When we left off in the early 20th century in the last issue of HIAS, A Brief History of Psychiatric Diagnosis, Part I, a few themes had emerged:

Keep these themes in mind as we explore the origin story of the Diagnostic Statistical Manual of Mental Disorders.

Though it was Richard von Krafft-Ebing and Josef Adolf Hirschl who propagated the biological model of mental illness thanks to their work with syphilis, it is German psychiatrist Emil Kraepelin who is most responsible for the genesis of the DSM and its stronghold over our modern psychiatric system.

Born in 1856, Kraepelin’s work began to attract attention in 1893. Kraepelin ran a clinic at the University of Dorpat and determined that because patients often showed similar symptom patterns, he could use those patterns to classify psychiatric disorders. For example, he observed that manic-depressive insanity did not deteriorate into dementia praecox (what we now call “schizophrenia.”) Dementia praecox, on the other hand, appeared in adolescence and progressed to dementia and institutionalization. One did not morph into another, indicating to Kraepelin that despite some similar symptoms, they were two separate ailments.

Kraepelin took this theory and applied it to all expressions of psychiatric distress that existed at the time. He coined the term “depression”, distinguishing it from the melancholia umbrella that had described human suffering for centuries, and separated the “paranoid thinking of schizophrenia” from “paranoia.” He was fixated on objectivity and measurability, eschewing notions of stress, environment, personality, and their potential impact on mental illness.

He was also a rampant eugenicist. A letter to the editor published in the American Journal of Psychiatry put it bluntly:

In a 1919 paper titled “Psychiatric Observations on Contemporary Issues,” Kraepelin proclaimed that “dreamers, poets, swindlers and Jews” possess “distinctly hysterical traits” and fall outside the bounds of normality, adding that Jews exhibit “frequent psychopathic disposition.”

Kraepelin died in 1926, but his belief that “reasonable policies of racial hygiene” were the solution to Germany’s “degeneration” problem deeply influenced Nazi ideology and the rise of the Third Reich.

While an obvious display of eugenics was playing out in Europe during the first half of the 20th century, the American Psychiatric Association (APA) was busy with a more inconspicuous systemization. In 1913, the APA set up a statistics committee that eventually took responsibility for classifying psychiatric diseases. Combining American observation with Kraepelin’s work, these publications ruled American psychiatry through World War II.

We need to pause for a moment in order to highlight an oft-ignored aspect of this early American classification. It must be noted that as reported by the American Psychiatric Association itself, “Between 1892 and 1947, 31 presidents of APA acted in leadership positions in eugenics organizations, during their time as president, but also in the years surrounding their presidencies.”

Let that sink in for a minute. During the time in which the foundation for all modern psychiatric diagnostic strategies was built, the people in charge of creating that system held the same beliefs as Hitler. Literally, your kid’s ADHD diagnosis or your bipolar diagnosis is rooted in the same categorization and rationale that led the Nazis to exterminate six million Jews.

Combine this with the Social Darwinist movement pervading white-collar industries at the time, and it’s no surprise that the intellectual elite worked to sort folks into acceptable and flawed stock. And don’t think this was an act of good intentions gone awry. Even the modern IQ test that we still use today, which was developed around the same time, is rooted in eugenics. Developed by noted American eugenicist Henry H. Goddard, the IQ test ranked those he considered “feebleminded” into three categories of perceived incompetence: pre-verbal “idiots” illiterate “imbeciles,” and high-functioning “morons.” According to a law review of the landmark murder trail Atkins vs. Virginia, which hinged on the definition of mental retardation, Goddard “found morons wherever he looked: criminals, alcoholics, prostitutes, and anyone ‘incapable of adapting themselves to their environment and living up to the conventions of society or acting sensibly.’”

But by 1948, though the foundation for systemization was already laid, German eugenic sentiments weren’t exactly popular among the collective. Thus, the APA asked its Committee on Statistics to rewrite the diagnostic system. A rebranding, if you will.

Spearheaded by George Raines, the first edition of the Diagnostic Statistical Manual of Mental Disorders pulled away from German language and theories, instead drawing from the en-vogue influences of Sigmund Freud and Swiss psychiatrist Adolf Meyer. Both Freud and Meyer attributed psychological distress to childhood experiences and in Freud’s case, sexual repression. Kraepelin’s symptom-based sorting system still remained, but because of this shift, psychotherapy dominated psychiatric thinking for a short time.

Right around the time the DSM-I was making its way into clinical practice, psychopharmacology was on the rise after the first mood-altering drug, iproniazid, was accidentally discovered in a tuberculosis ward in 1952. Iproniazid induced euphoria in terminal tuberculosis patients and phenomena so profound, the drug was given to 400,000 depressed people to see if it would have the same effect. It did, but it also caused the blood vessels to constrict to dangerous levels, and administration of the drug was stopped. However, its brief existence brought the chemical imbalance theory of mental illness back to the forefront, and the DSM-II was written with this in mind.

It is at this point that the “pill for every ill” strategy leaves psychiatric wards and enters the homes of everyday folks, in part due to the introduction of tranquilizers and benzodiazepines aimed at women in the early 1960s.

In the early 1970s, after the US/UK Diagnostic Project determined that American psychiatrists and British psychiatrists operated by wildly different criteria for diagnosing schizophrenia (a not-so-surprising twist given that there wasn’t and still isn’t any medical test for schizophrenia or any other mental illness), American psychiatry determined it needed to tighten up its diagnostic strategy.

Robert Spitzer, a biometrician at Columbia University, was assigned the task. It is Spitzer who came up with the checklist, in that in order to meet the criteria for a certain mental illness, the patient had to experience X symptoms out of a list of Y.

The DSM-III also introduced bipolar disorder, borrowing the term from yet another set of World War II-era German psychiatrists, Karl Kleist and his student Karl Leonhard. We all know where this leads. According to Edward Shorter, PhD., “The term went on to become among the most popular diagnoses in psychiatry, as well as the foundation of pharmaceutical fortunes selling ‘mood stabilizers.’”

The DSM-III also added attention deficit disorder to the lexicon, as well as post-traumatic stress disorder and a variety of anxiety disorders.

Shorter continues, “What psychopharmacology had begun, DSM-III finished off; the [psycho]analysts were shown the exit sign from the field, or at least from its commanding heights…the DSM-III began a rapprochement between psychiatry and the rest of medicine.”

Since the publication of the DSM-III in 1980, the “bible” of psychiatric diagnosis has been revised three times, with the DSM-V appearing in 2013. From a clinical level, little has changed in the world of diagnoses since the DSM-III appeared. Patients are still judged by a checklist of diagnostic criteria, psychotherapy and root cause are generally ignored, and no test, scan, or lab exists to confirm or refute a biological or chemical cause for mental illness.

One thing, though, is noticeably different. The size of the Diagnostic Statistical Manual of Mental Disorders has swelled with each edition.

The DSM-III registers at 494 pages and weighs 1.9 pounds.

The DSM-IV is 886 pages and 3.4 pounds.

The updated DSM-V, published in 2022, is 1050 pages and weighs 4.6 pounds.

He who knows syphilis knows medicine.

—William Osler, co-founding physician of Johns Hopkins Hospital

In 1885, the Boston Medical and Surgical Journal made an observation: mental asylums in the United States were full. The journal noted that the number of patients had risen dramatically, with people wandering the halls of asylums with a jerky gait, grandiose illusions, and dementia—a collection of symptoms deemed “general paralysis of the insane.”

On the rise, too, was syphilis. In its late stages, syphilis also creates a jerky gait, grandiose illusions, and dementia. In 1885, it was unclear whether the rise in the insane was due to pathological disease or other influences. But in 1897, a causal link between these symptoms and syphilis was found thanks to German psychiatrists Richard von Krafft-Ebing and Josef Adolf Hirschl.

Krafft-Ebing and Hirschl knew that syphilis could only be contracted once, so they created an experiment where they injected the pus from sores of syphilictics into people suffering from general paralysis of the insane. If the patient became infected, they could say with certainty that the patient had not had syphilis before. However, none of the subjects became infected with the disease, leading Krafft-Ebing and Hirschil to conclude that not only had all of their patients’ been previously infected by syphilis, but that it was a disease that caused their psychiatric symptoms.

Thus, the biological theory of mental illness was born. The connection between the biological nature of syphilis and the undesirable psychological side effects of that illness led researchers to assume that all expressions of mental illness boiled down to a biological malfunction. Given the first neurotransmitter wasn’t discovered until 1921, and more robust science on the matter didn’t appear until the mid 1950s, neurologists at the turn of the century instead focused on what could be observed in autopsies. However, little progress was made. Common psychological ailments of the time, like hysteria and shell shock, left no visible sign of brain tissue damage. This lack of biological evidence bolstered the theories of Sigmund Freud, the father of modern psychology, to say: “The case histories I write should read like short stories and that, as one might say, they lack the serious stamp of science.”

The link between syphilis and mental distress came at a time when a concept called Social Darwinism was hitting its stride. Rooted in Charles Darwin’s theories—though he himself was not directly connected to the movement—Social Darwinists believed that human groups were subject to the same evolutionary principles as plants and animals. Natural selection and survival of the fittest could be applied to sociology, economics, and politics because, in their view, sociocultural ideals were inherently biological. Said another way, it was biology that determined if you were white, male, and physically fit, so therefore, natural selection should be applied. Practically, this meant that Social Darwinists believed the strong should see their wealth and power increase, while the weak should see their wealth and power decrease.

The connection between Social Darwinism and the rise of the global eugenics movement of the late 19th century and the first half of the 20th century is obvious: a group of intellectual white men decided the human race was “de-evolving,” and wielded their power and influence to reverse this perceived course by professing who should and should not bear children. This influence stretched into all white-collar industries, from major businessmen like the Carnegie’s and Rockefeller’s to legal theorists, academics, criminologists, and of course, psychiatrists.

The science—although “science” is a loose term given not a shred of evidence existed then or now to back up the theory—became so pervasive, that by 1914, 44 American colleges had introduced eugenics into their curriculum. Rooted in the language of protecting the average citizen from those who threaten the fabric of society thanks to inferior genes and beliefs (note the connection between the language being used at this time and the language surrounding both sides of modern American political movements), Social Darwinists pushed the idea that the species could not evolve if people of good stock mingled or procreated with undesirables. The undesirables, as you’ll remember from high school World War II history lessons, included everyone from Jews to Blacks to the “feeble-minded” and physically disabled.

As Dr. Boonie Burstow, Canadian feminist professor and psychotherapist wrote of the Social Darwinists a few months before her death in early 2020, “While they saw themselves as progressive and as following the dictates of modern science, what they were wrapping themselves in was a combination of hatred and pseudo-science for there was not a shred of credible evidence supporting their position.”

Again, note the connection between Burstow’s commentary on Social Darwinists of the early 20th century and the mental illness propaganda being pushed into the zeitgeist today.

It is at this time in history when the open practice of eugenics simultaneously becomes both obvious and insidious. In 1920, German psychiatrist and eugenicist Alfred Eric Koch and German jurist Karl Binding penned Die Friegabe der lernichtung Lebensunwerten Lebens, which translates to “Permitting the Destruction of Life Unworthy of Life.” This work directly led to the German T4 program, which allowed for the killing of disabled patients in institutions under the guise of mercy. In 1939, Hitler secretly signed an authorization protecting physicians and administration from any prosecution associated with the program. It was also this program that would develop the gassing chamber used throughout World War II.

To help identify who “qualified” for the T4 program, planners developed questionnaires that were distributed to patients in hospitals, old folks homes, and institutions. Worded and formatted in a way that appeared like a simple census to the average citizen, these forms were actually designed to parse out ancestry not of German blood, those suffering from schizophrenia, epilepsy, dementia, encephalitis, and other chronic psychiatric or neurological disorders, criminals, and those who had previously been institutionalized.

A group of prestigious physicians evaluated the forms and identified those deemed undesirable. After their identification, they were coerced from their institution and transported to their death in a gassing chamber. The families of the victims received an urn and death certificate noting a fictitious cause of death.

---

In the next installment of A Brief History of Psychiatric Diagnosis, we’ll look at how the eugenics movement influenced the bible of all psychiatric diagnosis, the Diagnostic and Statistical Manual of Mental Disorders (DSM).

During my sophomore year at Middlebury College, I took notoriously tricky course called Introduction to Modern Logic. An early requirement for philosophy majors (one of the many declarative detours I flirted with before landing on the equally useless History degree), it focused on good reasoning and the technical breakdown of arguments.

A basic example:

If Bellaroo is napping on her dog bed, then Bellaroo is not taking a walk.

Bellaroo is napping on her dog bed.

Therefore, Bellaroo is not taking a walk.

The statement is true in all circumstances, regardless of time, interpretation, or the laws of physics. If Bellaroo is napping on her bed, she is irrefutably not taking a walk.

The point of this course is to help students identify patterns of good reasoning and patterns of bad reasoning, so they have a better idea of what to follow and what to avoid. The tricky part occurs when a statement seems true at first glance, but breaks down when logic is applied. These are called logical fallacies, and they are everywhere.

A few examples:

The Appeal to Ignorance, where we assert a claim because no one can prove otherwise.

People have been praying to God for years. No one can prove He doesn’t exist. Therefore, He exists.

The Bandwagon, where we assume something to be true or good just because many others believe it to be true or good.

Everyone at the gym is wearing Lululemon. I need to buy their yoga pants.

The Red Herring, were we use irrelevant information to distract from an argument.

There are starving children in Africa. Eat your broccoli.

---

Psychiatry, more than any other branch of medicine, is saturated with logical fallacies. Hell, we can apply all three of the above examples to cultural rationale within the world of psychiatry and mental health:

The most pervasive logical fallacy in psychiatry and mental health diagnoses, though, is circular reasoning, which is an argument that uses the same statement as both the premise and the conclusion.

The reason why circular reasoning is so pervasive in psychiatry compared to other specialties is because psychiatry doesn’t have any form of objective boundaries. The rest of medicine, generally, agrees on parameters that define a pathological disease. Diabetes in the United States is only diagnosed as diabetes when two fasting A1C blood sugar tests read 6.5% or higher. Doctors—and even different countries—debate 6.5% as the cutoff, but all agree that at a certain point, high blood sugar levels indicate disease.

But psychiatric criteria cannot explain behaviors or experiences through any means beyond subjective opinion. Furthermore, as we’ve been exploring throughout the last few issues, these subjective opinions are rooted in norms and meaning. They can’t be measured independently, and they are not necessarily true across time and culture.

And yet, the flywheel of circular reasoning continues to spin, flinging the world of mental and emotional health further away from the solution. As British child psychiatrist Sammy Tammi said in his open letter on the diagnostic model of psychiatry to the Society of Humanistic Psychology, “The result of this basic [logic] error is that medical scientific knowledge in the area of mental health is at a standstill. No chemical imbalances, consistent neurological differences, genetic abnormalities or markers found. None. Billions of dollars of wasted money on wasted biological research that leads nowhere…higher levels of reported stress and anxiety, higher numbers of people disabled due to a mental health condition and rates of significant improvement from those attending mainstream services hovering at around a quarter to a third of those they see. These are not the outcomes you would expect to see from an effective model of clinical care.”

“When humans do not assume they have rather complete control of their experience, they do not so deeply fear those who have appeared to have lost it.”

—Juli McGruder, anthropologist

As of late, I’ve been learning about the different expressions of perceived mental illness around the world. I use “perceived” in this context because the more I learn, the more I understand that symptoms of mental/emotional distress are tied to cultural expectations. (See the TikTok tics from issue 105.) Said another way, the lifecycle of mental illness is influenced by the macro and micro-level beliefs that surround it. What’s considered crazy in one culture is accepted in another.

On a macro level, the prevalence and intensity of schizophrenia vary from place to place. Men living in urban areas of Sweden, for example, are at a 68% higher risk of being admitted for psychosis than those who live in the countryside. This is also true for urban settings in the United States and Europe, and it remains constant even when migration, drug use, and poverty are taken out of the equation.

Furthermore, a 25 year study conducted by the World Health Organization that began in the 1960s found that people diagnosed with schizophrenia in developing countries have better outcomes, longer periods of remission, and higher levels of social functioning than those in industrialized nations. Known as the International Pilot Study of Schizophrenia, the data showed that over time, 40% of schizophrenics in countries like the United States, Denmark, and Taiwan were considered “severely impaired” compared to 24% of people in countries like India, Nigeria, and Columbia.

Of course, these findings ignited a hot debate because the results are counterintuitive. You’d think all the money, research, and resources would lead to better outcomes. But alas, the data showed the opposite to be true.

(Side note, half a century later, our use of psychotropic medicine continues to reflect what we knew in the 1960s and 1970s. Are poor nations tragically underserved by psychiatry? Or have they avoided the crosshairs?)

This debate is the heart of cross-cultural psychiatry research. While it’s interesting in its own right and the conclusions are, to me, dead obvious, I find the micro influences to be even more interesting. It’s not just about the culture we live in. But the roof we live under.

Expressed emotion (EE) is a term used to describe the way that family members and caregivers interact with a person. High EE is characterized by critical, hostile, and emotionally overinvolved behaviors. Low EE is characterized by warm, supportive, and accepting behaviors. While expressed emotion is not the cause of distress, it can influence the course and outcome in an individual.

We all know that when our actions are met with criticism or hostility, we don’t fare as well. But emotional over-involvement requires more explanation.

Emotional over-involvment is characterized as a range of dramatic behaviors ranging from self-sacrifice, extreme devotion, overprotectiveness, or intrusiveness over a person’s life. Control, essentially.

Ethan Watters uses an example in his book, Crazy Like Us, that describes a mother who was so emotionally over involved with her son’s schizophrenia that she “dropped all other interests from her life. Her sole activity, she reported, was to take care of him and protect him, ‘like a pearl of a diamond.’ This same mother said that she often became so distraught over her son’s plight that she considered committing suicide by throwing herself down the family staircase.”

In addition to raising stress levels in the sufferer—which in this case, could trigger schizophrenic episodes—this maligned strategy is a constant reminder to the person suffering that those around him perceive him to be ill, which in turn, reinforces the idea that something is wrong.

Watters gives a contrasting example of a family in Zanzibar with a schizophrenic daughter, Kimwana, who overdosed her medication and nearly died. Juli McGruder, an anthropologist who witnessed the scene said, “There was no noisy woe-is-me talk or dramatic wringing of hands. [The family] seemed to take it in stride like everything else…When I asked what I could do, [the mother] told me I could take a carton of milk to Kimwana in the hospital.”

The ability for the family unit to keep calm and carry on benefitted Kimwana. The family’s perspective, in part because of Zanzibarian beliefs include spiritual possession, allowed everyone to embrace the idea that difficulties—and even voices in the head—are a natural part of life. Therefore, disruptive behavior as a result of these difficulties was more understandable and forgivable. Kimwana wasn’t viewed as other, or as someone to be feared. She was viewed as a strong expression of what we all have inside of us. This kept her within the social group.

Anglo-Americans have the highest level of expressed emotion compared to different groups around the world. Given that we no longer let our kids have sleepovers, have unsupervised play, or breathe without parental supervision, this shouldn’t be surprising. According to researcher Jill Hooley, Anglo-Americans have a strong “locus of control,” which means they believe a person can be master of their own fate and control their own issues through force of will. The critical, hostile, and emotionally over involved actions stemming from this locus of control aren’t necessarily cruel in intent, but are instead an expression of assumed (and flawed) human nature.

Cultures with more fatalistic or spiritual values place less focus and/or blame on those with mental and emotional distress. Conversely, in cultures that value personal accountability and individualism, highly emotionally involved relatives are actually more hopeful about the disease because they are convinced recovery is a matter of will—both on their part and the part of the sufferer.

But as they say in football (soccer), “It’s the hope that kills you.”

Watters says, “One typical father described his reaction to the schizophrenic break of his son: ‘I went to the library and began reading books about mental illness…I thought: “No, I’m going to fix this.” That is your first instinct as a parent. You’re going to fix it. I thought, “I can get him help. I can get him cured.”…That intense focus, even when it springs from a hopeful engagement of the problem, might be the very thing that exacerbates the illness.”

Furthermore, our obsession with the biomedical model of mental illness only exacerbates emotional over involvement. Take the following Euro-American norms:

By applying these norms to an individual, we separate them from the group by labeling them as Other, all while promoting the idea that recovery is never really possible. How could it be, if mental illness is nothing more than a stroke of bad luck and questionable genetics?

In 1997, Sheila Mehta of Auburn University got curious about whether or not the “brain disease” narrative of mental illness actually reduced stigma, as promised.

In her experiment, she paired up people for what test subjects thought was a simple learning experiment. Unbeknownst to the test subjects in the study, their partners were actors and were instructed to inform the test subjects during the get-to-know-you phase that they suffered from mental illness.

The actor told the test subject that the distress occurred because of the “things that happened to me when I was a kid or that they had “a disease just like any other, which affected my biochemistry.”

In the experiment, the test subject was assigned to teach the actor a pattern of button presses. When the actor got the pattern wrong, the test subject was told to give the actor a “barely discernible” to “somewhat painful” electric shock.

Test subjects who believed their partner had a “disease like any other” increased the severity of shocks at a faster rate than those paired with the actor whose issues were caused by childhood events.

Mehta said, “The results of the study suggest that we may actually treat people more harshly when their problem is described in disease terms. Viewing those with mental disorders as diseased sets them apart and may lead to our perceiving them as physically distinct. Biochemical aberrations make them almost a different species.“

And what is our instinct when we encounter Other? Critical, hostile, and emotionally over-involved behaviors.

So it goes.

As of late, I’ve become fascinated with the idea that mental illness is contagious.

The fascination started with a New York Times article about a wave of thousands of female and gender-nonbinary teens who developed Tourette’s-like tics during the pandemic—because of TikTok.

Arriving in the zeitgeist when people were forced to stay home, TikTok exploded during the pandemic. Videos of people claiming to have Tourettes multiplied on the platform, and because TikTok’s algorithm is built on showing users a wide variety of content—regardless of the user’s preferred interests—Tourette’s videos began popping up on people’s feeds. As of this writing, #Tourettes on TikTok has 8.7 billion views.

Like mental illness, there aren’t any scans or biological markers to diagnose or identify Tourettes. However, Tourettes is categorized as a movement and neurological disorder marked by uncontrolled physical or verbal tics, not a mental illness. It typically presents in males and first appears in childhood, with waxing and waning symptoms.

For the girls with “TikTok Tics,” however, the Tourettes-like symptoms arrived suddenly, with a wave of new cases popping up all over the world. Notably, though, when life began to regain some normalcy and the stress of the pandemic waned, the wave of TikTok Tics receded as well. Thus, it is hypothesized that the unique stress of the pandemic + the unique vulnerability of teenage girls created a tinderbox of stress that manifested in psychologically contagious tics.

This isn’t the first time we’ve observed psychological contagion. This phenomenon repeats itself across both time and cultures. In the Middle Ages, it was believed that humans could be possessed by the spirits of demonic animals, leading a group of nuns at a French convent to meow like cats.

In the 1800s, “hysteria” was a known psychological diagnosis that afflicted women. It included a diverse range of symptoms, including paralysis, stomach pain, amnesia, and day blindness. Hysteria was almost worshiped and certainly fetishized by popular magazines, newspapers, and even public hygiene literature. Much like today, male doctors and scholars of the time filled lecture halls and pontificated on the “quintessential illness of womanhood,” as Ethan Watters said in his book, Crazy Like Us. But by the time the 20th century rolled around, hysteria had largely evaporated from the collective consciousness. Women stopped reporting paralysis and leg weakness, and the symptoms of psychosomatic illness moved on to other expressions.

Even the human reaction to war is tied to the cultural temperature. Medical records of war veterans show that the psychological and even physical effects of war are a reflection of time and place. For British soldiers in the Boer War, the psychological trauma manifested as muscle weakness and joint pain, while American soldiers during the Civil War complained of a weak heartbeat and an aching in the left side of the chest. During World War I, both British and American soldiers experienced “shell shock,” with symptoms that included tremors, ticks, and sensory disturbances. Today, addiction affects veterans of modern war.

As Watters explains, “Although the potential psychic damage of war is indisputable, the process by which that damage becomes an outward symptom is a reflection of the cultural beliefs in a particular time and place.”

Said another way, whether as a PTSD response to war or TikTok, people will unconsciously produce symptoms that reflect the culture’s prevailing cultural diagnosis of the time. The TikTok Tics were not so much a measurable illness, but a subconscious yearning for recognition of internal distress.

The implications of viewing mental illness through this lens, in my opinion, destabilize the entire foundation of psychiatry and psychology. I know, for example, that as a young ballet dancer, the eating disorders I experienced as a teenager were created through community. Anorexia is rampant in ballet not just because thinness is an aesthetic ideal, but because everyone else is doing it. Toss in the death of my father and the emergence of the internet in the early 2000s, and the fixation on thinness festered as a direct result in order to satisfy a need to belong to something while expressing suffering. There wasn’t ever anything wrong with my brain. If anything, it was a sign that my psyche was doing exactly what it should be expected to do in times of great stress. I was simply exhibiting symptoms consistent with the time—no different than if I had started meowing with nuns in the Middle Ages.

For an affliction to be pathological, it seems to me that it should ring true across both time and culture. A cancerous mass viewed under a modern microscope looks the same in Taiwan as it does in the United States. But if mental illness and psychological distress cannot be separated from the culture in which it is experienced, how is a blanket biomedical response ever going to be the answer?

Welcome to Science Corner by Happiness Is A Skill, where I take a few minutes to teach you about the relevant neuroscience of antidepressants and antidepressant withdrawal. No more half assed assumptions without evidentiary support, like the whole chemical imbalance theory of mental illness. The idea that “too little” serotonin causes depression? Or that “too little” dopamine causes ADHD? Obsolete, oversimplified, hogwash conveniently packaged by marketing departments of pharmaceutical companies in order to convince you to “talk to your doctor about Zoloft, because when you know more about what’s wrong, you can help make it right.”

That’s the actual tagline for Zoloft by the way, from 2001. Brilliant, isn’t it? Here’s a very simple explanation for your distress. It has nothing to do with your life or your choices or the bad things that happened to you, but instead has to do with some chemicals in your brain you can’t control. So take this pill and the sun will shine and flowers will bloom and scary thoughts will go away and we’ll all be content. Right? Right? 

If one could die of bullshit overload, I would long be gone.

Instead, let’s talk serotonin transporter (SERT) occupancy, something researchers have actually measured and analyzed in labs.

Let’s start with some background information. The serotonin transporter is a protein in the brain that helps regulate levels of serotonin. When someone takes an antidepressant, the drug binds to the SERT protein and blocks it from transporting serotonin out of the brain, disturbing the brain’s longstanding homeostasis by increasing the amount of serotonin available. When early test subjects reported an elevated mood after taking antidepressants in clinical trials, the assumption was that the increase in serotonin was responsible for this relief, therefore thus forming the basis of the serotonin theory of depression. If more serotonin = happier people, then less serotonin = sad people. And that’s how Prozac was born!

Too bad it was all a pipe dream.

Over time, the brain adapts to the presence of the drug and learns to produce less serotonin on its own. The body is always trying to get back to homeostasis, remember. The pharmaceutical industry spends billions of dollars trying to convince you that they can override hundreds of thousands of years of evolutionary physiology, but the bottom line is the body has to remain in equilibrium to stay alive. If you’re hot, you sweat to cool down. If you’re cold, you shiver to warm up. If either of those systems don’t work like they should, you die.

So let’s say you’ve been on 20mg Prozac (fluoxetine) for ten years and you decide it’s time to come off. Your doctor drops you to 10mg for a few weeks and you tolerate it. Maybe you’re a little emotional and antsy but you can handle it. Your doctor has heard about all this withdrawal stuff so he thinks he’s got it all figured out and tells you not to drop from 10mg to 0, but to instead cut the capsule in half and take 5mg for a week or two. You don’t feel great and wonder if it’s the depression coming back. But you figure you’ll drop to zero and give it a few weeks to know for sure. After all, 5mg is miniscule. Smaller than the smallest dose on the market! They give 5mg of Prozac to six year olds!

You drop to zero and all hell breaks loose—akathisia, huge emotional swings, paranoia, brain fog, gut issues. Back to the doctor you go, because clearly you’re sick and how stupid you were to think that you could operate without the Prozac. So you go back on 20mg. Hell, make it 40mg this time. Clearly, you need it. Your doctor suggests an antipsychotic as well because the paranoia suggests an emergence of Bipolar Disorder. Life, now, is all about managing symptoms.

Where did everyone go wrong? A fundamental misunderstanding of SERT occupancy.

Let’s look at the following graphs, courtesy of researcher Mark Horowitz:

The black curve is the measure of SERT occupancy as determined through brain-imaging techniques called PET scans that allow researchers to see the biological workings of the body. As you can see, at 25mg of fluoxetine, 80% of the serotonin transporters are occupied.

Figure (a) is a representative of the conventional line of thinking for linear tapering of antidepressants. Rather, the idea of lowering dosages by equal, measured steps—5mg, in the case of this graph. The problem is that if you lower the dose of Prozac from 20mg to 5mg—a 75% reduction—SERT occupancy only reduces by 20%. This means that not only are there fewer operating receptors, there is also less serotonin in the brain because the body long ago lowered its production. It is likely that withdrawal occurs at least in part because of this chemical imbalance created through linear tapering. And yes, it is ironic that this time, a true chemical imbalance is responsible.

Due to the hyperbolic nature of SERT occupancy, this dissonance is even more extreme at lower dosages, as seen in Figure (b). At 2.5mg of Prozac—20% of the lowest dose available on the market—SERT occupancy is 40%, just half of what it is at a robust dose of 25mg. This explains why it can be more difficult for people taper as they get closer and closer to zero.

Though SERT occupancy occurs with all antidepressants, the levels of SERT occupancy vary from drug to drug, as shown by this systematic analysis of 10 different psychiatric drugs, done by Anders Sorenson, et al.

The reason why you need to know about this is because it’s likely your prescriber is completely unaware. More understanding of SERT occupancy, as well as more robust research (especially when multiple drugs are involved), would lead to better de-prescribing practices that will likely lessen or eliminate severe withdrawal effects.

In the fictional example I gave above, our now “bipolar” patient needed a much slower taper that followed the hyperbolic curve and was adjusted only once she stabilized from the previous dose reduction. Had she tolerated a 10% reduction—from 10mg to 9mg to 8.1mg to 7.29mg and so on to 0—her brain likely would have had much more time to fire up dormant receptors and naturally ramp up serotonin production, leading to a more gentle, symptom-free re-introduction into a world without SSRIs.

Instead, when she was pulled off too quickly, her system went haywire because neurotransmitters are responsible for regulating the entire body. Instead of recognizing this as withdrawal, both she and her doctor assumed it was mental illness and plunked her back in the system with a shiny new diagnosis. This happens all the time. All. The. Time.

I hope you’ve enjoyed this Science Corner issue of Happiness Is A Skill. Please keep in mind that we are very much in the infancy of antidepressant withdrawal research, and that no single piece of information is the whole answer. But as they say on NBC, the more you know! Ding ding dong!

In the midst of the pandemic, a 35 year old man I’ll call Sav, began shooting hoops in his hometown in Italy. First, he shot from the three point line. Then, he turned around and shot backward, sinking the basketball into the net. A few weeks later, he did it blindfolded. Then backward, blindfolded, and while jumping on a trampoline. 

The trick shot obsession grew to kicking ping pong balls into narrow-mouthed water jugs and launching soccer balls into basketball hoops with a golf club. In less than a year, he amassed millions of followers and cashed fat checks from merch and ad sales. 

Then, in the summer of 2022, Sav went dark. 

As it turns out, the followers, the money, the trick shots—all of it was a result of psychiatric drug withdrawal-induced akathisia, a constant state of tortuous restlessness and burning agitation that Sav described as “dishumane.” Unable to sleep or stop moving, Sav channeled his distress into intricate human tricks.

The circus nature of it all kept him occupied in between months long hospitalizations over 30 sessions of controversial electroconvulsive therapy (ECT). He spoke to every known doctor, expert, and advocate on the subject of withdrawal—including me—in hopes that someone could stop the pain. Nothing helped. Most suggestions just made things worse.

Today, Sav is in the process of ending his life through an assisted suicide organization in Switzerland. 

There is an aphorism in medicine, coined by former Dean of Medicine at Harvard Dr. Charles Sidney Burwell that says, “Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don’t know which half is which.”

I think about this quote constantly, both in the context of my own health and when people like Sav reach out to me for help. I can’t give medical advice since I’m not a doctor, but I can talk about my experience and share resources. Even when I’m passing along research done by other people, it’s a paralyzing to know how much we don’t know, how much I don’t know. What works for one person causes havoc in another. That’s all well and good if the body is strong enough to recover from all the self experimentation. But in a case like Sav’s, any little change seems to set off a cascade of irreversible negative effects.

So much of medicine, and especially a new field like psychiatric drug withdrawal, is focused on the how, not the why. The why is too expensive, requiring oodles of money and serious research. Sav’s case is the perfect example. He followed the leading theory of tapering off psychiatric drugs—hyperbolic tapering—a strategy that encourages small dose reductions, each one smaller than the one before, over a long period of time. Research shows that generally, this method lessens or eliminates withdrawal symptoms by allowing the brain and body to adjust without getting overwhelmed by the sudden lack of drug presence.

But there is a subset of people like Sav who don’t seem to tolerate this method. Instead, it’s like their body hits a limit with how much of the drug they can process, and these long tapers basically become prolonged poisoning. Sav told his doctors over and over again that he thought the taper was hurting him. He was dismissed and told to stay the course. Not knowing what else to do, he followed their advice. And he’s now going to Switzerland because of it.

I’ve heard similar stories from enough people to know that Sav’s story is not a one off. For these folks, there’s something going on physiologically that’s outside of the norm. My hunch is that it has something to do with the genetic component of their body’s CYP system, a complex bodily function involved in the metabolism of drugs, chemicals, hormones, and neurotransmitters. But until someone designs a study for people in withdrawal that analyzes genetic variants in the CYP system, it’s all just a guess. And I’m sure it’s not that simple. I’d also like to see fMRIs, qEEG, hormone panels, and VO2 max tests for people in withdrawal. Until that actually happens (if it ever happens), people like Sav are going to suffer thanks to well intended but myopic views.

Personally, I don’t know know how to deal with this. I’m heartbroken over Sav. I feel like the community failed him. It’s an impossible position for everyone. What percentage of people are sacrificial lambs on the path to truth and understanding? How do you instill hope in the hopeless? How do you help when sometimes the help is poison?

If there is any silver lining to this story, it is this: Sav told me he does not want to go quietly. He wants the world to know his story. We have a little bit of time. The checks and balances in Switzerland are many, for good reason, and he does not yet have a date.

Of course, I hope that between now and then some miracle shows up and he finds some relief. If not, I have to assume that he is a player in a bigger game. That somehow, his suffering won’t be in vain because it will lead to more awareness and education. He is, after all, a bit of a showman. Every trick shot sunk not just to distract himself, but to prove that nothing is impossible.

I will share his real name when he is ready to fully go public. In the meantime, he has given me permission to share his story. Thank you for reading.

In the year before and months after MAY CAUSE SIDE EFFECTS released, I didn’t read a single book. I’d just finished writing one, and reading other people’s work did nothing but invite comparison and insecurity. But something shifted when we flipped the page to 2023, and I’m back to devouring books at all hours of the day.

Among the stack I’ve recently finished is Dr. Ellen Vora’s The Anatomy of Anxiety: Understanding and Overcoming the Body’s Fear Response.

Ellen is a Yale and Columbia University educated, board-certified psychiatrist who speaks openly about antidepressant withdrawal and the overprescription epidemic. Though Ellen and I haven’t ever met, we’re in occasional contact since she’s one of the few working psychiatrists with the balls to speak out about the pill for every ill “strategy” that seems to be doing more harm than good. Also an acupuncturist and yoga teacher, she practices from a functional-medicine foundation, meaning she believes most (if not all) mental health issues are caused not by disease or a chemical imbalance but by everything from unresolved trauma to lifestyle choices to blood sugar crashes.

The perk of this approach is that unresolved trauma, lifestyle choices, and blood sugar crashes are all things we have the power to fix. What a concept!

The conventional theory of anxiety is that it exists in the head and causes downstream, emotional and physical effects. In The Anatomy of Anxiety, Ellen argues that anxiety begins in the body, and that it’s the physiological stress response that causes mental anguish. Said another way, our brain chemistry changes as a result of an imbalance in the body, not the other way around. This is good news, she says, because this anxiety is both preventable and responsive to basic adjustments to habits, diet, and lifestyle.

Just as I did with Johann Hari’s Stolen Focus, I’ve compiled what I think are the 10 most important and interesting ideas from Ellen’s book. One caveat: The Anatomy of Anxiety is an outstanding starting point for those beginning to explore the mind-body connection and the basic science of anxiety. For those of you who spend a lot of time in this space, you’ll likely recognize much of the content. I worry that my familiarity with the topic means I’ve skimmed over obvious lightbulb moments. Thus, if you’re someone who struggles with anxiety and you don’t spend your free time nerding out over the science like I do, I highly recommend you take my word for it and get a copy for yourself. Understanding how your body works and why it reacts the way it does is a key first step in managing and healing anxiety.

Onward to the good stuff! (Bold emphasis mine.)

Ellen likes to differentiate from “true anxiety” and “false anxiety” in order to help her patients understand what is anxiety they can control (false), and what is anxiety that’s baked into human existence (true)

“False anxiety is the body communicating that there is a physiological imbalance, usually through a stress response, whereas true anxiety is the body communicating an essential message about our lives. In false anxiety, the stress response transmits signals up to our brain telling us, something is not right. And our brain, in turn, offers a narrative for why we feel uneasy…this type of anxiety is not here to tell you something meaningful about your deeper self; rather, it’s offering a more fundamental message about your body. When we recognize that we are experiencing anxiety precipitated by a physiological stress response, we can address the problem at the level of the body, by altering our diet or getting more sunshine or sleep. In other words, false anxiety is common, it causes immense suffering, and it’s mostly avoidable.”

True anxiety arises from having strayed from a vital sense of purpose and meaning. This anxiety is what it means to be human—to know the inherent vulnerability of walking this earth, that we can lose the people we love and that we too, will one day die…it is essentially a guide for how to make our lives as full as they can be.

Between 2019 and 2021, the Kaiser Family Foundation estimated that rates of anxiety and depression skyrocketed by 270 percent.

Genes simply don’t adapt that quickly, which punctures quite the hole in the theory of anxiety as a genetic disorder. (Never mind the fact that an “anxiety gene” has never been identified.”

Ellen says: “These rates would not have risen so precipitously if these disorders had a predominantly genetic basis—which was our presiding understanding over the last several decades. Our genes cannot adapt so quickly as to account for our recent catapult into anxiety. It stands to reason that we are increasingly anxious because of the new pressures and exposures of modern life—such as chronic stress, inflammation, and social isolation. So, odd as it may sound, this recent acceleration is actually good news because it means there are straightforward changes we can make.”

Though we have the same stress response as we did thousands of years ago—when stress meant running from a saber-tooth tiger or finding consistent food supply—modern life gives us a very different set of circumstances to cope with. Rarely are we in life or death situations and instead experience regular, low-grade stressors like a bloated email inbox or road rage.

Still, “with our modern diets and habits—which frequently trigger stress responses in our bodies—many of us live in a near constant state of feeling under siege. Your blood sugar is crashing after eating something sweet? The body interprets this as a mild threat to survival. You stay dup too late doom scrolling on your phone? The body feels surrounded by danger. Sleep deprivation, chronic inflammation from eating foods you don’t tolerate, and the comment section on Twitter—these are all, from your body’s perspective, indications that your environment is not safe. So, the body releases stress hormones into your bloodstream, and this invisible chemical cascade manifests as the feelings and sensations of false anxiety.”

Because false anxiety is often caused by outside stressors, it’s also manageable if you know what to look for. The book goes into the science behind each of these bullet points, but as a starting point, here are Ellen’s recommendations for “pausing in the midst of turmoil” in order to understand the particular false anxiety that’s occurring as well as how to address it:

“I’m anxious, and I’m not sure why. Am I…

• Hungry? (eat something)
• Sugar-crashing or having a chemical comedown? (Did I just eat something sweet, processed, or laden with food coloring or preservatives? Have a snack and focus on making different choices next time.
• Overcaffeinated? (Perhaps this jittery anxiety is really caffeine sensitivity; tomorrow, drink less caffeine.)
• Undercaffeinated? (I drank less caffeine today than usual; dose up and aim for consistent daily caffeine consumption going forward)
• Tired? (Take a nap; prioritize an earlier bedtime tonight.)
• Dehydrated? (Drink some water.)
• Feeling sluggish? (Take a quick walk outside; dance.)
• Dysregulated? (Did I just engage in an internet rabbit hole or social media binge? Dance or go outside to rest the nervous system.)
• Drunk or hungover? (File this away to help inform future choices around alcohol.)
• Due for a dose of psychiatric medication? (Right before the next dose, I’m at the pharmacological nadir—or the point where the level of medication in my bloodstream is at its lowest, and this can affect mood. Time to take meds.)

(A note from Brooke in bold: I’d argue that the last bullet point could also include, “Time to take meds or if coming off meds, recognize this as a sign of psychiatric drug withdrawal and be kind to yourself.” )

True anxiety serves a purpose in society, as demonstrated by this fascinating 1980s study of primates:

“Studies of primates show that some members of the tribe are more anxious than others—these are the ones that tend to hang back, gathering the peripheries of the main group. In the 1980s, the late zoologist Dian Fossey decided to remove these more sensitive members of one group of chimpanzees to see how it would affect the rest of the community. Six months later, all the chimps were dead. ‘It was suggested that the anxious chimps were pivotal for survival,’ Sarah Wilson writes compellingly of this experiment in her book First, We Make the Beast Beautiful. ‘Outsiders, they were the ones who were sleeping in the trees on the edge, on the border, on the boundary of the community. Hyper-sensitive and vigilant, the smallest noise freaked them out and disturbed them, so they were awake much of the night anyway. We label such symptoms anxiety, but back when we were in trees, they were the early warning system for the troop. They were the first to scream, “Look out! Look out!”’”

(Side note, I’ve never used that many quotation marks before. My 10th grade English teacher Mrs. Utter would be proud.)

Though this study was on monkeys, the same can be said about more sensitive and anxious folks in the world. They alert everyone else to potential problems and dangers. (I.E., climate activists.)

The most positive (and counterintuitive) change I ever made to my sleep hygiene was when I started eating a hefty portion of starchy carbs at dinner.

Prior to this directive—which came from a high performance nutritionist and professor of muscle science at Cal Fullerton—I’d often skimp on starchy carbs at dinner in order to rationalize dessert, or go low-carb all together in a misguided attempt to cut calories and stay lean. My shitty sleep, I assumed, was unrelated.

As it turned out, this strategy was causing blood sugar spikes and crashes (with dessert) or causing overall low blood sugar (low-carb) that disturbed my sleep. When I added about a cup of cooked white rice or potatoes to the meal, my sleep issues evaporated. What happened?

Ellen explains: “If you typically get ‘hangry’—angry and irritable when you’re hungry—at 3pm, the overnight equivalent is waking up at 3am with racing thoughts, unable to fall back asleep. This typically happens when your blood sugar crashes overnight and your body counters with a stress response…a stress response can make your sleep more superficial, shunting you out of the deeper stages of sleep and making it more likely you’ll be jolted awake.”

The solution is to stabilize blood sugar throughout the night. I do this with a big, starchy carb heavy (but low sugar) meal. Ellen likes to eat a spoonful of almond butter before bed, and eats another spoonful if she wakes up jittery and anxious.

“Our bodies are increasingly bombarded with unrecognizable chemicals and food—ranging from pesticides to phthalates to Pop-Tarts (essentially, foreign agents our bodies didn’t evolve to deal with)—that provoke the immune system in much the same way a genuine infection would. A daily ingestion of Doritos, for instance, leaves the immune system belligerent and confused. It keeps fighting, thinking it stands a chance at killing off the ‘infection’ of Doritos, but our immune system isn’t build to defeat chips—not to mention that we get ‘reinfected’ with every snack. Over time, a consistently inflammatory diet can result in a dysregulated, hyper-vigilant immune system, an inflamed body, and sustained feelings of depression or anxiety.”

“The body is hardwired for survival,” Ellen says, “not for feeling calm.”

She’s says this in the chapter about psychiatric drug withdrawal, specifically in relation to benzodiazepines. But what I find most interesting about the statement is that we’re all walking around under the assumption that calm should be the norm and anxiety a pathogen to eradicate.

In reality, a part of our body is always looking out for dangers. It’s why we startle when we hear an unfamiliar thunk. Debilitating anxiety needs to be dealt with, of course, but bouts of it is just the body doing its job of trying to stay alive.

“We’re taught from a young age that when something is difficult, it is necessary to distract ourselves. When a child has a tantrum, we think, How can I make the crying stop? We know that if we hand the kid some sugar or a screen, they’ll probably be satisfied. Problem solved, right? Well, actually, now we’ve taught the kid: I can’t handle your big emotions, you can’t handle your big emotions, and should ever feel big emotions in your future life, quickly find something that will distract you, offer you a hit of dopamine, or numb you out. It’s no wonder even we adults turn to our phones or emotional eating when in fact we just need to feel our feelings and let our tantrums run their course.”

This is where true anxiety comes into play. Safety is an illusion. All our effort put into keeping our kids “safe,” building equity, or eating clean could be undone in a matter of moments. We do these things to bring a sense of order into our lives, but trying to white-knuckle our way to control often creates the exact anxiety we’re trying to prevent.

“We are anxious and exhausted because wee are fighting with reality, beliving things are supposed to go a certain way. Instead of showing us where we need more control, anxiety actually alerts us to where we need to let go; when we need to take a breath and patiently, courageously see where our particular path will take us.”

Last weekend, I was invited to sign copies of MAY CAUSE SIDE EFFECTS at a new bookstore in Santa Monica called Zibby’s Bookshop. A dozen or so other authors, including my writing mentor, were signing at the event as well. Afterwards, we all gathered in the lobby of a fancy hotel to drink wine, eat cheese, and bitch about the disaster that is publishing books. Everyone had a horror story, from “my Gen Z publicist will no longer talk on the phone because she says the phone is too stressful” to “my book came out two days before Covid shut the world down” to “my former agent stole my royalties and fled town in a Winnebago.” (I get to take credit for that last one.)

As nurturing and fulfilling as the evening was, I was exhausted from the intensity of it all. As a few of the ladies were transitioning from the party to the after party, I declined, instead deciding it was time to head back to my AirBnB.

“Brooke’s got strong boundaries,” my mentor said, her eyes scanning me like I was some sort of curious, alien species. “I need to work on that.”

This observation stuck with me because it butted up against a series of recent encounters where my “boundaries” caused confusion, discontent, or outright pain in other people. I put boundaries in quotes because to me, it doesn’t feel like a boundary. It feels like the most obvious thing in the world. By doing what’s best for me—in this case, getting a good night’s sleep—I guarantee that I won’t be exhausted in the morning. I’m nicer and more patient when I’m rested, which leads to more pleasant encounters with others, which means my day and everyone else’s is going to be easier. A win for me, a win for the world.

This is called egotistical utilitarianism, a phrase I first heard coined by Matthew McConaghy in an interview with Tim Ferris.

It’s a counterintuitive concept. An egoist does whatever is best for them. A utilitarian does whatever is best for others. How can such opposition fit together?

Because when we take action based on what benefits us the most, it also benefits those around us.

As McConaghy put it, “The decisions we make for the I, for ourselves, the selfish decisions are actually what’s best for the most amount of people — utilitarian — they are where the ‘I’ meets the ‘we’, where the selfish is the selfless.”

Don’t get confused by the “egotistical” part of this. Our negative connotation of the word, in the sense that people who are egotistical operate as if they’re the only mattering person on Earth, disappears when egotistical utilitarianism is fully understood. In this sense, it is about the reason for the action, not the action itself.

As an example, a fireman spends hours at the gym lifting weights, running on the treadmill, and staring at himself in the mirror. His friends and family are chuffy because he isn’t around that much or comes off too rigid in his adherence to the gym schedule. They want him to spend time with them. To tend to their emotional needs. But what’s really happening is the fireman’s inner drive to be in the best shape possible also allows him to have the physical ability and confidence to carry heavy firehoses, pull people out of burning buildings, and trust in his body’s carbon dioxide capacity. His usefulness as an individual, in this specific area where he excels, benefits the collective every time he goes out on a call. And when he is able to do his job to the best of his ability, he is more fulfilled in his life. The more fulfilled his life, the better and more present he can be with the people around him during the time he makes for them.

In my life, it plays out like this:

My work on antidepressant withdrawal is my priority. Full stop. It takes a tremendous amount of energetic effort to navigate a topic this heavy, leaving little energy in the tank to manage the needs of other people. It’s why I’m not married and don’t have kids. I simply don’t have the bandwidth.

As a result, most of my day to day choices are based on what’s best for me and my energy conservation. That means I’m often non-committal, have zero issues cancelling social plans, and don’t express a natural interest in other people’s lives. This comes off as flaky and uncaring, especially to the people in my inner circle who feel they deserve to be put ahead.

But the reality is I can’t do this work and impact the collective if I’m constantly shifting my focus because someone wants attention or pat on the back. If they’re dying or in a real crisis, then of course I’ll drop everything and show up. And I make a conscious effort to speak their love language and spend time with them when I do have the bandwidth. The folks who understand this balance—and more importantly, practice it themselves and manage their own feelings around it—are the people who have staying power.

To harness our drive and use it for the good of the whole is a powerful strategy for both individual and collective happiness. It’s doesn’t mean there won’t be times where you are called to perform an entirely selfless or selfish act, or where obligations and ethics won’t trump individual wants. But it’s worth exploring what exactly is best for you, and to watch what happens around you when to act upon it.

Today, I’d like to share with you an essay by Dr. Bonnie Burstow, a professor and psychotherapist who spent most of her career at the University of Toronto’s Ontario Institute for Studies in Education.

The essay, published in the academic journal Ethical Human Psychology and Psychiatry in 2017, is the sort of work that burrows into your psyche. The core idea presented—that psychiatric drugging of children (including with ADHD drugs) is a form of child abuse—seems radical at first glance. But the deeper you get into the paper, the more difficult it is to argue with the claim.

I am going to refrain from injecting my own thoughts on the essay and instead leave you to process it on your own. However, the paper is quite dense and the language has an academic bent that can make it difficult to understand if you don’t speak academic-ese. Thus, I have pulled key highlights from the work and added them below. Everything blow is a direct quote from the essay. All emphasis (in bold) is my own.

I have also linked to the full paper through a public Google document. I encourage you to read the full piece and share it with your friends and family.

To learn more about Dr. Bonnie Burstow, who died on January 4, 2020, in this New York Times profile.

“Abuse is any behaviour that is used to gain and/or maintain power and control over another person” (Kelowna Women’s Shelter)

“Child abuse refers to any form of physical, psychological, social, emotional, or sexual maltreat- ment of a child whereby the survival, safety, self-esteem, growth, and development of the child are endangered. There are four main types of child abuse: neglect, emotional, physical, and sexual. (Royal Canadian Mountain Police, 2012)”

The United Nations Convention on the Rights of the Child, Article 6:

1. State parties recognize that every child has the inherent right to life

2. State parties shall ensure to the maximum extent possible the survival and the development of the child (UNCRC, Article 6).

The United Nations Convention on the Rights of the Child, Article 37:

1. No child shall be subjected to torture or other cruel or unusual punishment.

2. No child shall be deprived of his or her liberty unlawfully or arbitrarily (UNCRC, Article 37).

If something constitutes abuse, it is not in the best interests of the person being subjected to it—not with women being battered, not with children being assaulted with harmful drugs.

There are, of course, people who would argue that a definition like this cannot cover the area of child abuse because, irrespective of other considerations, it is always critical to do what is in the best interests of the child. (Don’t claims like this frequently underlie oppression?)

Well folks, it’s happened. After a year that I will henceforth refer to as, “The Year That Changed Everything,” I have completely, utterly, all the overused adverbs in the world-ly, hit a wall of systemic exhaustion. 

Not that I can stop. 

I’ve got four trips planned in the next eight weeks, all for work or book-related endeavors. Los Angeles —> Las Vegas (lord help me) —> San Francisco —> Virginia Beach. 

I’ve put myself on a work embargo in between trips, which means after I write this, I’m going skiing. (That’s how embargoes work, right? They’re conditional upon finishing work, right? RIGHT?)

Burnout is a manifestation of chronic, unmitigated stress. Or, as the World Health Organization defines it, an “occupational phenomena” characterized by “feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy.”

One google of “burnout” provides a whole host of solutions, but frankly, I’m too burned out to even look through it and throw some research at you. Instead, I’ll share my unscientific philosophy on the matter: the BBC.

Boundaries

Bordem

Creativity

The thing about publishing memoir is that everyone wants to talk to you about it. If you’re trying to sell as many books as possible, which I am, this means taking every opportunity to chat. MAY CAUSE SIDE EFFECTS is gaining traction and the bigger the opportunity, the more focused I need to be. 

Thus, for the next eight weeks, I’m postponing, cancelling, or avoiding any work that’s not directly MCSE related. No more bullshit meetings. No more “picking my brain.” The same goes for social obligations. If I don’t fully want to be in an experience or around a group of people, it’s just not happening. I don’t have the bandwidth. 

The only cure I’ve ever found for burnout is boredom followed by creativity. Not standing-in-line-at-the-grocery-store-boredom, but true boredom. Like pandemic levels of boredom. The kind of boredom that transitions from agitation to openness, where the brain shuts down and the instinct to pick up a paintbrush, go for a walk, or play an instrument kicks in. 

In my experience, true rest only occurs in this state. And it’s why vegging out in front of the TV for an hour isn’t all that rejuvenating. What the mind and body needs is primal rest, the sort that occurs in nature or in the nurturing presence of close friends or family. 

It’s a cumulative process, too. One that isn’t all that compatible to modern life. But there are little things we can do to facilitate boredom, like leaving your phone at home when you go for a walk or taking a social media break. One of the more amusing strategies I heard involved locking yourself in your bathroom with nothing but a pen and paper, setting an hour-long timer, and not allowing yourself to do anything but scribble or doodle while you’re in there. No reading lotion labels, no organizing the makeup drawer. No bubble baths. Just pure, private, glorious boredom. 

The great tragedy of the digital world is that fewer people—kids, especially—get bored enough to pick up a pen, eliminating countless writers and artists who might be filled with talent but are instead wasting away playing Fortnite.

I don’t think it’s an accident that our abhorrent collective mental health coincides with the massacre of arts funding in schools. As the beloved author Kurt Vonnegut said, “The arts are not a way to make a living. They are a very human way of making life more bearable. Practicing an art, no matter how well or badly, is a way to make your soul grow, for heaven’s sake.”

Making art for art’s sake is the only thing that rejuvenates my brain during times of burnout. But purposeless creativity does not exist without boredom, which is why the two need to go together. The second moneymaking is involved, it moves into the realm of adding to burnout rather than removing it. 

Of course, I don’t have kids or an elderly parent to care for. Caregiving burnout is its own beast; one that trickier to address. So I’m not even going to try. But if you’re burned out keeping other humans alive, consider yourself hugged. You’re doing a hard thing. 

With that, I’m going skiing. Without my phone. If I have time left in the day while it’s still light out, I’ll paint something. And then in 36 hours I’ll get on a plane. Rinse and repeat.

Last weekend, I did something I rarely do: I went out. Like out out. I put on heels, wore makeup, and made chitchat with strangers at a fundraiser for a local museum. 

I was invited as a date for a friend whose husband went on a last minute business trip, leaving her as the lone stag in a group of eight couples. My butt did a great job of filling the seat, but a table of familiar faces brought not a sense of inclusion, but the sting of loneliness. 

The experience highlighted a nagging feeling I’ve had since MAY CAUSE SIDE EFFECTS was published in September. The book was, in many ways, my best friend. A constant, intimate presence, it persisted through the ebbs and flows of my life, the work often reflecting my reality. It gave me a sense of purpose, never wavered in its dedication, and showed up when I needed it. When it hit bookshelves, it’s like it moved away. It isn’t mine any more. It belongs to other people now, influencing their lives while I scramble to fill the void. 

Though the loss has gifted me oodles time, it also illuminates neglect. All of my relationships have suffered over the past five years, particularly my friendships. As a single person with no kids and a minuscule family unit—it’s just me and my mom, no siblings or notable extended family—I’ve always kept a mental running list of friends who would step up in a crisis, no questions asked. 

I don’t know if there’s anyone on that list anymore. 

Years ago I might have blamed this development on the failure of the parties involved, assuming we just didn’t try hard enough. Now, I understand that biology and social psychology is at play, and that itinerant life I’ve led isn’t conducive to creating and maintaining intimate friendships.

The number and quality of friendships is the single most important indicator of longevity and happiness and as we age, friendships become more important for health than family. 

But in 2021, 12 percent of American adults said they had no close friends, contributing to the loneliness crisis that began well before, but was exacerbated by, the pandemic. 

So how do we make friends as adults? More importantly, how do we create meaningful friendships that increase happiness? I dove into the research of evolutionary psychologist and friendship expert Robin Dunbar to find out.

Robin Dunbar is best known for Dunbar’s Number, which he defines as the number of relationships people are able to cognitively able to manage and maintain at once. He puts this number at 150, which unsurprisingly, is just about the size of the average American wedding guest list. 

These 150 people are made up both friends and family and sorted into a sort of circular hierarchy. The closer the ring of people around you, the fewer the people in the ring. 

In the bullseye with you is an spouse or intimate partner, followed by three to five people who make up the first ring, usually family members and a close friend or two. The next ring expands and holds secondary characters. Grandma, perhaps. Friends you know very well but maybe not the one you call in a crisis. From there, we expand through the rings of fair weather friends, colleagues, extended family, old friends who live in different places, and so on through the target.

Meaningful friendship is woven by shared experience and regular exposure. Therefore, the best way to make new friends is to engage in a consistent, social activity like a weekly meetup group. 

When we’re kids, this is automatic. We go to school or an after school activity, see the same people every day, and become friends. As adults, we lose opportunities for that natural interaction. Some people get it through work, but for someone like me who works alone and at home, I have to create it. It’s no surprise, then, that the people in my “close” and “best” friend circles over the years have come from going to the same CrossFit class, at the same time, five days a week for years. 

It’s also not surprising that over the past six years, when I was either traveling internationally or splitting my time between Canada and the US, my friendships suffered. I’d be in town for three weeks and leave for two months. People had babies in the time I was away. 

In my head, they still remained in the “close” or “best” category because I didn’t stay in one place long enough to forge a friendship strong enough to fill the space. But while I was away, my place in their hierarchy shifted, knocking me to outer circles. 

Where people stand in the hierarchy is constantly shifting. When you see less of someone because you see more of somebody else, it pushes people in and out of different circles. We see this happen all the time when people enter new relationships. In an interview with Dan Harris on the Ten Percent Happier Podcast, Dunbar said that falling in love can actually take the place of two close relationships, because the mental energy and attention devoted to the new person inevitably boots two people out of the ring. This explains why people disappear when they get into a relationship. It’s not because they don’t care or are blinded by love. It’s because we have limited capacity.

When life separates “close” and “best” friends, the instinct is to hold those people in their circles by keeping in touch through social media or phone calls. Though social media has a reputation for, you know, toppling democracy and obliterating societal mental health, it’s actually supports relationship intimacy. But with limited energy to devote to friendships, time spent on Facebook eats into opportunities for in-person connection. 

For relationships in the outer rings, this isn’t a big deal. But at the inner rings, intention is crucial. As Dunbar says, people might be “better off finding a new shoulder to cry on just round the corner, so when the world does fall apart, they can walk around the block, knock on their door and get a hug.”

Said another way by the lyricist Stephen Stills: “If you can’t be with the one you love, love the one you’re with.” 

The hardest part of making friends—especially in a new place—is the beginning. But once you engage in a community and show up consistently, proximity will eventually lead to connection. Once those connections are made, the circles naturally expand as people get introduced to one another, creating a flywheel affect that ultimately leads to the sort of event I found myself at last weekend. 

As I felt sorry for myself at the table, envious that these sixteen (!) adults had so much support for one another, I wondered what it was about me that made me feel so separate. 

The answer is that while I was off in Cambodia or Croatia for a month at a time, they were all moving back to Reno and starting their families. All of them have kids around the same age. They get together for play dates and PTA meetings. When the kids aren’t around, they share the common ground gained from so many years of similar experience, often within walking distance of one another. 

It’s a barrier I’m just not going to be able to crack. But that’s okay. There’s plenty of room for them in my “good friends” category, and now I won’t beat myself up wondering why I can’t bring them closer.