# The number of people with chronic conditions is soaring. Are we less healthy than we used to be – or overdiagnosing illness?

Are ordinary life experiences, bodily imperfections, normal differences being unnecessarily pathologised? One doctor argues just that.

## Introduction

School was a difficult time for Anna. It still haunts her. She recalls being a sociable child, good at making friends. But she also remembers becoming hyperfixated on one friend, then another and another in succession. She tended to be impulsive and, wanting to please others, easily led. One distressing incident in particular has never left her. On the first day after moving to a new school, she was relieved to be taken under the wing of two girls. At lunchtime, in fits of giggles, the girls egged each other on to do naughty things. Anna spat orange juice at the boys. She did it with relish, only to reproach herself later. She feels the episode coloured her whole school experience.

As a child and an adult, Anna felt sanctioned, judged and misunderstood. She considers herself a chameleon who adapts to new environments and survives by being funny, but all too often regrets things she has said. Her self-esteem is low. Anna is a nurse and, although she loves her job and is good at it, she still often feels inadequate. “People don’t think I’m as clever as I feel. I can’t get the words out quickly enough,” she says.

## Anna’s Diagnosis

Anna has sought medical advice many times throughout her life. In her 20s, she remembers being exhausted all the time. She couldn’t control her emotions and complained of a poor memory. She left her keys in ridiculous places – one time in the fridge. She forgot to turn off the hob and unplug the iron. “I can never remember things people tell me, like how many children they have. I hate it because it makes me look as if I don’t care, and I do.”

Anna has taken the stimulant drug methylphenidate (Ritalin). “The first time I took it, I couldn’t believe how clearly I could think.” She could make decisions more quickly, prioritise, and had more energy. I wondered how this affected the practical aspects of her life, in work and relationships. “Is my life better? Yes and no.”

Anna’s workplace have been supportive. They have made adjustments, such as giving her a private, low-ceilinged office, which she feels reduces noise reverberation and provides quiet when she needs it. She is also allowed to wear noise-cancelling headphones if she is in a busy environment. Colleagues have been taught not to burst into her office without warning. Despite this, Anna still finds work challenging and feels she has to constantly remind people that she has a disability. So much so that she is off work now and does not see herself ever returning. Part of the ongoing problem is that neither Anna nor her employer know what she really needs. “When somebody asks if I want help, I don’t know what to ask for,” she tells me.

I ask how family and friends received her diagnosis. A common response when she describes her symptoms is “everybody has that”. Everybody is a bit disorganised. Everybody finds work hard. “The difference is I feel like that all day, every day,” Anna says. “I never feel OK.”

### Diagnosis and Overdiagnosis

I have been a doctor for more than 30 years and a neurologist for 25 of those. I have recently grown particularly worried about the large number of young people referred to me with four or five pre-existing diagnoses of chronic conditions, only some of which can be cured. Autism, Tourette syndrome, ADHD, migraines, fibromyalgia, polycystic ovary syndrome, depression, eating disorders, anxiety and many more.

The startling rise in people diagnosed with mental health disorders, behavioural and learning difficulties features regularly in newspaper headlines and in our conversations: “ADHD: what’s behind the recent explosion in diagnoses?”, . “Autism prevalence rises again, study finds”, . The story is the same for multiple categories of mental health disorder. “PTSD has surged among college students”, . “Depression and anxiety rates have increased by 25% in the past year”, .

What do these astonishing statistics say about the state of our health? On the surface, they make it seem as if we are considerably less mentally and physically healthy than we used to be. But there are other ways of interpreting them. Could they simply reflect the fact that we are much better at recognising medical problems and identifying people in need of treatment? Disorders such as autism may be on the rise because people are finally getting the right diagnosis and being given support. But there is a third possibility. It could be that not all these new diagnoses are entirely what they seem. It could be that borderline medical problems are becoming iron-clad diagnoses and normal differences are being pathologised. These statistics could indicate that ordinary life experiences, bodily imperfections, sadness and social anxiety are being subsumed into the category of medical disorder. In other words: we are not getting sicker – we are attributing more to sickness.

Which of these explanations is most likely to be correct is a matter on which it is hard to find agreement. But it is very much in our interest to find the answer because the trend of detecting health issues in milder and earlier forms, and the assumption that is always the right thing to do, is pressing forward relentlessly.

I would make a case for possibility number three: that we are becoming victims of too much medicine and it is time to turn back the dial. That we are living in the age of diagnosis for mental and physical health conditions. And there is no better illustration of this than the recent explosion of people diagnosed with ADHD.

### ADHD and the Rise of Medical Diagnosis

ADHD started out as a defined medical condition in the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-2) in 1968, in which it was referred to as hyperkinetic reaction in children, described in a single line as distractibility and restlessness that went away in adolescence. In 1980, the DSM-3 introduced the term attention deficit disorder (ADD), with hyperactivity added in the revised edition of the DSM-3 in 1987. The DSM-5 describes ADHD as a pattern of inattention or hyperactivity that interferes with social functioning or development. The diagnosis requires that the difficulties be present before the age of 12, that they are present in two or more settings, and reduce the quality of social, academic or occupational functioning. The distinction between mild, moderate and severe ADHD is very vague.

Like all medical problems, ADHD has a range of severities. One of my most vivid encounters with it was not with a patient, but in spending time with Kendra, the young daughter of a friend. Aged eight, Kendra, who had severe ADHD, had a level of energy and lack of focus that was impossible to keep up with. She pinged from person to person in a group, speaking quickly and jumping from topic to topic. She was a wonderfully affectionate child and I had the sense she was also very intelligent, but it was hard to test that theory because she couldn’t apply her attention to anything for long. I once joined her and her mother for a shopping trip. Such was her energy that no one could relax. I was sure she’d dash away and we’d lose her. She didn’t. She grew up safe and well cared for to become a creative adult. She still has problems with lack of focus. She found education hard, but she found her place. She’s an artist, which allows her to work at her own pace, in her own way, and which makes the most of her flexible thinking.

Diagnostic rates of severe ADHD, as Kendra had, are actually quite stable. But those with severe ADHD are now vastly outnumbered by those with mild ADHD. As with autism, there have been staggering increases in the number of people diagnosed with ADHD in the last 30 years, but that growth is almost all at the milder end of the spectrum.

New diagnosis in adulthood has gone from being very rare to  adults in some places. These are almost all in the mild domain. The UK has seen  in adults seeking an ADHD diagnosis between 2020 and 2023.

> Everyone has a right to be able to do what they want
> 
> When mental health problems are viewed in this way, recovery starts to seem far more possible

I have been a doctor for more than 30 years and a neurologist for 25 of those. I have recently grown particularly worried about the large number of young people referred to me with four or five pre-existing diagnoses of chronic conditions, only some of which can be cured.  and Tourette syndrome, ADHD, migraines, fibromyalgia, polycystic ovary syndrome, depression, eating disorders, anxiety and many more.

The startling rise in people diagnosed with mental health disorders, behavioural and learning difficulties features regularly in newspaper headlines and in our conversations: “ADHD: what’s behind the recent explosion in diagnoses?”, . “Autism prevalence rises again, study finds”, . The story is the same for multiple categories of mental health disorder. “PTSD has surged among college students”, . “Depression and anxiety rates have increased by 25% in the past year”, .

What do these astonishing statistics say about the state of our health? On the surface, they make it seem as if we are considerably less mentally and physically healthy than we used to be. But there are other ways of interpreting them. Could they simply reflect the fact that we are much better at recognising medical problems and identifying people in need of treatment? Disorders such as autism may be on the rise because people are finally getting the right diagnosis and being given support. But there is a third possibility. It could be that not all these new diagnoses are entirely what they seem. It could be that borderline medical problems are becoming iron-clad diagnoses and normal differences are being pathologised. These statistics could indicate that ordinary life experiences, bodily imperfections, sadness and social anxiety are being subsumed into the category of medical disorder. In other words: we are not getting sicker – we are attributing more to sickness.

Which of these explanations is most likely to be correct is a matter on which it is hard to find agreement. But it is very much in our interest to find the answer because the trend of detecting health issues in milder and earlier forms, and the assumption that is always the right thing to do, is pressing forward relentlessly.

I would make a case for possibility number three: that we are becoming victims of too much medicine and it is time to turn back the dial. That we are living in the age of diagnosis for mental and physical health conditions. And there is no better illustration of this than the recent explosion of people diagnosed with ADHD.

### ADHD and the Rise of Medical Diagnosis

ADHD USED TO HAVE a recovery identity. In the 1960s and 70s, the DSM described it as condition that went away in adolescence. By the 90s, it was recognised that the symptoms did not always disappear completely but did lessen as people got older. . Severe ADHD lessened but often persisted, while people with mild ADHD could expect a chance of full recovery. But ADHD is slowly being incorporated into the identities of many young people. Some support groups discourage the attempt to overcome ADHD traits. People are told to unmask and to share their ADHD selves with others. But learning to control our moods, behaviour and impulses is part of growing up, whether one has ADHD or not. We all become more socially competent, gain focus and are better able to cope through practice. Encouraging young people to do otherwise may be well-intentioned but potentially sets them up for non-recovery. The rise in subtler ADHD presentations in adults may also undermine a young person’s expectation that their difficulties will disappear in time. A growing population of adults have incorporated ADHD into their self-concept. When a medical problem is part of a person’s identity, it becomes inescapable.

> I suddenly believed I’d recover completely. I stopped reading about illness and discussing symptoms. I spent time seeking joy
> 
> When mental health problems are viewed in this way, recovery starts to seem far more possible

However, the problem is that the term is not used in that way. Instead, it is used as a counterpoint to the term “neurotypical”. A neurotypical person is said to organise their thoughts and behave in a “typical” way. A very common explanation for the difference between neurodivergent and neurotypical people is that the latter were born with an inbuilt handbook for life, which gives them an innate sense of social rules. Neurodivergent people did not receive the handbook and therefore have to work much harder to learn and fit in. The division of people into typical and diverse immediately contradicts the sensible statement that we are all different. It brings to mind George Orwell’s Animal Farm, where the pigs decide that “all animals are equal, but some animals are more equal than others”.

Neurodivergent conditions are still finding their place but what is clear is that people with that label are suffering. Their hardship is real or they would not have sought a diagnosis. Anna has struggled for a very long time. She’s had a lot of internal pain and needs support. But the question arises as to whether the benefits to those diagnosed with ADHD outweigh the drawbacks of being labelled with a brain disorder. If they do not, then this is an example of overdiagnosis – the diagnosis might be right but it is not beneficial.

The issue with overdiagnosis is always around the benefit of diagnosis and value of special accommodations to those mildly affected. One Canadian study compared university students with ADHD, some of whom received no special accommodations and some of whom were given help, such as extended time for tests and separate test-taking rooms. The students who got extra support perceived it as helpful but there was no measurable benefit in terms of academic performance. Several studies have looked at school-age children and students in higher education who were , including a reduced distraction environment, use of a calculator, more frequent breaks and oral presentation of written information. Again, people with ADHD who received this extra support performed no better than pupils with ADHD who did not. One study found children screened for ADHD in school did not benefit but raised the concern that they were harmed by being labelled at such a young age. Similarly, special accommodations made to support adults with ADHD have yet to be proved to make a useful difference to their lives.

Stimulants are not first-line treatment for ADHD in children. They are reserved for when behavioural treatments and support are not enough. The short-term efficacy of stimulants in children is considered to be well-established in reducing symptoms such as hyperactivity. They improve concentration and teachers perceive better behaviour in children taking them. However, most studies have followed the children for only a short period of time. What is less clear is whether or not that symptom reduction translates to something more meaningful in the long term, such as a better quality of life or academic performance. Stimulant medication reduces symptoms only while you are taking it. For a more lasting treatment effect, behavioural interventions are needed. Again, children with severe ADHD are the ones who stand to gain from stimulant medication, because their disability is such that medication has a more palpable effect on their ability to concentrate on tasks such as reading so they have time to learn. At the mild end, there is doubt that stimulant use has enough of an impact to offset either the negative effects of labelling or the low expectation that can be inferred from a mental health diagnosis.

> Nobody could help me with my psychosis. Then I was sent to jail for holding up a shop with a toy gun
> 
> It is only anecdotal, but the lack of palpable life improvements for people diagnosed with either ADHD or autism is something that concerned me many times as I interviewed people about this subject. Of the scores of people I spoke to, all of whom were adults, all perceived their lives to be better off thanks to a diagnosis. Every person welcomed the diagnosis into their lives. But almost all had left their job, dropped out of education and lost many old friends. Several were housebound. The same can be said about those I spoke to with chronic  and long Covid. I saw a worrying gap between the perceived benefit of being diagnosed and any actual improvements in quality of life. In most conversations, I was left wondering how long the positive impact of validation would last.

The people I talked to each got great psychological relief from their diagnosis and were sure it had made their lives better. Perhaps what they actually needed from a diagnosis was permission to do less in a world that values only very particular types of success. For some, medical diagnosis is a means to take the pressure off, so they no longer feel forced to continue chasing after an overly idealistic social and work life.

One woman’s story stood out. She’s an artist who has had some significant successes, but not the success she wanted. She would prefer to be an academic, she told me, but it wasn’t her talent. As a teenager, she imagined her adult self quoting poetry off the cuff. The pain of not turning out to be that adult was terrible for her. It stopped her enjoying the success she had. Eventually, a diagnosis of ADHD helped her accept that she could not be equally talented in every way she wanted. The diagnosis gave her some comfort but also caused stagnation in her life. It reinforced her belief in a lesser version of herself. Rather than being defined by a successful art career that others would envy, she became a woman whose life revolved around ADHD and was defined by the things she could not do because she was neurodevelopmentally different. I worry that a child told they are different in this way will underestimate themselves and limit their future.

Excessive medical diagnosis risks robbing people of a recovery identity and promoting intolerance by othering; by dividing the world into neurodivergents and neurotypicals. It must be very hard to set out or continue on life’s big journey if your aspirations have been narrowed by a diagnosis that is uncertain or offers very little. Let’s find a way to be more tolerant of difference and imperfections that still allows people to live a life unencumbered by a diagnosis.

This is an edited extract from _The Age of Diagnosis: Sickness, Health and Why Medicine Has Gone Too Far_ by Suzanne O’Sullivan, published by Hodder Press, on 18 March at £22. To support the Guardian and the Observer, buy a copy at 

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