Book review: Suzanne O’Sullivan (2025). The age of diagnosis: Sickness, health and why medicine has gone too far. Hodder.
Most of us have various minor physical and mental aches and pains which can cause us some concern, and for which we may seek professional help. If the complaint is persistent, and preoccupies us, a diagnosis may be ultimately obtained, and this can give us an enormous sense of relief. At last, a name has been given to our pain and we have been heard and validated.
So, what is likely to happen next?
Probably, the ‘patient’ (for that is what we have freely become) will have access to a special person (the ‘therapist’), and to medication, or a bespoke diet, or an individualised exercise regime, or to some other ‘treatment’ (for this is what we are now thankfully receiving). As well, we might join a support group, or as O’Sullivan describes it, ‘a tribe of fellow sufferers’.
The title of the present book proposes that this familiar sequence of events has come to define our times. Bravely, this award-winning author and senior neurologist also argues, that while medical responses are completely appropriate when there is an obvious physical or psychological problem, the personal costs of diagnosis are likely to outweigh the benefits when complaints are at the soft end of a spectrum.
Autism and ADHD are classic examples of spectrum diagnoses. At the severe ends are people who clearly cannot cope in regular life settings without significant support. Although, interestingly, in the past ‘nobody needed a label to tell them these children had a lot of extra needs’. Nevertheless, the diagnoses that they were given, and which have been changed over time, have now been expanded to include many more people who have much lesser symptoms. Indeed, the province of the neurodiverse (to use a sociologist’s term) has come to be ‘dominated by the mild voice’. And the growth in numbers of this population has been truly astounding, as instanced in the ten-fold increase in prescriptions in New Zealand for adult ADHD between 2006-22. The very real problem is that medical diagnoses have the power to change people beyond their control, and the labelling effect means that patients tend to assume all of the aspects of a diagnosis, and they can construct a personal identity around what they now believe they cannot do. The further consequences that can ensue include discounting other explanations of their distress; taking drugs that are no superior to placebo; being stigmatised for being different and special; and having few real improvements in their quality of life over the longer term. O’Sullivan suggests that it is often about what we tell ourselves, but embracing neurodiversity does not absolve a youngster from learning to control their moods, impulses, and behaviours like everyone else growing up.
A significant learning from this book could be that the controversies over medical overdiagnosis, which is a subset of overmedicalisation, in fact mostly take place about cancer and genetic screening. In screening for cancer, the presence of abnormal cells does not necessarily mean illness and death but it can provoke chemotherapy, radiotherapy, surgery, psychological costs, and financial burdens. Common sense may dictate that available therapeutic options should always be immediately engaged, but overall survival rates (or all-cause mortality rates) do not necessarily improve, and numbers of people are given treatments they do not need. It’s a difficult line that doctors tread between overdiagnosis and underdiagnosis in screening; while in the domain of genetic testing, people can sidestep health professionals entirely with commercial tests and self-diagnosis. However, the problem with genetic tests, whether competently done or commercially derived, are that they can throw up genetic variants of unknown significance, and again these findings can occasion overreactions and unnecessary angst. The increasing ease and availability of such measures is part of the problem; and the convenience now of testing for Down’s syndrome has meant that these people have virtually disappeared from some countries. Overall, O’Sullivan leans to the view that a person’s post code at birth maybe as useful as their genetic code to subsequent diagnoses as our natal post code can summarise the powerful social determinants of health that we were exposed to.
The author considers Long Covid to be a psychosomatic complaint when it has no specific symptoms and it is not evidenced in testing. In addition, many who have it have never actually tested positive for Covid-19 and they can belong to a different demographic. Furthermore, it is ‘very difficult to explain through pathological mechanisms related directly to a viral infection’. Note, psychosomatic problems cause genuine symptoms and real suffering, and those who are so afflicted are not malingering. But the inevitable question is why personal distress is being manifested in this way. O’Sullivan surmises that, as much as anything, Long Covid is probably about people being caught up in a colossal health event and having only medicine to turn to. In effect, this observation likely applies more generally to excessive screening and monitoring, and to the many other epidemics of overdiagnosis and overmedicalisation. As the author says:
People are struggling to live with uncertainty. We want answers. We want our failures explained. We expect too much of ourselves and too much of our children. An expectation of constant good health, success and a smooth transition through life is met by disappointment when it doesn’t work out that way. Medical explanations have become the sticking plaster we use to help us manage that disappointment.
Dr Peter Stanley is a retired psychologist and lives in Tauranga, New Zealand
