Dr. Suzanne O'Sullivan
Appearances
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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,
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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. way and therefore it does. So it's not actually that unusual for people to have problems a little bit like Matthew's.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
That's an extreme example. But for a neurologist dealing with these kind of issues, it's also a common example.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
There are great scientists working on it now, but during my training period, there was nobody.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
I was the absolute ultimate tourist. Oh, good. I did everything that you'd expect a tourist to do. First, I did the Universal Studios tour.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
It is more common in women. So about two thirds of the patients who develop psychosomatic conditions, seizures in particular, are women.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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, right, 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 collapsing.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
What's likely happened is that one person has fainted and then other people have sort of collapses in sympathy really with that person, sudden emotional overwrought situation.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
I did for six hours. Oh, my God. And the very first thing that happened was they put me on the Harry Potter ride. Oh, yeah.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 poisons.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 move to the town.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
There were 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
The effects and everything are amazing, but it was just very disorientating when you were expecting something entirely different.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
I'll give you another one, which is the belief in the sonic weapon.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
Somebody who is 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
And these sort of things do happen.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
Sound just travels along nerves into the brain. So scientifically it made zero sense whatsoever. But unfortunately, people really bought into it.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
I wear a lot of green, but I do identify very strongly as Irish. I mean, I'm from Ireland.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
The whole thing was so illogical. You've 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
It'll happen to them and it'll disappear. But vulnerable people We'll 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
Yeah, exactly. It's 100% Irish, but I've lived in England for a long time.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
Again, that's coming back to my current theme of overdiagnosis, which is when does worrying about your health become hypochondria? 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
If it isn't disabling you, I wouldn't call it hypochondria.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
And that's something I think people need to think about when they're kind of using medical terms in a casual way.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
Nobody could understand what it was. Although it was a small town, it had good health care 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
Yeah, she's woken up. They say you probably had a stroke. Go home.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
I should have applied. They had done as much as they could to it.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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. It 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
They spread from older people to children. And when it went to children, they started having different symptoms like hallucinations and things.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
Astonishingly 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
Yeah, because the world is so small now.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 70s, but had kind of bleach blonde hair.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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? Yeah. 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 that people were delusional when they said this town was paradise, but actually it had been.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 stalwart 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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. Yeah.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
There's survival mechanisms in some way.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 around.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 9, 10 different diagnoses.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
This is a kind of a collusion between society and the scientific world and the medical world.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 because I could kind of relate to these people in this situation being dismissed.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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, OK, 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
And the idea then is obviously you identify all these extra people with pre-diabetes and that particular change applied to the entire population of China would have meant that 50% 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 pre-diabetes 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
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
and consider success to be how many new sick people can we find, rather than the more important endpoint, 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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...
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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?
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 that
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
And does he put himself in it now?
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
Because you've got to the point now where you're 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
There's a program on TV. I don't know if you've seen it. It's called Love on the Spectrum.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
And I was resistant to watching it at first because I thought it would be kind of mocking or something.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
There's really lovely examples of masking in that where 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
That's sort of masking or camouflaging.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 job.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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? Yeah. It disincentivizes people from trying to overcome their difficulties.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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...
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
If they hear 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
Because we see there's a lot of people in the public eye who have these diagnoses 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 podcasts.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 overcome them. You should embrace them. Be your most authentic autistic self. But I've talked to the families of people with severe autism.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
If they didn't help the children in the family to overcome their difficult behaviors, they would be institutionalized.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 that needs to be answered is, is it benefiting them to be labelled? Because no one can say where the line between
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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, how 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 a medical label is actually helping anybody.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 differently. 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 their children must understand what a dangerous thing that is to do, to label your child at such a young age.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
And of all those people who could have that test, only about 10 or 20 percent of people actually have the test.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 counselors 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
And she just couldn't face the idea of looking at her children and thinking, I'm going to 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 and had the test, it was negative. She didn't have it.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
Obviously, yeah. But you see, that works both ways. But that's how strong it is.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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'd seen her mom get sick. She knew exactly what was going to happen next.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 a
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
If you do an EEG in someone having these psychosomatic seizures called dissociative seizures, even when they're unconscious and completely unresponsive, you see a normal waking brainwave pattern.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 disabled by them. We've become very casual about this sort of like I'm on the spectrum or... I have ADHD.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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. Also, I can't remember whether it was ADHD or autism, but there was something like 11 billion TikTok videos about, I think, autism.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
It's Looks awake, but for some reason, people are not able to access that awake part of the brain.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 to my clinic, then they're not well and there's a problem.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
If you look to the brainwaves of someone in one of those seizures, they look normal.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
If you look at the brain in a different way, so you mentioned FMR,
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 diagnosis will stick and that becomes really problematic.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
rise 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
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 pains and things like that, which quite frankly are symptoms of everything.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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. It comes with 100 caveats.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 laterally.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
You know, it went from Twitter to mainstream news to medical newspapers with phenomenal speed, with no scientific study whatsoever, with just it being sort of a word of mouth.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
There is really good evidence that most people, however, with 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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?
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
So it served an important social purpose.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
They don't feel the need to be labeled to belong to a group and to get support.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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, I'd say 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
difficult for people to hear some of the things that I'm saying. And I do understand that.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
I was absolutely thrilled and delighted to be here. I'm honored. So thank you so much.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
The purpose of writing the book was very often this something affects really young people. And I was seeing these young people who are 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 am seeing it every day. but they can't even believe that such a thing exists in the world.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
Absolutely. Well, I always say to people, imagine your next door neighbors in a wheelchair. You understand that they've got multiple sclerosis or motor neuron 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
Even the most caring and understanding a person, there's something in us that kind of says, oh,
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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. Yeah. 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
So it's the same with these sort of seizures. When my heart races because I'm frightened, it's not because of a heart disease, but neither am I doing it on purpose and neither could I stop it.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
And yet, because they have a psychological origin, we kind of think that's less seriously
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
It won't work. It may work as a placebo.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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?
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
That's fairly 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
We don't fully understand. You know, 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 evidence.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 expect it 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 but
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
So Matthew had some tingling, I 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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 and he was completely wheelchair bound.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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, palpitations. patterns of sensory loss that fit with the brain.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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, etc, was all normal. It was very obvious that this had a psychological cause.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
So the question Matthew would have for me is, how could I not be able to move my legs? You're telling me my nervous system is healthy. Why can't I move my legs?
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
Well, I think it's very unbelievable for people.
Armchair Expert with Dax Shepard
Suzanne O'Sullivan (on over diagnosis)
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 instantly.
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Well, I mean, with regard to sort of if somebody notices a symptom and goes to the doctor, we do. You know, I'm certainly not advocating that they don't do that. The distinction I'm making is between us as a scientific and medical community seeking out patients who are asymptomatic. So I'm talking about asymptomatic cancers and asymptomatic hypertension patients. and asymptomatic prediabetes.
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If we work really hard to try and find loads of asymptomatic people at risk of problems, we overdiagnose. But obviously, symptomatic disease is a completely different thing that does need to be taken more seriously. However...
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When it comes to things that come to a doctor and how one should approach that, very often the time is a better answer to medical problems than bunches of scans and loads of blood tests. You know, medicine and diagnosis is still a clinical art. Tests need to be put into a clinical perspective.
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you will get a better and more reliable diagnosis from a good doctor who takes time listening to you and examining you than you will from a scan. Because again, the problem is that scans and blood tests, they pick up irregularities all the time. You can be overdiagnosed very, very easily if a doctor sends you for a scan every time you go and see them.
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I mean, obviously, finding progressive cancer early is the aim. But the difficulty is that... Our science isn't very good at doing it yet. So I'm not suggesting this won't be a wonderful strategy in the future. But unfortunately, there are some cancers and pancreatic cancer would be one of those that spreads very quickly and therefore screening programs don't work very well for those.
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So, for example, ovarian cancer spreads very quickly. You don't have a screening program for that because by the time it's found, it's often already spread and that can be a difficulty. So other cancers spread very slowly or grow or don't grow at all. And that's where overdiagnosis, so underdiagnosis occurs in some cancers because they're hard to detect or they spread very quickly.
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Overdiagnosis occurs in other cancers because some don't grow at all. So there's absolutely no doubt that the logic behind that we should try and find them early is the correct one. But the point is, we're not very good at doing that yet. We just have not mastered that yet.
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Well, that's precisely the point of how one could perhaps think about how one deals differently with this issue of screened cancers. So, again, I'm talking a cancer that presents with symptoms is completely different. But let's say a cancer found on screening. You can actually consider a watchful waiting program for those cancers.
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So a lot of abnormal breast cancer cells and a lot of abnormal prostate cancer cells don't necessarily progress to be life threatening. And what you can do in those situations is do exactly what you're suggesting, which is monitor them with scans over time to look to see, is this one that's progressing or is it staying the same?
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At the moment, because the word cancer is such a frightening one, you know, we feel a bit compelled into action. People need to know that, you know, these cancers are not all equal. A screen cancer is not exactly the same as a symptomatic cancer. And you do have time to think. But to be able to have time to think, you need to understand that these cancers don't all grow.
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And you also need to have a good doctor by your side supporting you while you have serial testing to see whether you are one of the lucky ones who has just cells that aren't going to grow or if you're one of the unlucky ones.
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I guarantee you, Mike, I would be exactly the same. You know, if I, you know, I do have cancer screening because in the UK it's recommended on a regular basis. I have the standard screening. And if something is found, even with the knowledge that I have now, I would be just as frightened as anybody else. And I would also feel compelled to act.
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And I think probably one of the issues there is we're calling all of these things cancers. But that's not necessarily representative of what is being found. So what some people would argue is that we should give these kind of abnormal cells found on screening a different name to cancer.
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Because the minute we kind of hear, oh, it's a cancer, well, you just want it out and you'll be subjecting yourself to treatment which could be harmful in itself.
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So to solve that problem of fear, because fear compels us into doing things that aren't necessarily the best thing for us, and perhaps to solve the problem of fear, we should give these screened abnormal cells a name that is less frightening than cancer.
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No, obviously you can't withhold those kind of findings, although, you know, I don't want to frighten your listeners in any way, but, you know, doctors, to a certain degree, withhold things all the time, you know, because it's quite unusual, not things of the magnitude of cancer, I should add, but, you know, it's quite unusual.
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If you see a patient and you do a bunch of blood tests and a couple of scans and a chest X-ray and a few things, you know, the likelihood that every one of those tests is going to come back saying, giving a 100% clean bill of health is actually quite unusual because every single blood test is open to a range of different results and scans constantly show little white spots and cysts and things.
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You know, they are just incredibly common. And it's a doctor's job all the time to decide what is important and what is unimportant. You know, we could frighten the living daylights out of our patients if we kind of made a big deal of everything abnormal we found on tests. Medicine is an art, diagnosis is an art. So a doctor is constantly sort of weighing up
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little irregularities that they find on tests against their patient's story and deciding whether those irregularities are worth a mention or not. But of course, screen cancer, well, that's a whole other story. But it is part of the art of medicine to decide what is important and what isn't.
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And there is an argument for some tests, not cancer per se, but some tests that, you know, not everything needs to be passed on to the patient if it's judged to be likely to cause them more anxiety instead of putting their minds at ease.
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Yeah, I mean, you know, there's surprisingly few real emergency situation unless you're working in a big trauma center where you're constantly seeing road traffic accidents, etc. You know, a lot of a lot of medicine isn't an emergency situation and a lot of time a better diagnosis is made and the patient is better treated if you take a little bit of time to think.
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And most problems are not rapidly progressive. And usually, you know, a patient working in concert with the doctor, where the doctor has a few meetings so that you can kind of really get a sense of the story and that you can kind of understand the person you're speaking to. That's how you make an accurate diagnosis.
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Feeling a need to label things immediately to satisfy the patient isn't necessarily the best type of medicine. And very often, things disappear. I'm sure you already know this, but doctors don't have the answer to everything. We don't know what causes every ache and pain. We don't know why people go through various transient symptoms.
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Once we've ruled out through the history and examination anything serious, often the safest strategy is just a series of meetings and time to think.
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Yeah, so I think that there's some fairly sort of there's some received wisdom, which is that earlier diagnosis are always for the better. If you catch a diagnosis early, you'll promote long term health. You know that the more health conditions you recognise, the more treatment you give, the more you promote long term health of the population.
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And those assumptions, you know, they make a huge amount of sense. One can understand why we think that way. However, when we look at the statistics of diagnosis, we see something that suggests those assumptions may actually be quite problematic. So for several decades now, we've really been focused on diagnosing lots of things at earlier stages.
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So, for example, we have screening programmes for cancer. that detect very early cancers. We have screening programs for learning problems that are detecting milder forms of problems like autism and ADHD. Now, if the assumption that early diagnosis and recognizing mild conditions was to our benefit was correct, We should be seeing the downstream effects of all that improved diagnosis.
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We should be seeing fewer late stage cancers, fewer deaths from cancer. We should see children with better mental health going into adulthood, better able to progress through life. But we are actually seeing the opposite of all of those things. We are diagnosing lots of conditions earlier. So we've got lots of people becoming patients earlier than they would have before.
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And we have just as many people with late stage problems.
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Very often, time is a better answer to medical problems than bunches of scans and loads of blood tests. You can be over-diagnosed very, very easily if a doctor sends you for a scan every time you go and see them.
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If you look at people who have been diagnosed with early cancers on screening, you will see fewer deaths from cancers in those groups. But if you look at the overall mortality from cancer, we have a gradually increasing amount of cancer diagnosis with late stage cancer also.
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And the reason that happens is because if you diagnose lots of people with early cancer cells, what people don't realise is that not every abnormal cell that looks cancerous will actually grow and cause long term health problems. Only certain cancer cells grow to become malignant, life threatening cancers. If you catch lots and lots of early cancer cells and treat them all as if they are
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potentially going to be life threatening in the future, you'll be treating a lot of those people unnecessarily. But if you look at the survival rates for cancer in those people, they'll look fantastic because a lot of those people didn't need to be treated in the long run. They'll be very healthy. They'll attribute that to the cancer treatment, not knowing that the treatment was never necessary.
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Yeah, so what I always say to people is, you know, you have to remember that a lot of the technology we have now to look inside the healthy body has only been available to us for a couple of decades. You know, the MRI scan came into regular use in the 1990s. The really good MRI scanners have only been around for a couple of decades now.
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So we did not know for a very, very long time what the inside of the healthy body looked like. We were not able to genetically test mass numbers of people until the last 10 years. So what we have is...
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sort of we've got all these new types of technology that allow us look inside the healthy body in a way that we never have before and we're detecting things that were always there that we didn't know were there so for example if you look at autism studies of people you will often find that they have small abnormal cells that didn't progress there was a study in detroit of men and they found that 45 of men in their 50s had prostate cancer at the time of death
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their deaths were for things other than prostate cancer and that those numbers were substantially higher as men got older. So huge numbers of men have early cancer cells that never caused them in their prostate, that never caused them health problems. We didn't know about them because we didn't have the means to look for them.
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So now that we're finding them, we're kind of acting on the assumption that all of them will progress because we simply don't have the knowledge base yet to know what factors make cancer cells grow in some people, but they don't grow in other people. How do you tell a serious cell that will progress from one that doesn't? So these cells have always been there.
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And the difference now is we have the technology and the ability to see them.
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Precisely. And, you know, a lot of countries don't do prostate screening because of the problems of overdiagnosis of prostate cancer. So some estimates would be that if you screen a thousand men for prostate cancer, you won't save any lives, but you will over-treat 10 to 20 men for prostate cancer who didn't need treatment because these abnormal cells in the prostate are so common.
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The difficulty is that if a man presents for screening of his prostate and abnormal cells are found, how is he to react to that? Because it's very frightening to learn that you have abnormal cells. And there are watchful waiting programmes that suggest we don't have to overreact when this sort of thing is found.
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But that can be very hard to do on an individual level if you don't know ahead of time that these things exist.
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So a lot of focus at the moment with regard to something like heart disease is on identifying the risk factors that might put you at higher risk of heart disease going down the line. So, for example, something like diabetes or something like hypertension. So over the years, you know, there's no point at which a blood sugar suddenly turns into diabetes. There's no right point.
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At some point, too much glucose on your blood means you're diabetic, but no one can say what that exact point is. And similarly, you know, what is normal blood pressure? You know, is it 140 over 80? Is it 130 over 80? Nobody knows. So what has been happening over the years in order to reduce the risk of something like heart disease or strokes down the line?
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Committees of specialists have been gradually changing the parameters required to be diagnosed with something like prediabetes or hypertension, with the idea that if you address these issues, you'll prevent heart disease at a later date. Now, this runs into the same difficulties as the early cancer diagnosis.
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If you adjust the parameters of blood pressure to identify more people as hypertensive, as happened not that very long ago, you can... identify huge numbers of people as being potentially hypertensive and potentially at risk of heart disease or stroke. But actually, of those huge number of people, you will certainly be helping a percentage of them.
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Maybe 20% of them will genuinely be at risk of stroke. But you are inevitably going to be over treating maybe 80% of them who are never at risk because they didn't have other high risk factors. And similarly, if you identify lots of people with prediabetes, only a percentage of those people would actually develop diabetes if you didn't identify them.
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So you've always got this health economics going on where you're saying, I identify 100 people. 10 of them might benefit, but 90 of them will probably not benefit from this intervention. And the assumption all the time is that the intervention doesn't do any harm, so that's okay. You've saved 10 people and the other 90 people have just gotten some good advice in health monitoring.
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But of course, it's not as simple as that. Health monitoring in itself has problems.