Are we Over-Diagnosing Mental Illness? (w/ Dr. Alastair Santhouse)

Dr. Alastair Santhouse is a consultant psychiatrist and author with over 20 years of experience in the field. He has worked at both Guy’s Hospital and the Maudsley Hospital in London, treating a wide range of mental health conditions.

His clinical expertise includes the psychological impact of physical illness and persistent physical symptoms, as well as more typical psychiatric conditions such as depression, anxiety disorders, obsessive-compulsive disorder (OCD), and adjustment disorders.

Dr. Santhouse is the author of Head First: A Psychiatrist's Stories of Mind and Body (2021), and No More Normal: Mental Health in an Age of Over-Diagnosis (2025).

Find out more about Dr. Santhouse here - https://www.alastairsanthouse.com/

Interviewed by Dr. Alex Curmi. Dr. Alex is a consultant psychiatrist and a UKCP registered psychotherapist in-training.

If you would like to invite Alex to speak at your organisation please email alexcurmitherapy@gmail.com with "Speaking Enquiry" in the subject line.

Alex is not currently taking on new psychotherapy clients, if you are interested in working with Alex for focused behaviour change coaching , you can email - alexcurmitherapy@gmail.com with "Coaching" in the subject line.

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Transcript

Welcome back to The Thinking Mind, a podcast all about psychiatry, psychotherapy, self development, and related topics. Today we're in conversation with Dr. Alistair Sandhaus. Dr. Sandhaus is a consultant, psychiatrist, and author. He's been working as a psychiatrist for the last 20 years at Geis Hospital and the Mosley Hospital in London.

He's experienced a treating a range of mental health conditions, including depression, anxiety, OCD, adjustment disorders, as well as medically unexplained symptoms. He's the author of Head First Psychiatrist, stories of Mind and Body, and most recently No More Normal Mental Health and an Age of Over-Diagnosis, which just came out last April.

I really enjoyed that book. I think it's essential reading if you're training or working in mental health at the moment. The book discusses really important questions like how we define what normality is, what is the difference, for example, between low mood and [00:01:00] depression, when a distressing experience should qualify as trauma or not, and when a cluster of symptoms indicates an underlying mental health condition as opposed to just a set of adverse experiences.

As the conversation around mental health has moved from the consulting room to the public arena, so the concept of normality itself is shifting. Today we're seeing a significant rise in diagnosable conditions, in waiting lists, in diagnoses, in medication. So today we discuss this book in some depth. In particular, the issue of over-diagnosis and some of the other difficulties facing modern psychiatry.

There's very useful conversation for me to have, and I hope that you guys get something out of it too. This is the Thinking Mind. If you like the show, there are plenty of ways you can support it. You can share it with a friend, give us a rating or a written review, like follow or subscribe on whatever platform you listen to.

You can also now check out The Thinking Mind blog, which is out on [00:02:00] Substack, and the link for that is in the description. As always, thank you for listening. And now here's today's conversation with Dr. Alistair Sandhaus. Alistair, thank you so much for joining me today. Oh, it's a great pleasure to be here.

Thank you for inviting me. What motivated you to write this book? I know in the book at the beginning you say, actually, you were a bit reluctant to write it, so I'm really curious what motivated you and, and why were you reluctant to write it? Well, you've put your fingers straight on the dilemma, if you like, of a book like this.

And I, I think you said it in your introduction, that culture is changing the whole time and it changes in two ways. And I think one of the ways it's changed is how easy it is to find a good faith discussion about things at the moment, where it's not about winning and losing, but where there's nuance. So the reluctance or.

Anxiety came from whether or not what I would wanted to say was going to be heard in, in the way that I'd meant it. And what I'd noticed [00:03:00] in my clinics over many years now, maybe 10 years or more, is, is a different relationship that. Members of the public have with mental health and illness. When I was starting off in psychiatry, it was the mid 1990s and it was really very stigmatized.

I think people weren't coming forward who genuinely could have been helped by mental health services, but a generation or so later. It felt as though quite properly the stigma had been broken down, or at least to some extent had, but people were increasingly identifying with mental health labels in a way that I felt wasn't always therapeutic.

Perhaps not always accurate, and I want you to understand and explore why that was happening. Part of the answer I felt in the end came down to something about the cultural context, but the anxiety or the hesitation in writing, perhaps I would better say is whether that message would be [00:04:00] heard and. That it would stimulate a discussion rather than an argument.

When I think about these issues, I think about how different virtues often compete with each other and our intention with each other. So one virtue, especially when it comes to. Healthcare might be accuracy, getting the right diagnosis, you know, figuring out the problem and describing it appropriately.

That would be one virtue. Uh, another virtue might be compassion, caring for the person in front of you. Just as an example, I find that tensions are often brought in conflict with each other, perhaps unnecessarily. Like for you to advocate for more diagnostic accuracy, for you to say, Hey, maybe we're having problems over diagnosing things here.

Some people could misinterpret that as, you don't care. You don't care about my suffering, and I've seen this in the clinic, you might not give someone a diagnosis of a mental health condition, and even though you might expect that to be good news, what you often get is actually a sense of, oh, my problems haven't been validated.

[00:05:00] Or you as a doctor saying, my problems aren't real. Or that I'm imagining them because I'm not getting a mental health diagnosis. So is that the kind of misinterpretation you would be worried about? Yes. I, I think that's pretty well it, uh, I, I think it's an interesting sort of point you make about these sort of competing virtues or sometimes competing rights.

The um, which is, where does that balance lie? I think I would take it one step further, which is that sometimes things that seem to be compassionate, for example. Uh, endorsing a mental health label might, in fact be the exact opposite of what benefits the individual and might be, in fact not compassionate at all in the longer run because I think that diagnostic labels really need to be made carefully.

They are often sticky labels. I think the risk of being diagnosed where the diagnosis doesn't apply is that people can start to see themselves differently, [00:06:00] can start to feel perhaps. That they're not in control anymore, that someone needs to do something to them. To help them get better. So I think that we have reached a point where we often understand and explain people's suffering through a mental health diagnosis in a way.

I don't think that used to be the case. We used to have lots of different ways of understanding people's suffering. And by the way, it does lead me to the point that none of what I'm saying I hope undermines the fact that people really are struggling very often and suffering. Very difficult adversities of all kinds of social pressures, reverses and job, and securities and housing and securities, financial reverses, relationship breakdowns.

Life is not easy. But the difference I think in recent years is the framing of the distress and suffering that we experience in terms of a mental health problem. And the question [00:07:00] really is why have we got to that point and. Is it a good thing? Do you think we've lost the sense that life is hard by default, pretty much for everyone?

Like yes to different degrees and intensities, but pretty much life is hard for everyone. I, I really like that you used the words like distress and harmony in your book, that perhaps people are searching for a sense of mental harmony that's a little bit unrealistic, and if they fail to reach it. Then they might, in today's culture think, oh, I must have some kind of mental health condition.

I, I think culturally, I, I sort of observe the same as anyone else does, but there was a particular way of expressing enthusiasm for something. Say that you are passionate about it. People's job, for example. You might enjoy being an accountant or a lawyer or a, you know, working in trade or whatever it is, but passionate suggests that you sort of leap out of bed each morning full of that enthusiasm for life of the commute to work where you can sit pouring over spreadsheets and just feel like that.

[00:08:00] First rush of love each time you go to work. You know, I began to think, well, maybe I'm not doing life right because I, I wasn't sure what I felt that passionate about. I mean, I like reading a lot and I enjoy my job well enough, but, but there is something about the language and I did wonder whether people's expectations of what life is.

Has shifted as well. I mean, I'm talking primarily about sort of Western Europe, north America, Australasia, but I do think I have wondered at least whether that might be one bit of the explanation is what our expectations are of what life should be. Yeah, I've thought about that. And I, I worry about similar things.

I think in the West we've dealt with socioeconomic concerns. We've become, you know, wealthy, obviously there's a huge amount of wealth inequality, which needs to be addressed, but there's a huge amount of absolute wealth. And now we have devices in all of our pockets, which can give us. An insight to what the most [00:09:00] successful among us do in their day-to-day lives.

And that's totally unprecedented. Like in the 1950s, say you couldn't, with your phone, see what Charlie Chaplin might be up to on a Tuesday morning, whereas now with your phone, you could look and see what Jay-Z is up to. And I know even probably using Jay-Z as an example is aging me, but you could see what Jay-Z is up to on a Tuesday morning flying in his private jet.

And I think we really, our brains weren't designed for this. You know, I, I think about things quite a lot along. Evolutionary lines. And I think our brains can be easily fooled by looking at an image of a person on a screen and thinking that in some sense they're part of our tribe and we identify with them.

And if we see them living this ridiculously luxurious lifestyle, I think it really taps into our primate instincts to think, why not me? You know, why am I not living that lifestyle? And there's this sense of. Really, really, as you said, really high expectations for what our lives should be, that there's no room for Jory or, or tedium in life.

Yeah, I understand what you mean and, and I think that we can't help but be [00:10:00] influenced by what people around us seem to be doing. And of course we see a heavily edited version of their sort of perfect lives. And it's the curated life that someone wants you to see that we're showing to each other. But I think it does lead to another.

Point that I sort of touch on in the book, and I mean, we've not got round to specific diagnoses yet, but I sort of broadly talk about the atomization of society as well. Uh, there's a reference to a paper. I think he, he wrote a book subsequently Robert Putnam called Bowling Alone. He refers to Americans who enjoyed bowling, but in the eighties seemed to bowl more in teams, whereas by the nineties and 1990s, and presumably it was starting then Americans were bowling more, but less likely to be bowling in teams.

And so he called this bowling. Alone, and it refers to the sort of loss of social capital. The mm uh, I guess you broadly say the loss of social [00:11:00] cohesion, the loss of civic engagement, the sense of people living these separate lives, and I don't think that's healthy for people either. I think community and support and feeling a part of something bigger than you is both psychologically healthy, but also you can sort of understand and compare your life in a much more meaningful way, as you said, than than looking at.

What someone else is doing on, on their phone. You are part of a, like situated community. Yeah. I, I really see that. I'm in America at the moment and the stock has difference, I think between the US and the UK is patriotism. Patriotism is everywhere. You see American flags. In grocery stores, the national anthem is frequently played before sporting events or things along those lines.

And it's very fashionable, particularly in the UK, to look down on patriotism. Mm-hmm. To be quite cynical about it. And obviously there are dangerous to patriotism when patriotism bleeds into [00:12:00] nationalism, et cetera. And we see that a lot in politics, but. Isn't it nice to feel that you, you're part of a community.

Isn't it nice to feel broadly positive about the community that you're a part of? And wouldn't that engender or more likely engender better mental health? If you feel kind of good, if you kind of on some level endorse the community that you're in as opposed to. A more sort of disparaging attitude that we might often take in the uk?

Yes. I mean, I, I think we, we know from the figures about loneliness in the uk, I'm not sure where it is worldwide, but there was a figure about the percentage of older people whose only sort of form of companionship is their television and. We know that that sort of, uh, sense of isolation is not healthy for people, and I suppose it's not surprising that health outcomes might be worse because of that.

So when I started to look at solutions. For how we might address some of the problems that I [00:13:00] describe. I think that some reinvestment in social capital, in reintegration of communities of something, something along those lines, I think would be a step at least, that we could think about taking. I mean, in the UK at least, social prescribing has at least some recognition now in which.

When someone has a problem that you think would be better addressed, not pharmacologically or not with therapy, but just by helping someone reintegrate and feel part of something bigger than them. It might be a football team or it might be Pilates class, or it might be petting animals on a on a farm, or it might be a walk in nature.

There's lots of things that people can do. That are probably pretty good for their mental health and those things that we often conceptualize as a mental illness, depression or something like that might be better understood and thought of and managed in an entirely different way from our current cultural model.

Yeah, I think that makes a lot of [00:14:00] sense. And even if you think of something like psychotherapy, in a way, psychotherapy is a kind of social prescribing. Often psychotherapists like to think about all the different clever ways they might help people and all their really intricate concepts. Uh, and I say this as a practicing therapist.

A lot of the heavy lifts of therapy are really done by non-judgmental listening, like having someone who's willing to listen to you and not try and change things too much, not overreact. It's super helpful and studies would suggest that just having a good relationship with a therapist helps deliver the majority of like the beneficial outcomes from therapy.

So in a way, therapy is kind of like a social form of social prescribing. Yes. I mean, I, I think there was an interesting study that I read that I didn't quote, and I don't have it to hand now, but the study talked about the different types of therapy and the benefit that they had. And as I recall it was therapist more than the therapy that really made the difference.

Someone, as you say, who [00:15:00] is able to listen to be warm and empathic and not judgmental, and. Be there for an individual, seem to make a great deal of difference and perhaps be more relevant than whether they said that they were doing cognitive analytical versus behavioral or some other type of therapy. So I, I don't know all of the statistics, but I, I'm sure it accounts release some of the therapeutic benefits.

I, I wouldn't say of course, all of it. Yeah. I think the actual technique does matter to an extent. Yeah. But I think the interpersonal qualities. Are important. So the title of your book No More Normal obviously implies kind of that there's importance to an idea of normality. And funnily enough, just two weeks ago on the podcast, I interviewed someone else more coming from a sociology perspective.

And the word normal was also on the title of her book. Her name was Mari Big. And you guys, you guys might find, actually, if you listen to that podcast and this one together, they might actually make quite a nice pair. That book is actually saying it's a little bit more critical of psychiatry. It's [00:16:00] actually saying that Normalities, but besides the point when it comes to treating people in mental distress.

Particularly individuals in a one-on-one kind of therapy or psychiatric patient relationship. We shouldn't be trying to concern ourselves with what is normal. We should just be doing our best to try and help the person in the position they're in. And I suspect from your book you, you actually take a different tack.

Do you believe in this idea of normality and that this idea of normality is useful when it comes to helping people with mental health problems? I, I mean, it's a really interesting. Question, and it's an interesting point, but I think you are broadly correct to say that I would take a different tack. I think we do need a concept of normal because we need a concept of where the boundary lies so that we can start to try and make accurate diagnoses.

I think it's of course, important to want to help just the individual across from the. Desk or the other end of the room. But what we need to be doing is to ask ourselves, can we [00:17:00] conceptualize their suffering as a mental illness? I think that's the first step. Has it progressed to a degree or is it a difference in kind way We would say, and the person themselves would acknowledge that their normal cells has been lost somewhere.

Their thinking and feeling is now different in a way that requires a clear approach. I think the importance is that we have to make accurate diagnoses to be able to help people, and if we're making a diagnosis, then we need to know what might help them. And the only way to do that is randomized control trials of large populations of people with the same diagnosis that needs to be accurately made.

I think then we do need clarity. We do need a line, and we say within these boundaries broadly, we wouldn't consider this meets the threshold for a diagnosis. And beyond that it does. And I think the problem with the increasing number of diagnoses, in my view [00:18:00] is that it starts to dilute the effect of treatments and medications.

We've seen that, there was a study very recently, I forgot which journal, but it's one of the journals that looks at. Treatments for A DHD, which talks about the benefit that they have, and there is undoubtedly benefit where the right population is selected. But increasingly they've noted that the benefit is being diluted now as the prescriptions are being given to people who possibly don't have really all of the features and the benefits are less clear cut.

I think the problem is that when you take a position like mine, as you said right at the outset of the uh, of this discussion, that you are often seen as lacking compassion, and it's a really hard thing to hear because I think what we need to give people is the right help. And the right help comes from knowing what it is that you are trying to manage.

Yes. And uh, you know, the, the business of diagnosis is really [00:19:00] difficult. I imagine people might think it's easy. Someone comes to you and says, oh, I feel really depressed, and, you know, the, the next thing is not, well, you must have depression. Then it's, you know, there's a lot more conversation that needs to happen before you reach that conclusion.

I think depression is a really good example. I'd like to talk about it. You devote a chapter to depression. I think this issue of over-diagnosis and diluting the diagnosis, it's really does a disservice to both the people who, let's say, should be diagnosed, who have what you could call clinical depression, but also does a disservice to the people who are being overdiagnosed.

And I think it does that because it, it robs them of the sense that actually, if your mood is low, as human beings, we have a mood for a reason and a, and a mood that might go in concert with our appetite and our sleep and how much joy we take in life. That, uh, our emotional systems have a function that might tell us useful things about what's happening in our [00:20:00] lives and what we might need.

And to say, you know, to classify every case of low mood. As a depression is to say, you know, you've got a broken brain. We need to fix your broken brain with some sort of intervention. Uh, don't pay attention to the fact that you, you, you feel quite, uh, despairing of your job or that you have significant relationship problems, or that you spend 90% of your time alone or that your nutrition is really poor.

I can go on. You see my point, but really this issue of overdiagnosis really robs both parties of something useful. Well, absolutely. I, I think that's exactly to the point that I was trying to make, which is that can reduce the sense of agency that someone has. I don't think you can reduce the iniquities of 21st Century society into a diagnostic label and provide a, an antidepressant medication and assume that that's going to make everything better.

DSM, the diagnostic statistic. I'm gonna get this wrong and it's, uh, I've been writing diagnostic statistical manual. Yeah, just those words just suddenly didn't go together. Right. [00:21:00] I've been writing about it for years. In, in 2013 when they talked about removing the. Bereavement exclusion for depression. So it had previously been the case that you couldn't make a diagnosis of depression during the period of time post bereavement.

I think it was a period of about six months, based on the fairly universally understood notion that within those months. Those emotions are pretty normal and common, and when that exclusion was removed so that you could diagnose someone with depression in the aftermath of a bereavement, there was a big outcry in the press, and I don't think.

In reality, we've seen a flood of diagnosis of depression in bereavement, but I think what it said to the public was something really important and worrying to them, which is the increasing [00:22:00] intrusion of bureaucratic standards into everyday life. There was something about making a diagnosis of depression and bereavement and the experience that many people have unfortunately gone through.

Which people didn't want to see themselves as depressed. They wanted to see this as part of the normal reaction to, to a loss. Now, of course, people can get depressed and I suspect that the rates of prescribing didn't change. But I think it said something about the mindset that we had about how we think about depression and, and mood.

I think there's issues around mood. For example, seasonal affective disorder. Where the evidence is actually pretty weak for the being an entity called Seasonal Affective Disorder, but intuitively, it strikes many people as true. We think back to last winter, and we remember short days and cold and wet [00:23:00] and rain and all those sort of dark associations we have with it, but.

Actually trials haven't really borne that out. Mm-hmm. Respective trials in Iceland and in the United States and elsewhere haven't really shown that there's a separate entity. And I think when it comes to a diagnosis like depression, you've got a range of, uh, emotions that, on the one hand is unmistakably depression.

In my clinical role, I've seen people catatonic with depression, with very dark hallucinations that they might already be dead or dying or rotting away inside of really quite disturbing and unhappy things. And at the other end, you have experiences that are common, relatable, and you would say difficult to differentiate from the range of, let's say, common and relatable human experience.

The question is, where are you gonna [00:24:00] put that boundary? Then? I think we know that for those depression that we currently diagnose as mild, the evidence for antidepressants is a lot weaker than for those at the moderate and severe end. In other words, what is this that we're capturing in the middle? How do we understand it and what should we be doing about it?

It's not to say that depression is trivial. Of course it's not low mood and this great suffering that people have, but what do we do about it? Is the question. And I think putting a label on it and giving antidepressants or sending some to therapy may be exactly the wrong solution for some people. Yeah, it depends.

And I guess one of the things that I really liked about your book, and I had never really heard it phrased like this, is that diagnosis in psychiatry or otherwise is not a checklist of symptoms. It's always symptoms and context. The context is crucial. Without [00:25:00] understanding the context, you're essentially flying blind and a different context might make all the difference to how you think about that person to what diagnosis you should or should not apply, and to how you might treat them and help them.

Well, I think we've moved to an age of sort of standardized assessments, a little bit of checklists of symptoms, and you can see that with depression. I mean, if a lot of people are diagnosed with depression, just sort of sad, tick. Not sleeping, tick, poor appetite tick as though those things are what depression is.

Those are symptoms of depression, but they're not depression itself. Um, there's a, an US psychiatrist who I came to admire greatly during the writing of my book called Kenneth Kindler. He wrote a paper on depression and how it used to be described a century or so ago. And the descriptions were so much more colorful and vibrant.

Even people were described as being broken hearted, wretched in [00:26:00] agony. It wasn't this sort of checklist kind of approach. You felt that the interview had a real sense of engagement with the individual. I think, uh, in the 1970s, depression was a rare illness treated by specialists in secondary care in hospitals, and we come to now, and it's a very common illness treated by generalists in primary care, by gps and.

You could say, well, certainly some of it is due to people more readily coming forward, and I would support that unequivocally. It's got to be a good thing, but I think a lot of it is that the label of depression is now so common and there's been lots of awareness raising on. People wonder if it applies to them, and there is a kind of a looping effect.

And, and I think that trying to sort of find where that boundary is, is, uh, really the question I was asking in this book, and I come back to it a few times. [00:27:00] Yeah. And it's a really difficult question. And, and as you said earlier, we, we as psychiatrists are put in quite a difficult position. I you referenced Alan Francis in your book, who was a psychiatrist on the chair of the DSM four task force.

We had him on the podcast last year and he made a really good point, which is. Psychiatry. It's a method of diagnosing and treating is, was really a lot more effective when we were treating the more severe ends of the population. And now that we've come to expand and like think about a, a much larger group of people, as we've referenced earlier in this conversation, really the effect is becoming diluted.

And of course. With that psychiatry, uh, itself as a discipline often comes into question. Along with that, as a clinician trying to make these decisions between normal and abnormal, what are some ways that you try and do that? What are some principles that you apply? For example, in the case of low mood depression, that kind of issue, and trying to distinguish.

Normal functioning versus, you know, clinical depression. The [00:28:00] illness, I, I think there's a number of ways. I think first of all, we do try and rely on guidelines, the DSM or in the rest of the world, ICD, the International Classification of Diseases, to look at the symptoms that they have, that we recognize as being depression.

But I think more broadly. I think it is important to understand the context of someone's life, the situation in which the depression arose, what the maintaining factors are. I think what's often gets lost is that in, in nearly all the cases of depression, I've seen that, that have gone beyond mild. People are really not functioning either in their social life, their home life, their work life, you know, in whichever domain you look at.

And I, for me, that's one of the more significant factors. I think, again, not to say that people aren't suffering or distress, but if someone is able to go to work, to have a [00:29:00] normal relationship to. Socialized normally. I mean, of course you get exceptions, but in many cases you would say that it's difficult to do when someone's got a moderate or severe depressive illness.

So I think you, you look at the symptoms that someone presents with, it goes beyond sadness. It can get to a sense of pessimism. Someone rewrites their past in terms that they think that the past was a total failure. Look at their future as one of futility. People think about death and dying a lot. They often have just stopped sleeping.

They have a particular pattern to their mood during the day and often just lethargic and staring ahead of them. Really unable to sort of gather that motivation and energy and, and when you see people. In that degree, or sometimes even having hallucinations along those lines, when you see that, I don't [00:30:00] think anyone, even with no training would mistake that for some sort of variant of normal.

They would say that's a difference in kind. Mm-hmm. And, and so you are really looking for both the symptoms that they've got as well as the functional outcome. Yes. That makes a lot of sense and I, I definitely use those principles. Something that's really helped me as well is just kind of understanding more about human nature.

Immersing myself in things like philosophy, literature, even great cinema to understand, you know, how people's lives often work. Archetypes, the trajectories that people's lives often take. History, you know, and all that means is the more I mess myself and all that stuff, that means when I'm seeing someone in the clinic, I have a much richer context in which to put their experiences in.

So if someone said, oh, I'm kind of in the midst of crisis where I don't really know where my life's going or what it's all about, then I might be able to think, oh, this person sounds like they're having an existential crisis. [00:31:00] And I know that because I've watched this movie where a guy was having an existential crisis, and I've read this novel where he was having an existential crisis.

So it's really helped me to just immerse myself in the humanities. But I, I worry about it because it's quite starkly absent from psychiatric training. Do you think as psychiatrists we should be made to mess ourselves more in these disciplines? 'cause I, I do feel part of our responsibility is to understand human life at quite a deep three dimensional level if we're to make these decisions, which are so impactful, I, I have to say I love that idea.

I really hear it. I mean, I, I mentioned I like reading actually like it a lot and I spend a lot of time reading books from places that, um, that I've never been about. People whose lives I would never have come across before. And I think it's an essential prerequisite, I would say for a psychiatrist is to have that curiosity about people in their lives.

When I was a medical student, there was a, a psychiatrist I [00:32:00] was training with and I said to him. What do you think is the best quality for a psychiatrist? And and he said nosiness. In other words, that sense of interest in what other people's lives are like, what they're doing to ask those questions, to get under the surface of it.

And I mean, I'm not sure how you would prescribe it for a psychiatrist, but I would hope that most psychiatrists would have that sort of curiosity about people and their lives. And, and a lot of that comes from literature. It comes from, you know, when, when a parent chastises you, when, when young, how would you feel if someone did that to you?

That's how you are when you're reading a book. That's the you in that situation. Yeah. You have the opportunity to like enter someone else's life, as you said, have their experiences so that you don't have to hopefully. Um, yeah, I mean I think it'll be amazing if. Psychiatric training programs could design a part of the curriculum that's just immersing oneself in human nature.

Thinking more [00:33:00] about trauma, so we devote a chapter to trauma. Much discussed. I'm a bit torn when it comes to trauma, but first I'd like to hear what are your contents when it comes to the directions we've moved in culturally in terms of trauma? I think the term trauma has really become a little bit devoid of any hard meaning.

I mean, again, going back to Victorian times, if you told someone you'd been traumatized, they would've assumed that you'd been stabbed or shot or something. The, the notion of a sort of psychological or psychiatric harm just didn't really exist. Then the sort of concept of trauma really gained traction in post-Vietnam.

After the post 1973, um, and trauma at that stage was meant to be something beyond the range of ordinary human experience. It was meant to be something that most people, thankfully in their lifetimes would never be exposed to of war, of natural [00:34:00] disasters, earthquakes, that sort of thing. The weather was a real and genuine threat to life.

And that was really the, the essential requirement to be potentially qualifying for a diagnosis of post-traumatic stress disorder. Not everyone exposed would, but some people would. And PTSD. A lot of people think PTSD has been around forever, but it was within the lifetime of my trainer when I was a psychiatrist.

It's a relatively new diagnosis, not that it's an invalid one, but. It is quite a new one, and that was how it was defined. Coming to your question about what's wrong now, I think trauma has become rather self-defined. I think people will tell you I was traumatized. And the question isn't, well what was the threat to your life that you are referring to?

And, and I understand that there is, if you like, the small T trauma and the Big T trauma, but these have got really conflated and I think that [00:35:00] the word trauma is being used as a little bit of a catchall to account for any form of human difficulty. Any bad experience. Yeah. So, well, you might see. Someone who's got a story to tell you that something that they're feeling or experiencing something in their lives, there's a difficulty, an interaction, or whatever it happens to be.

If you say, well, it's because you were traumatized, someone might say, yeah, yeah, that, that, that could be, but actually what does that mean? And how meaningful is it? And to tell someone they were traumatized, I think is not a trivial thing. Because again, you are suggesting that they're a victim of something that they might not be able to fix.

But a lot of things are being attributed to trauma, and I think the trauma itself is often a bit loosely articulated and. I wonder in the end when someone says to me that they've been traumatized or they've got trauma, I'm not always clear what they mean, and [00:36:00] I don't wanna seem unkind by trying to undermine their experience.

Yes. But it's presented as a diagnosis and it can become very hard to challenge. Yeah. And you gave the example in the book of someone saying they felt traumatized after having an argument on television, a verbal argument on television, and. Of course, it's very common for relatively minor events like that to be classed as trauma.

And again, as clinicians, we feel we're on the back foot for someone to tell us they've had a negative experience and for us to say, no, actually, you know, we're gonna say no. That's not Trauma feels very uncompassionate. Yes. But there is again, an importance to accuracy because trauma in the psychiatric definition means something very specific.

It means you've had a majorly stressful event. Possible threat to life where the event after a long period of time stays with you. You relive it as though it was still happening. Now in the form of flashbacks, dreams, nightmares, you avoid similar situations. You might [00:37:00] feel tense and anxious quite a lot of time.

Might make your heartbeat fast. Or you get short of breath when you think about the event, or you're in a situation which reminds you of the event. It's a very, very specific definition, which clearly, you know, most people on TikTok aren't adhering to that definition. Right. I think that's exactly it. What is trauma?

What do we mean by it? I mean, you've articulated very well a lot of the symptoms of. P-T-S-D-I. I think trauma, you could say at a, at a most elemental level is a breach of a defense. You know, we talked before about being shot, but you could say in a breach of a psychic defense somehow. And the PTSD type of trauma is the inability really, you know, when something bad happens to us, what we want is to integrate that memory, process it, put it where it belongs in the past, and we try and deal with it in that way.

When people have a traumatic event, they can't process that memory. It feels like it's still in the present. They keep reliving the [00:38:00] event. It's not put in the past where it belongs, and a lot of the things we try and do are aimed at doing that. A lot of the things that come to us under the badge of trauma, as you said, sometimes we want to say that's not quite what we mean.

By trauma, but again, you are seen as lacking compassion. Mm-hmm. And so you get to a stage as a clinician where you don't want to challenge a narrative or a, or given diagnosis that you don't necessarily agree with and that's not a good position to be in. Yes. That totally agree with that. Now, on the other side of the coin, and I said I was a bit to, when it comes to trauma.

I do think there is a real value as psychiatrists to start taking a more trauma informed approach. And a lot of the experts I've spoken to will talk about the fact that in the histories of many people who end up getting diagnosed with mental health conditions like depression, even, uh, psychotic conditions like schizophrenia, A DHD.[00:39:00] 

Much more likely to have some sort of history of trauma on their background, borderline personality disorders, and so I really think it is helpful to start to understand certain mental health conditions as arising within a context of previous trauma and sometimes even perhaps being an attempt to adapt to a previous trauma.

But I'd be curious to get your thoughts on that. Do you think there is a value to take a kind of more trauma informed approach? Well, I mean, I've heard the argument and I haven't been fully persuaded by it. I, I think perhaps like you, I get to speak to hundreds, thousands of people and I hear lots of different stories that people have of their backgrounds and what happened to them.

And I think it's difficult really to say much more about the diagnostic value. Of those things I, I think one would need to acknowledge them as being important. But then what we want to do in psychiatry, I think, is to understand what we've always [00:40:00] called bio-psychosocial, which is the biological reality of people's illness, mental illness, which is of the neurons in some way.

Misbehaving. Are the neurochemicals not the right balance that they should be? Can we fix that in some way with psychotropic medication, but also the psychological, which is to say people's habitual thinking patterns, the way they understand and appraise situations, the way they see themselves and the world around them.

And the social, of course, the social adversities. Difficulties, financial hardships and abuse even that people unfortunately will experience all those sorts of things forever have been part of a psychiatric diagnostic formulation, and I'm not sure. If the trauma-informed approach can really say with any predictive value or explain why it needs to be sort of singled outta the other adversities.

[00:41:00] Right. And sort of foregrounded in that way. You know, I'm open to the discussion, but going back to the 1960s of what used to be called the Antip Psychiatry Movement, SAS and others. Would say that there is no such thing as mental illness or it's the reaction of people to living in, in this sort of world.

And it might even be a sane reaction to this world. Uh, again, I can understand why some would say that. I just can't agree with it. You know, I, I think that when trauma is advanced, and I'm not saying these things are unimportant, but the extent to which they have explanatory value in, for example, why someone might develop a psychosis.

Mm-hmm. I just, I don't see it. We know a lot more about the genetics and we know a lot more. About the brain changes. We know a lot about the biological factors too, and I, I remain to be convinced. I guess I would say, I think maybe, maybe there's some difference [00:42:00] between me and you on this. I think certainly I don't think trauma is, I, I wouldn't necessarily isolate it as some uniquely important factor.

I would put it as an important piece of the jigsaw where when I've spoken to people like Mark Horowitz, for example, who talk a lot about the withdrawal effects of antidepressants, he cited studies that suggest that one of the most important risk factors for developing something like depression is how many stressful life experiences someone has had.

Now, obviously, we're not necessarily creating stress with trauma, but we, what we are saying is that negative adverse experiences increase the likelihood of developing some sort of mental health condition. And similarly, when I've spoken to people like the psychologist, Richard Bental. They'll also say trauma seems to be markedly more common in cases of like schizophrenia, and therefore I just think it's an important piece of the jigsaw to take into account.

And perhaps if you're sitting across from someone and taking that trauma history, you know, [00:43:00] accurately as, as we've already outlined, perhaps helping them to process those events could help them even with their current difficulties. Well, it's an interesting perspective and I guess to. What we would define as trauma.

Yeah. I would sort of answer the argument that when we're trying and do those kind of things anyway, whether or not you called it trauma, but I think to tell someone they were traumatized, I'm not sure how helpful Mm it is for that individual, you know? In other words, it's, it seems to be a way of. Saying something that I think we've already known for a long time and already expressed differently.

Yeah, I see your point. There's like a semantic issue, like again, the difference between negative adverse experiences and trauma, and is it helpful to say, Hey, these really bad experiences you've had, you've been traumatized, therefore this happened. And I guess you could see how that might ossify or fossilize someone's narrative about what's happened to them as well.

I think that would be my worry. And I understand that everyone [00:44:00] is coming from a place of compassion and trying to do their best for the individual sitting in front of them. So, you know, I think it's an important discussion and, and one that no doubt hopefully will be furthered by more research in the area and also understanding these conditions a bit better.

Yeah. Yeah. You, you wrote a chapter about neurodiversity. Mm. Things like autism, A DHD, and you said before we started that actually a lot of the feedback you've gotten about the book has been related to things like autism and A DHD. Really curious, what's the feedback you've gotten? What are the reactions that you're getting?

Well, I think it's the first chapter that most people want to talk to me about. It was something when I was writing it that I was writing from the position of a psychiatrist. I've been practiced just a few months, short of 30 years, and it was one of those areas where I've seen a huge expansion in the rates of diagnosis.

And so for me, I wanted to understand where [00:45:00] that's come from, why it's happened. So I wrote about it, not quite realizing that it might be the sort of area that sort of attracted the most interest, you know, from every detail, including the language used and and everything else. So that was a bit of a surprise.

Yes, and as I talked about my podcast two weeks ago with Marie Ka, big as a Condition, one of the most interesting things about autism and A DHD as opposed to pretty much every other mental health condition is that patients often attend the clinic pretty much having already arrived at the conclusion that they have the diagnosis.

Mm-hmm. Not everyone, but many. And they feel really a lot of the times quite relieved or happy to get the diagnosis and quite irritable if they don't get the diagnosis. And as I said in that podcast, I understand it. There'd been people who may have struggled with, let's say, problems commonly associated with A DHD for like 30 or 40 years.

Or the same with [00:46:00] autism. And what a relief to finally get some recognition of these problems. Yet. Could there be something else going on at the same time? Your thoughts? I think we have to start with maybe some facts. When I was, uh, leafing through an old textbook from, it was written in the mid 1990s and it said, autism is a rare disease with a rate of two in 10,000.

Is what it said and, and they said that 15% of people would develop an independent life and the rest wouldn't, and only about half would develop useful speech. So we used to think of autism as a severe disabling illness. We are now 30 years or roughly a generation later, and the rates are about roughly one in 30.

And we could see from another study that the rates of autism had increased by, it was 787%, I think between 1998 and 2018, so 20 years. So I mean, putting aside [00:47:00] a DHD for now. If you take that neurodevelopmental disorder, autism, you would say something needs to account for this very substantial rise. Now, I think some of it is perhaps about increasing our ability to make these diagnoses and you can see that, uh, and, and I think it was about merging the categories of what we used to call Asperger's and autism into a category.

When you see a rise that's almost year on year, you have to ask yourself, how do we understand that and how does it benefit the person being diagnosed and what do we make of it and are we getting accurate? I mean, the same really in, in A DHD we've seen a, a very substantial increase in A DHD diagnoses over the years, so that I think it was.

I, I think it was about 7%, close to 7% of US children had the diagnosis, and I think about one and a half percent [00:48:00] of adults. You look at the rise and, and you can see the graph showing the increase, and you compare it worldwide and it's very uneven worldwide. So in France, the rates, uh, in children, I think from one study was about 0.3% compared with about 6.7% in the states.

You know, so something's going on. Are the states getting it completely right and everyone else getting it wrong, or where does it lie? I mean, I, you said you spoke to Alan Francis, and, and perhaps you touched on, on that, but he, he has a view too. I think one thing we know is that for A DHD, where there's a September cutoff for the school year, children in August are far more likely to be diagnosed with A DHD.

In other words, it's a sign of immaturity in young people. Adult, A DHD. I mean, looking at the studies on that, we know that some people were missed in childhood unequivocally and, and I've seen people whose lives are transformed by a well-made diagnosis, which does in retrospect [00:49:00] explain a lot that went wrong in their life.

But one study, I think it might be the American Journal, but I'd have to check it, looked back at people diagnosed in adulthood and they showed that. About 90% of people diagnosed in adulthood didn't have any childhood forerunners of a neurodevelopmental problem. Now, if you're gonna postulate that something is a neurodevelopmental disorder.

Then it stands to reason. Mm-hmm. That there would be neurodevelopmental problems. And if you can't find those, then that person might be suffering. But whether they're suffering with A DHD is the question. And of course, someone could have problems with their attention or impulsivity or even a degree of restlessness and hyperactivity.

Not necessarily warranting a diagnosis of A DHD. And there's still a ton of things a person can do to improve their ability to focus, to improve their attention. Like not getting a diagnosis. The only thing that takes off the table typically is medication. Mm-hmm. But there's ton of other strategies that are [00:50:00] recommended to people who have the diagnosis that anyone can employ if they wanted to improve on those issues.

Right. I mean, we used to think that people grew out of. Childhood, A DHD, and, and I think commonly people do. So there are a number that persist into adulthood. There is a few percent that persist into adulthood, but you, you have an 34 fold increase. Uh, I think one study showed of, of children being prescribed.

A DHD medication, um, between 1995 and 2008, we're giving medication that's not trivial sort of medication to often very young children, and we need to be sure that we're giving it to the right children for the right reasons. I, and I think part of my criticism is that the diagnostic guidelines like DSM just aren't doing a.

Good enough job of differentiating, again, we come back to this concept of normal, but differentiating the concept of normal from pathology, uh, that, that was gonna be my next question. So [00:51:00] as a, as a specialty, we, you know, we've talked about this problem in overdiagnosis as it might relate to a few different conditions.

How do we start to pull it back? How do we start to rein these things in? Is that even possible at this stage? Well, it's, it's something that I've really wrestled with that question. What, what are we meant to do about it? And you know, like a lot of people, I'm always better at describing the problem than, than the solution.

But the starting point is a public conversation. Exactly the sort that we're having now. I understand that people might disagree with me, but that's, you know, why would that be a bad thing? But I do think we need to ask ourselves, have we ended up in the right place? Are we moving forward to sort of an ever more enlightened future or, or has this in some way taken us backwards?

I think we'd, you know, if we broaden out not just on sort of. Neuro elemental. But if we look more generally at the future, I think there's two divergent paths. I think one is a, is a [00:52:00] hopeful path where the science will show us exactly what neurobiologically is happening in our brains. And so that when you, Alex say to me, I'm feeling anxious and I can follow that thought round your head and see the activated networks and pathways and describe.

We have a validated way of making our diagnoses. We might be able to use large language models and similar to look at clusters of symptoms and say something about them, and then I think there's a second if you like, a sciencey pathway of trying to get biological validation for our diagnosis. Something that psychiatry has been striving to do for a long time.

We have in a few of them, we know some autoimmune disorders can cause psychosis. And similar so that we can validate depression, let's say on a scan and see what that looks like. And then the sort of other pathway is to really look at. Other sort of treatments of the sorts [00:53:00] that we discussed before and that you mentioned just now about ways of managing symptoms, of connecting people in communities of something more broadly social that will improve people's quality of lives without needing to label everyone who's suffering or distressed as mentally ill.

Mm. Which is fundamentally. What's happening now? Yes. And, and maybe I would suggest a third pathway, which you alluded to earlier, which is the cultural conversation. Mm. To have a culture that can allow for life being difficult for someone experiencing mental distress. For not achieving total mental harmony.

And again, that not being a symptom of, uh, mental illness, but rather depressingly being a kind of a symptom of the human condition, which we're all subject to. Well, it's an interesting 'cause I do, you know, we talk about, or we've come back to culture a little bit and I think there is something about our culture that likes to sort of locate the, for of better word blame within the individual.

Yeah, [00:54:00] that's a good point. That they're depressed because the, you know, their brain isn't quite functioning in the way that it ought to be, or, or something like that. Rather than locating the problem outside of them a little bit, the context of their lives, the adversities they face, the difficulties, the exclusion.

Problems getting work or any number of, and as you said, you know, we use different words for it, but the adversities growing up, which we could, or you could or I might in the future call trauma, but, but you know what I mean? And so I think that sort of cultural conversation. About how we understand these things.

I, I think, is an important step because it's not benign to tell someone that there is something wrong with them, and you need someone else to fix it for you. Yeah. The, the writer, Alan De Baton makes a really good point, which is we've, we've, we, we don't make room for misfortune anymore for people's lives that in the past.

Previous cultures held a lot more space [00:55:00] for this idea that you, like a lot of bad things could happen to you and that could negatively affect the trajectory of your life in a lot of ways. Whereas now it feels like there's a, like you said, in a, in a weird way, more individual responsibility in some ways, in some ways less.

We locate sort of someone's problems just within themselves as an individual, not in their social, cultural context necessarily. And at the same time we say, you know, if you are experiencing mental distress, you must be subject to some condition, some sorts of disease that requires a medical treatment.

It's a strange, then it's somewhere, somewhere else. In the self-help space, which I'm very familiar with. There's what I call the optimization fantasy, which is the sense that if only you do everything right and were perfectly hardworking and had all the right routines. Your life could be absolutely perfect.

And I think that's, you know, that has its own problems too. Yeah. I mean, I think as, as human beings, our, our lives are messy and difficult and full of challenges and often adversities and sadness and you know, I [00:56:00] talked before about this sort of bureaucratization of life. Of the sort of infiltration of bureaucratic standards into our sort of day-to-day lives.

And I think diagnosis is in danger of doing that same thing. Uh, I mean, I believe passionately in psychiatric diagnosis, a well-made diagnosis is transformative, but I think it's really important to say what the boundaries of that. Diagnosis are. Yeah. And when we fail to do that, I don't think we're being kind in the way that we like to believe.

And I think that's our challenge now is do we want diagnoses that are specific at the risk of excluding some people who could qualify? Or do we want them to be broad enough to include absolutely everyone but that. Might include people that really don't belong there. We've not resolved that, but I think we are moving steadily in the wrong direction.

Yeah, I think that's the key question at the heart of your book and what you're saying is that [00:57:00] when we over-diagnose, when we use diagnosis too much, it strips away its value. And suddenly it starts to lose its meaning. Well, I think it's, I mean, just on that point and, and it's not something I've mentioned before, but I think that when diagnoses are talked about a lot, I think the public can get quite skeptical of those diagnoses too and begin to wonder what they mean when, when they hear from lots of people that they were diagnosed with X or Y last week and they begin to wonder what the validity is.

Uh, I think it was something you alluded to. Before as well. And, and so I, I think we need to have that conversation. Yeah. We're out of time, Dr. Au It's been wonderful to speak to you, to learn from your experience. I'm sure we could have a number of other conversations on this podcast, normal, normal, your book that just came out a few months ago.

I'll put a link in the description. I encourage everyone to read it. Thank you very much for joining me. Thanks. It was great to be here.