am more than happy to take up space in that conversation.
That's right. And that's one you have, and we could count them.
I might have automotive knowledge over him. Yeah, great.
But in general, you and I aren't going to be around anybody ever who has a more comprehensive knowledge of all things like that man. You and I are going to have a couple of things.
When you and I meet a normal person, it's very equal. We probably know equal amounts about the world.
Yeah. But Bill knows the entire history of the planet geologically and chemically.
I'm not uncomfortable with him having that knowledge and me not. I'm not either.
I think it's great. He should keep, let's engage about it.
Absolutely. And you're deferential because you know better than to enter the conversation about the green revolution or biology while he's giving information because it would be a waste of everyone's time.
You're not going to add more than he can add to it. There's a reality to the space that can be taken up and who should take it up because who has the expertise? That's just a reality of life.
If it's fashion, you should be talking. But it depends on, I guess it's like if I'm in a one-on-one conversation or the four of us are together.
Group dynamic. That's where it's really relevant.
If we're in a group dynamic with four people on a plane, it's not like he's on a stage and he's giving a lecture. These are people in conversation.
I think it's totally allowed for anyone to ask a question, to bring up a topic, to say a thing. I don't think it's like, well, we have to sit here in silence and let Bill just talk for four hours because he's the smartest person here.
I don't think that at all. I think you're being pretty extreme about it, like shut up and let Bill talk for four hours.
I'm saying if we're talking about software, if the conversation is about software, you and I should have much less to say than Bill Gates has to say. We could give some experiential experience.
You know, some firsthand anecdotal account of how we feel about interacting with software. But he should probably do most of the talking about that.
Yeah, I don't disagree with that. Great.
So we agree on it on software. And what I'm saying about Bill is you can pretty much then add any category of knowledge.
And that's consistent with him. He's uniquely like this.
Yeah. I'm not arguing with you about that.
I don't under, but I don't feel, I don't feel inadequate. I don't either.
This isn't a question of value. I think you're, you're having a conversation about value as humans, and I'm having a conversation about deference to knowledge.
Yeah, but you're saying I'm uncomfortable in those situations, but I don't feel uncomfortable in that situation. I'm talking about someone doesn't have a chair for you at the thing and wants you to sit somewhere, and it's like it levels you.
Yeah. Right? That to me is not—that's like a human respect thing.
That's not about who has knowledge or who has something to say. If you come to a party and there's no chair for you there, I don't think that's unique in feeling like, ah, that doesn't feel good.
Right. But if the table you want to sit at happens to be a table of people on television at the Golden Globes and you feel disrespected that you're not allowed to sit at that table, even though you're not that thing.
Yeah. That would be, in my opinion, in denial of reality, which is like, it's a table for people on television, on a show about television.
To be fair, that hasn't happened. No.
Well, what was the thing that you didn't have? It was a gala of sorts or something that I was with Kristen. She was invited.
She told them she was bringing me. She was bringing, I was her assistant at the time.
So yes, no, I wasn't like, yeah, I should be invited to this gala. That's the difference.
I wasn't like, oh yeah, I belong here. I came as her guest and then, yeah, there wasn't a seat and they had to move one and put one in the middle of the thing.
And it was very uncomfortable. I wasn't like, well, I deserve to be at this table and why isn't there a seat for me? It was, oh my God, this is so uncomfortable.
I'm obviously not supposed to be here. It's become way more obvious now that there's a chair blocking everybody that they scooted over that Mariska Hargitay is like, you can share my CU with me.
Like that's uncomfortable. That's not because I think I should have been invited all along, or I should have been, that's, there's a difference there.
I mean, maybe you're different. I think anyone in that situation would have felt uncomfortable.
I think I have a ton of experience with that situation, which is like my whole childhood, I tried to sit at a table that he decided sometimes I was old enough to and sometimes I wasn't. Or I wanted to join in an activity that sometimes I was old enough for and cool enough for, and sometimes I wasn't.
So I have a ton of experience with that. Yeah, but you don't like it just like I don't.
Like if you had gone, if you've even said it, you're like even at the Golden Globes, like when there's a shot on Kristen, what do you do? Do you get in it? Do you stay out of it? It's uncomfortable when you don't know your place.

That's normal to think like, this is weird. Yeah.
Yeah, so I just know that I'm very used to being low status and being disinvited. And so it's not new to me.
It's not novel. It's not new to me either as far as feeling like I'm not enough growing up, feeling like I'm not enough.
Yeah. So I have to do these things to be enough.
My thing with Bill Gates is I don't have a—there's no right or wrong. There's no value for me.
There's no injustice. I'm going to shut up when we're talking about things that he knows a lot more.
And also, I'm going to recognize I have comedy and he doesn't. So I'm going to take up a lot of space comedically because it's real.
I deserve to take up a lot of space comedically. And everyone likes to laugh.
And he likes to laugh too. And so I know what zone I should be being a tall poppy in.
And I know which ones I shouldn't. Right.
And I think that's a good skill set for people to have. Yeah.
I think it's Dunning-Kruger if you don't have it. I think if you think you should be educating Bill on software or any other topic, mostly.
Yeah. I mean, I don't know anyone who's, I don't think anyone would do that.
A lot of people don't recognize that you should evaluate whether you're adding value to something. Sure.
Of course. Well, I don't know, of course.
Like, if it's just everyone has the right to talk equal amounts in all situations. Well, part of it is social awareness.
There's social awareness. That's what I'm arguing for.
I happen to be framing it in status because that is a big elephant in the room in social awareness. If you are three months into the job and you're at the board meeting and you're going to take up all the time when the CEO's been doing it for 25 years, that is, you're blind to the reality of that situation.
And I think you, I don't think it's wrong that some people take up more space at times than others. I don't think everyone's entitled to equal space.
That's what, maybe that's the underbelly of what I'm rejecting about your argument is that everyone deserves equal space at all times. Well, I didn't say, when did I say that? Well, you're saying I'm going to talk, everyone should talk the same.
There shouldn't be so. I didn't say the same.
Okay. I said everyone should be able to, in a conversation, provide a question, an anecdote, not be afraid to talk.
I don't think people should be afraid to talk. I think you should know when in any conversation you're having with anyone, doesn't matter status, doesn't matter anything, if you're the only one talking, if you're making everything about yourself, that you don't have social awareness.
That's a big problem for people. But I don't, the is, to me, irrelevant.
It's understanding a social dynamic when you're in it and being able to read that. I think you and I often use words.
We have different definitions for words, and then we keep bumping up against each other. Like, the way I use alpha is you have a very negative connotation of alpha.
A lot of people do, yeah. Yeah, great.
A ton of people do. I have a very anthropological definition of alpha and beta and all these things.
And I think status for you is like, that's a negative word. Yeah, I think chasing it leads people to be crazy.
And I think what you're saying is popularity. No.
Okay. So for me, status is not negative.
It's a reality of social creatures. It's not negative or positive.
It is the actual structure of social hierarchy. Yep, I agree.
So it's like, it's not good or bad. It's a real thing that all social animals adhere to.

And then in any given context, status is achieved in different ways.

On a basketball court, it's one way.

Totally.

In an intellectual conversation with Bill Gates, it's that way.

In an investor's meeting, it's money.

In some other domain, it's looks. Sure.
Yeah. Yeah, all that's true.
I agree. I think status to me is problematic when you are chasing it and manipulating your way in.
It's not by effort or prowess, but by manipulation, you will, you want to be at the top of that totem pole. I think everyone should pursue status.
I think your life is better the more status you have in any given situation. And I think what you should not do is misuse status.
I think the real issue maybe that people have in conflating these is they're thinking of how people misuse and mistreat others because they have status, which I would be in lockstep agreeing. That's the problem.
People being dismissive of people, not hearing people. Yeah, that's a problem.
But there is a huge problem in social climbing. It's disgusting.
And it is repellent. People who are around it.
Are we disgusting for trying to be the number one podcast? That's a skill. Yes, everything's a skill.
If you want status in the Math 55 class at Harvard, you have to get the highest on the test. That will give you the status of smartest mathematician.
No, what I'm speaking of for a lot of people now is followers. See, that's what I think you're always using status as popularity.
I think that's why we fight. Well, in this world, it's connected.
But status in the math class is the highest test. Status in the podcast world is your ranking.
Yeah. And you should always try.
That's why I'm saying you should try to climb status. That means you're the best at the thing you're doing.
You should try to be your best at what you're doing. I agree.
Yeah. But I'm talking about social climbing.
And you should try to get to the top of the heat. That's a different beast.
I don't think you should try to be the most popular person in your friendship group. Yeah, or in the world.
Like that's that you have the most followers or the most approval or the most likes or the most famous friends. I'm trying to help us because I think when we're arguing so much, you think I'm in support of chasing popularity.
Right. And I'm not.
Yeah. And I'm not talking alpha like you bark orders at people.
Oh, yeah. I know that.
I'm talking about who in the room do you most trust to make the decision about X, Y, or Z. Yeah.
That's alpha. And it can change in every context.
I agree. When we had Allison on about conversation and we talked about group conversations, yes, she's like, at any given moment, somebody has the status.
But part of it is understanding everyone does have status in different domains. Even when we talk about like a CEO or something, I actually think it has to be very, you have to be very aware when you are the CEO or the person on top that everyone defers to you as having the most status because you're in charge.
Yeah. But let's say you're talking about something very specific and probably you don't know as much as your employee.
You have to police yourself a ton if you have status to not presume status in all domains when you don't have it. Yeah.
But when you say chasing status is repugnant, like you and I would have, like we're totally crossing paths at that point. What? When you say chasing status is repugnant, we're like totally crossing line.

Like we're talking about completely different things.

That's fine.

Yeah.

Okay, hold on.

A couple of facts for Suzanne.

Okay, sonic weapons.

Sonic weapons affect, can they affect the brain?

Yes.

Acoustic weapons use sound waves to injure or incapacitate an opponent by emitting very loud noises

that they can cause pain, nausea, dizziness, and even permanent hearing loss.

You said you want to want in the bathroom.

To make me shit.

Yeah.

I basically had that today.

You had a sonic boom?

Well, I did three servings of Metamucil yesterday, spaced out throughout the day.

Were you constipated? I was underwhelmed with what I was getting. Yeah, me too.
I almost prefer constipation to 40% output. I'm like more bothered by 40%.
I'm like, what is going on? I know. So I went really, really hard yesterday.
And then, you know, I have a routine in the morning, as you know. But I was like mid-meditation.
I'm like, am I going to have to quit my meditation? Wow. I'm like, no, you got to get through your meditation.
But it was dicey. And I'm like, there's no way I can journal through this.
Wow. Yeah.
Well, that's good. You fixed your problem.
We wouldn't recommend three servings of Metamucil.

I think go by the jar.

I kind of do.

No, go by the prescription amount on the jar.

It might be three more today.

I have very high status right now in evacuation.

You do, because mine isn't going well today.

Teddy Roosevelt did have asthma.

As you said, he was a sickly boy.

Procured by his time on the ranch.

Exactly, and then I think his was psychosomatic.

Yeah, maybe.

Because if he got cured by the ranch, which is outside and lots of dusties, it doesn't make sense. Working with animals, he was on horseback.
Yeah, dander. Dander, pet dander.
Yeah, right. Okay, have we reduced the number of amputations from diabetes? Yes, we have, but— Asterix.
Asterix, because care is much better. Right.
Like, to catch before, you're going to have to have an amputation. It doesn't mean we've done better, really, as far as lowering diabetes problems by diagnosing it more.
This is like the death by gunshot data is misleading. Exactly.
We've just got really good at treating gunshot wounds. There's as many people getting shot.
Yeah. Videos associated with the hashtag autism hashtag accrued 11.5 billion views collectively.
Billion? Yeah. Billion.
Whoa. An examination of the top 133 videos providing informational content on autism, which totaled 198.7 million views and 25.2 million likes, showed that 27% of the videos were classified as accurate.
Well, 41% were classified as inaccurate and 32% as overgeneralized. She got that stat.
She nailed it. That's a disheartening stat.
I know. If you're getting your medical information from TikTok.
Yeah, exactly. And then she also said one in five people in the world has a mental health diagnosis.
Correct again, according to the National Institute of Mental Health. In the world? One, United States.
Oh, I was going to say, that seems high for the world. United States, one in five dollars.
Indians aren't fucking with all these diagnoses yet. I don't know.
Our guest, Blaze, is like, there's not a single CBT-certified therapist in a country of a billion people. But there's a high rate of suicide.
That's why he's going there. So there is— I just don't think they've been diagnosed yet.
Yeah, maybe not. They'll get there.
There's a great signal in developing. It's true.
Yeah, you'll stop having kids and you'll have a ton of mental health issues. Exactly.
All to aim for. Well, they've had a ton of mental health.
So then this is another one of the, like they have mental health stuff a lot. Yeah.
But if it's not diagnosed, but is that better? Because it's still, it's all the same if people are suffering, I guess.

I think it ends up being mutually assured annihilation at some point where it's like everyone has a diagnosis and everyone stops caring.

Yeah.

So one in five adults have a diagnosed mental health condition.

That's, I'm in there.

So that's it.

That's it.

That's it for Dr. Susanna Sullivan.
All right. Okay.
Bye. Love you.
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