‘Tis not just your typical self-diagnosis skepticism, of which we have seen much in recent times — nay, Ms. Buttons was professionally diagnosed as an adult, and found in it quite a plausible explanation for a litany of childhood troubles:

“My monotonous voice, flat emotional expression, lack of eye contact, and failure to respond to humor—all of which were noted in psychological testing I endured as a teenager — seemed to confirm it. My all-consuming fixations on things like sharks and parasites became autistic special interests. My habit of overcomplicating basic tasks became executive dysfunction, my clumsiness a gross motor impairment, and my fidgeting “stimming.” Even my food intolerances and obsessive-compulsive tendencies seemed to fit the pattern.

But the clearest sign was in my daily war against bright lights and loud noises, which finally seemed to have a real name: sensory processing sensitivity. Suddenly, every aspect of my life, every little inadequacy or abnormality that had once tormented me, had a medical explanation.”

These are, my dearest sluggy reader,2 all textbook autistic traits. What’s more, Buttons has also said she was placed in a special education program in school, which means she was formally recognized from a young age by professionals in both education and medicine, so: why doesn’t she believe in her diagnosis now?

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In 2022, Ms. Buttons started working as an ‘investigative reporter’, mostly ‘investigating’ detransition for Ben Shapiro’s conservative propaganda rag:

“I soon began taking on stories that required heavy reporting. As I spoke with sources, built rapport, asked sensitive questions, and earned their trust, I realized something that should have been obvious much earlier: I do not have a social communication deficit. Not only was I competent at socializing, I was good at it, and I improved the more I did it.”

A smoking gun this surely is not — journalism can be a friendly career for the observant autist who takes great notes. Interviewing is a highly scripted and structured social interaction, and gaining a source’s trust doesn’t require sparkling charisma, so much as quality time and keen listening.3

Ms. Buttons’ life narrative is hers to craft of course, but she is wrong to suggest that her personal story is happening at scale, especially when there’s a curious lack of engagement with the literature on masking.

Research has shown autistic women like Ms. Buttons can be quite competent at performing social skills — struggles in childhood can lead to learned compensation, particularly motivated by the desire to connect, albeit with severe mental health consequences.

In addition to the academic work, numerous books have been written on this phenomenon in recent years. Ms. Buttons’ personal story reflects this pattern, and her omission of this research is a major weakness in her writing that, frankly, doesn’t inspire confidence in her investigative journalism skills!

But of course, this is no mere personal essay, and Buttons is no random journalist — she writes for a major right-wing think tank called the Manhattan Institute, which means this is really a policy argument gussied up by lived experience. The piece is a model of the broader, ongoing culture war about who counts as autistic, and I think her conclusion tells us something important about the politics at play.

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Much of it will sound familiar to my close readers, but I’ve added some things, too: like, if movement is a kind of attention, then we could see knitting and other repetitive crafts as a way of pacing the body, an idea inspired by Mikka Nielsen’s work on ADHD as a ‘desynchronized way of being in the world’.

She writes:

“Rituals of self-stimulation enable the body to become the moment—a body that ‘accrues time as a penalty in the form of understimulation, and that perceives this time as a burden’. (Goodwin, 2010:19)

Becoming the moment means slowing down the acceleration of inner time [and] insisting on the present through movement..”1

I also added a bit of history to help us understand the macro reasons everyone seems to be really into yarncraft again: The Revival of Handicraft by William Morris, a leading figure of the 19th century Arts and Crafts Movement, who saw the return to crafting as an encouraging sign that people were unhappy with the industrialization of society, and the way machines cut them off from the process of making to churn out ‘ugly vulgarity’.2

But there’s one thing I skated through in explaining embodied cognition that deserves a bit more time: the idea that the brain is a computer, embodied cognition’s ideological foil.

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What’s really interesting about this idea is the fact that computers were actually modeled after the brain, or at least, ‘a subset of human cognitive abilities, namely doing calculations’, as Romain Brette writes in a 2022 paper:

The brain-computer metaphor seems to offer a natural way to bridge mental and physiological domains. But it is important to realize that it does so precisely because computer words are themselves mental metaphors. In the seventeenth century, a “computer” was a person who did calculations (Hutto et al., 2018). Later on, by analogy, devices built to perform calculations were called computers.

We say for example that computers have “memory,” but memory is a cognitive ability possessed by persons: it is people who remember, and then we metaphorically say that a computer “memorizes” some information; but when you open some text file, the computer does not literally remember what you wrote….

No wonder computers offer a natural way to describe how the brain “implements” cognition: computers were designed with human cognition in mind in the first place.

Bette says the idea has become a ‘double metaphor’, circling itself — brain to computer back to brain again. This may seem like just a fun bit of trivia, but it actually forms the basis of a strange worldview shared by some of the most powerful men on Earth.

If the brain is just a computer, then who is to say our world has not been digitally simulated?

In one clip, Elon Musk is asked how likely it is that we live in a simulation, and he says, highly. It’s a popular idea — ‘glitch in the matrix’ videos have basically become their own genre on Tiktok, and tech billionaires apparently believe this secular theology3 so much that some are rumored to have funded research into breaking us out of the Matrix.

The idea can be traced to a 2003 paper by the philosopher Nick Bostrom, “ARE YOU LIVING IN A COMPUTER SIMULATION?”, in which he presents a trilemma:

“…at least one of the following propositions is true:

(1) the human species is very likely to go extinct before reaching a “posthuman” stage;

(2) any posthuman civilization is extremely unlikely to run a significant number of simulations of their evolutionary history (or variations thereof);

(3) we are almost certainly living in a computer simulation.

It follows that the belief that there is a significant chance that we will one day become posthumans who run ancestor-simulations is false, unless we are currently living in a simulation.”

Don’t worry if this doesn’t make any sense to you at first read, philosophers famously love convoluted thought experiments that they use to make more meta points about thoughts. That’s what this is, but pop culture has warped it into some kind of proof that we are all currently plugged into a supercomputer.

Bostrom explains that if you believe computing power will continue to accelerate into the future, to the point that we transcend the body and become “posthuman,” then due to mathematical probability, it is likely that we are actually in a simulation created by our successful ancestors right now.

This premise explains why tech billionaires like Musk wholeheartedly believe we are all simulated (and why you don’t really have to care about this unless you’re a techno-optimist, too) — their grand goals for the future of post-humanity have backed them into a philosophical corner.

Echoing Bostrom, Musk has said:

“either we’re going to create simulations that are indistinguishable from reality or civilization will cease to exist. Those are the two options.”

But are they? I could imagine several other possible futures for humanity right now that don’t center the endless acceleration of computing power.4 We could choose to do something else with our technology, if the capitalist demand for growth at all costs was not the driving force of our economy.

This seems like a failure of the imagination to me, not to mention a massive failure to account for the body. Aside from neurotransmitters and synapses, Bostrom doesn’t address the body at all in his 2003 paper. His argument relies on what he calls ‘the assumption of substrate independence’, which says that, in theory, consciousness doesn’t require a meat-brain and can function perfectly fine on silicon, or any other material.

Transhumanists like Bostrom view the body as an inefficient hindrance, something that needs to be tweaked and optimized and eventually left behind altogether.5 Disability, in this worldview, is a glitch, which is why Bostrom’s thought-child, longtermism, ends up being ‘eugenics on steroids’.

In contrast, embodied cognition says that we actually do need an electrified meat-body to think,6 because thinking is enacted in the relationship between the body and the environment.

In their seminal text, Varela, Thompson, and Rosch write:

“The core idea of enaction is that the living body is a self-organizing system. This is in contrast to viewing it as a machine that happens to be made of meat rather than silicon. Mechanisms act and change their state only because of input and programming from sources outside of themselves, whereas the living body continuously reorganizes itself to survive and maintain its own homeostasis… Survival means that the organism must preserve the integrity of its boundaries while having constant interchange with the environment.”

Through these interactions, with our varied bodies that have varied sensations and capacities, we create knowledges, but Musk and Bostrom’s posthuman agenda doesn’t see disabled knowledge.

As Alison Kafer has written, ‘disabled people are continually being written out of the future, rendered as the sign of the future no one wants,’ which is why it is important that we keep sharing the things we have learned in, with, and through our disabled bodies.

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Such as: movement being a valid form of attention! Watch the video and let me know what you think!

Okay, it’s not just the Lexapro, I don’t want to give the drug too much credit, but I don’t think I could have admitted to myself that we needed to move in my previous state of agitated despair.

Everything seemed too impossible then, but now it just seems kinda hard, and a little bit annoying. I’ve developed this strange ability to notice when I’m irked, say something to myself like, wow, that’s pretty annoying, and continue on my way. It’s the closest I’ll ever get to zen, I think.

My chemical unburdening has changed my close relationships, too. I love my dogs again, for one, because I now have the patience and confidence to train them. It’s cheesy as hell, but I guess they are better dogs now because I am a better me?

I used to lean my big feelings pretty heavily on my partner, but now I’ve become the calm one telling them it’s all going to work out, which has made a little room for them to unload some of their big feelings, too. This is how I discovered that they weren’t happy in the suburbs either, and I wasn’t the only one who felt like my life was over.

Gray and I bought our house four years ago, right around the time I started writing this newsletter. I think this is actually the longest, most consistent stint that I have ever done anything for money — my work life before this was a series service jobs and gigs cycled through in volatile seasons.

This house anchored me; my desire lines have worn grooves in her creaky wood floors, the ones we unearthed from old carpet, staple by rusty staple. But my life is also a series of projects, and I am cursed to forever race my waning attention for any given one, before interest jumps me sidewise into something else.

They talk about an inner sense of restlessness in ADHD, ‘being driven by a motor’, but I wouldn’t describe it that way. I think of the feeling I get on a train platform, that thrill of being in-between places, in motion. I love that feeling, going somewhere and leaving something, the mix of excitement and nostalgia.

A house in the suburbs doesn’t feel like that. It’s a stationary life, where walking has no purpose because everything you need is too far away, so you end up having to go on scheduled walks around the neighborhood for the sole purpose of wiggling your joints. You’re not going anywhere or leaving anything, just wandering in circles for the sunlight. I hate it, and I hate the person the suburbs have made me — isolated, fearful, sedentary.

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As long-time readers know, I love to do an annual hate-read, where I pick apart a book I know I’m not gonna like as a fun intellectual exercise. This year we’re looking at Joanna Moncrieff’s new book Chemically Imbalanced: The Making and Unmaking of the Serotonin Myth. And spoiler alert: it’s about Calvinism, because all roads lead to the Protestant Work Ethic somehow!

Moncrieff, a critical psychiatrist, has spent most of her career warning the public against antidepressants (I wrote about how she’d also convinced me, for a while, here), and Chemically Imbalanced is her ultimate anti-antidepressant manifesto. She argues, based on randomized controlled trial data and the work of a very famous placebo researcher, that SSRIs are essentially useless.

Her book, in my read, relies pretty heavily on cultural assumptions about the harms of drugs in general, and tends to discount the positive experiences that people report on SSRIs in particular. This culminates in a neat little gift for conservative figures who argue, like Moncrieff, that suffering is an opportunity for personal growth.

In the video I discuss a countertext, and I thought a mini-list of further reading would make a nice little extra. So, here are a few books that have influenced me and will expand your perspective on this issue:

• Ordinarily Well: The Case for Antidepressants by Peter Kramer / the countertext in question, Kramer defends clinical experience in the face of critics who over-rely on trial data to write off SSRIs entirely.

• Strangers to Ourselves: Unsettled Minds and the Stories that Make Us by Rachel Aviv / possibly the best book I’ve ever read on how multiple narratives about mental illness — medical, spiritual, political — all can exist at once in people’s lives. This offers a great counter to the binary at the heart of Moncrieff’s argument, that depression cannot be both a reaction to circumstance and an illness. Specifically, see the chapters on Bapu and Naomi.

• Psychopolitics by Peter Sedgwick / a political argument for the concept of illness from the left, and a great counter to the Szazsianism of Moncrieff’s work. Read chapter 1, 6, and 7 in particular.

Pls go like and subscribe and share the video, I am super close to 1,000 subscribers on Youtube!!!!

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When researchers actually tested this in 2009, their results were all over the place — 66 days was the average (so if you made a resolution, that would be about now), but some people took up to 254 days!

Complexity is a huge factor, too — a study in 2023 suggested that ‘developing a handwashing habit takes weeks, while developing a gym habit takes months,’ because going to the gym everyday is a much more complicated set of actions.

Speaking of self-help mythology, there’s something else floating around the internet that we must address: the idea that people with ADHD cannot form habits at all.2

Based on vibes alone, I am inclined to agree — I can’t seem to make an exercise routine stick, or keep a journal, or regularly vacuum my floors. But my critical brain doesn’t really buy it.

When people say this, their examples are usually chores and self-care, but habits are way more than that. They’re automatic behaviors triggered by an environmental cue, like how I always reach for a seatbelt when I sit in a car, or put my phone in my back right pocket when I’m walking around the grocery store.

ADHDers do stuff like this all the time, and when you look into the research, there’s actually some evidence that we are more habitual in our behavior.

ADHD and ‘habit-forming illnesses’ like addiction and OCD often go together — both of which have been framed by researchers as an over-reliance on the brain’s habit-learning system. And a 2019 study on children with ADHD found that they responded more habitually on a computer task than other kids.

Cognitive neuroscientists at Trinity College Dublin have theorized a ‘dual system perspective’ on habits, which might explain what’s happening here:

“This dual system account conceptualizes habits as resulting from learned [stimulus-response] associations, which can be modulated by goal-directed control… when sufficient attention and cognitive resources are available.”

So, you learn automatic behaviors through cues and rewards, but you can override these behaviors with enough brain energy and executive functioning skills.

If you accept that ADHD comes with higher rates of addiction — the extreme end of habit formation, according to the neuroscientist Marc Lewis — then clearly habits are possible. You can’t form “bad” habits without the ability to form “good” habits, since both involve the same cognitive learning process.

But, if you need to use executive control to break habits, then the EF challenges of ADHD would make that harder. And, since you need executive control to make a habit, too, that would also be harder! It’s a conundrum: we may rely more on automatic behavior, and be less able to steer the formation of it.

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One mistake I think people are making when they argue we cannot form habits at all is mixing up automatic behavior with consistent behavior. Researchers have found that consistency is the main thing that makes a habit stick, but remember the high end of habit formation they found, 254 days?

That’s eight months! Some of us need to do a behavior consistently for a really long time before it becomes automatic, but consistency is a huge challenge when you’re constantly getting whipped around by your interests and forgetting stuff!

Memory plays a huge role — people with better prospective memory (the kind you use when you plan to do something in the future and then actually remember to do it) have been found to form stronger habits more quickly.

Habits are also context-dependent; they ‘need a time and a space,’ Marco Stojanovic and colleagues write in a 2022 study, which found students who constantly switched up their study locations and times were worse at forming a habit.

So, if you’re a novelty-seeker who changes up your environment a lot: going to new places, switching jobs, throwing your entire life in the dumpster and leaving the country like I did a few times… you’re also chronically disrupting all your habits.

You might just need to use different methods to form habits, too. The philosopher Polaris Koi writes that self-control is commonly thought of as internal willpower, but there are also situational strategies that get overlooked.

Using internal willpower might look like deciding to quit drinking, going to a bar, and ordering a soda, but a situational strategy would just be avoiding bars altogether. Instead of trying to white-knuckle through temptation on your own mental strength, you use the environment as a scaffold to support habit formation.

These situational strategies, according to Koi, are the kind that ADHDers need, since executive dysfunction makes internal willpower more of a struggle. But, since the world is built on the assumption that self-control equals internal willpower full-stop, we are essentially set up for failure:

“..their different neurobiology may not make certain self-control practices, such as ‘willpower’ strategies, impossible—it merely makes them excessively effortful and difficult. As a result, one may hold on to the hope that with time, as one patiently flexes one’s ‘mental muscle’, these difficult practices would become easier. However, knowledge of a fuller array of effective self-control behaviours would better enable these agents to seek out a ‘toolkit’ of means to self-control that do not entail disproportionate difficulty.”

Koi also points out a material ‘double bind’ — the fact that low socioeconomic status is correlated with ADHD, meaning that a lot of ADHDers likely do not have the financial means to change their environments in ways that allow them to access to the self-control strategies they need to thrive.

If you can’t afford to switch jobs, if you can’t afford a smartwatch and app subscriptions, if you have unstable housing and lack social support, you’re stuck falling back on internal willpower strategies that likely do not work well for you, making conscious habit formation feel impossible.

For Koi, self-control is an access issue, and if his theory is true:

“..then individual differences in self-control are not merely a matter of inherent character: they are a matter of justice. By emphasizing intramental self-control behaviours over environmental ones, present discourse on self-control obscures the availability and efficacy of environmental self-control strategies, setting people with disorders such as ADHD at a disadvantage.”

One of the most popular situational strategies is something neurodivergent people have already figured out on their own: body doubling, which builds social accountability and motivation into the environment.

There’s also visual cues, like post-it notes, or keeping a work-in-progress out on the table so you’re reminded to finish it.3 And the oft-cited ‘point of performance’ advice, where you keep whatever you need for a habit within reach.

I keep my meds next to the coffee station, which consistently reminds me to take them every morning, since I have a severe addiction to caffeine. But on vacation, when they were in a plastic bag in my backpack in a hotel room in another time zone, my morning habit fell apart — I kept going oh shit at 2pm when I finally realized I’d forgotten to take my meds.

I don’t think that’s my brain being neurologically unable to form a habit, though. It’s just the context-dependent nature of habits in general. We are creatures of place, and our behaviors are tied to it.

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the only way I’ve managed to get any knitting projects done is just keeping them next to where I sit on the couch everyday, so I sit down and go, oh look! my knitting! let me do a couple rows! and then I do that multiple times a day and then eventually I have a balaclava, and a knitting habit.

I’m not sobbing several times a week anymore, not asking if we left the stove on, or running back to check. I haven’t taken a benzo since I started Lexapro. There’s a subtlety to this drug that I’ve never experienced before, a slight tweaking of the knob in my brain that controls the intensity of my fear, allowing new thoughts to take root.

The other day we were on a walk and the demon in my amygdala said, What if you have a brain tumor right now? which normally would have sent me on a catastrophe spiral. But instead I said, We’re not going to worry about that right now, and then I just…moved on.

I just moved on?! I never move on!! I obsess! I drive myself deep into a pit of doom until I’m freaking the fuck out and have to be sedated! But there’s been more distance between me and my worries. They’re still there, but it’s like I’m in a boat floating on top of the ocean, instead of being pinned to the seafloor in the dark.

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I told my therapist all this and then brought up another doubt from my OCDemon: What if it’s just the placebo effect?

To which she said: So what if it is? You’re doing really well.

The placebo effect argument against antidepressants bothers me, not because I deny the power of placebo — I actually find that really fascinating — but because of how it’s used to undermine knowledge gained through experience.

“Many people feel they have been helped by antidepressants; although whether antidepressants are actually effective and useful is, it turns out, uncertain,” Joanna Moncrieff writes in Chemically Imbalanced. But what is the difference between feeling you have been helped, and being helped?

There’s a limit to how much you can know about a psychoactive drug through trials and rating scales, a level of understanding that must be felt instead of counted. That is valuable data, too.

In Peter Kramer’s clinical experience, there’s a pattern to the placebo effect — immediate relief that tapers off after a couple weeks. But the pattern of an SSRI is different:

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The philosopher Raphaël Millière came up with a cheeky acronym for what is possibly the most intense experience you can have of your own consciousness without actually leaving this mortal plane: DIED, or, Drug-Induced Ego Dissolution. According to Millière, DIED happens when a drug disrupts the brain's ability to integrate a range of sensory information into a coherent model of a ‘self’ that is separate from the world.

I wasn’t ready when I DIED. I was cocky, and disrespectful. I’d snorted enough ketamine in nightclub bathrooms that I assumed we were well-acquainted already, but a heroic dose injected is a different beast.

It started as a sense of space expanding. I felt like I was lying on the floor of a huge room, a room where the ceiling went up and up forever until it turned into night sky.1 Eventually the space expanded so far that it began to collapse back in on itself, spiraling in and exploding out all at once.

The void branched and twisted, fractals on fractals. There was no more me; I forgot myself. I had no memories, no sense of being anywhere at all.

Leaving ‘I’ behind like this is a cosmic horror, but because ketamine is a strong sedative, I couldn’t physically feel afraid. This is a mercy — the drug took me to the edge of nothingness, while keeping me from feeling the terror of it. Right before my entire being collapsed, I thought: you have to remember what this is like so you can describe it later.

Joke’s on the part of me that describes, I guess, because there was nothing left to observe and categorize. Ego death is ‘beyond words, beyond space-time, beyond self’, as Timothy Leary wrote in The Psychedelic Experience.

I spent most of the next day trying to fathom what had happened, to find words to talk about it, but it was like trying to remember a dream, where the only part you can hold on to is the feeling.

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Some of the best descriptions of the ketamine experience come from the yoga teacher and past-life regression practitioner Marcia Moore, who documented her explorations of what she called ‘the bright world’ with her anesthesiologist husband in the late 70’s.2

She wrote that ketamine was like ‘a mill wheel’ that ‘entirely rubbed out’ her ‘small personal concerns,’ an ‘infinite washing machine’ in which she was ‘tumbling round and round,’ ‘caught up, turned inside out, and sucked impulsively into the revolving maw.’

“Even though the memory of that state remains it can only be called ‘indescribable’. To speak of a thunderous silence, or a multidimensional sphere turning upon itself, or of identification with undifferentiated vibratory energy is probably as close as words can come to portraying a truly ineffable condition of existence. This inner realm, full of sound, color, and sensation was itself entirely formless. Here there could be no distinctions between subject and object, this and that, I and thou. Only the vast nameless faceless process remained, churning on and on and on.”

Consistent in these descriptions is a sense of movement — churning, tumbling, spinning, revolving. That is one thing I do remember vividly from my own experience; it felt like being inside a swirling tunnel, expanding and contracting all at once. This “tunnel trip” is common, according to the expert Karl Jansen, who describes ketamine as ‘one of the most split drugs ever discovered’:

“It both wakes people up and puts them to sleep. It over-excites the calm brain and calms the over-excited brain. Ketamine is both damaging and protective, pro-and anti-convulsant, addictive and a treatment for addiction. It is given during birth and to ease the passage into death..”

Jansen likens ketamine trips to near-death experiences, in which people also report experiencing a dissociative, swirling tunnel journey. But what is up with the tunnel? Why do so many of us see it?

Maybe it’s another dimension, or what happens when consciousness breaks free from the body — that would be cool. I want to believe! Unfortunately, I also found a more boring, mathematical explanation.

In a 2002 paper titled What Geometric Visual Hallucinations Tell Us about the Visual Cortex, Bressloff and colleagues argue that drugs destabilize the visual cortex, which could lead to horizontal lines in the tissue getting mapped into concentric circles when the brain translates them into vision, where vertical lines could get mapped as radiating, like spokes on a wheel. Combined, this would create the illusion of depth — a tunnel.3

And what about the fractals? When I came back from the void, I couldn’t stop thinking about them. I started reading about how scientists think ketamine works in the brain, and found the theory of neuritogenesis.

Research starting in 2018 found that ketamine, along with other psychedelics like LSD, DMT, and psilocybin, ‘increased dendritic arbor complexity’ — they stimulated neurons to sprout new branches. Or, you could say: they made fractals.

This inspired a new term for these kinds of drugs: psychoplastogen, which etymologically means, mind-molding agent. There’s some debate in the field over whether the effects of psychoplastogens are biologically independent of the trip — can they stimulate neuritogenesis on a strictly biochemical level, or is the mystical experience is necessary?

So far I am in the latter camp — I’m not sure you can separate the drug from the experience, although some are trying. Psychedelic researchers have criticized psychiatry for trying to isolate the chemistry from its social context:

“The simplified mainstream narratives ignore broader knowledge and perspectives about psychedelic use and mechanism of action. The seemingly controversial argument that psychedelics’ therapeutic efficacy is dependent on suggestibility, social context, and cultural priors challenges traditional psychopharmacological views. But for anyone who seeks universal scientific truths about psychedelics, these might be their principal mechanism of action, a non-specific amplification of context,4 which is strongly-related to sociality, especially interpersonal relations and cultural setting.”

In other words, psychedelics are context-dependent, social tools, and trying to individualize them through mail-order service and market-based healthcare models may be denying the very thing that makes them effective — their sociality.5

While its become a 21st-century mental health craze (and certainly some people are being professionally swindled), Jansen calls the use of altered states ‘probably the oldest technique in medicine, dating from the period when the roles of priest and doctor were united in one person.’

“The practice was so ubiquitous in the ancient world that it should effectively be considered a species ‘norm’,” Daniel R George and colleagues argue.

“What is unusual is the active suppression of such substances, a late twentieth century global phenomenon led by the United States and United Nations (albeit with deeper roots in Christianity and the colonial Americas).”

Which brings up a good question from the researcher David B. Yaden:

“..if you can provide an experience that many people report as being the most meaningful of their entire lives, is it unethical to withhold it from them?”

The story of ketamine’s biology focuses on glutamate, an excitatory neurotransmitter that has become quite popular in recent years. “Like the shy kid who suddenly became visible with a new haircut, glutamate has taken the neuroscience literature by storm,” Mia Michaela Pal writes.

Dr. John Krystal, head of psychiatry at Yale and a leading ketamine researcher, analogizes ketamine’s mechanism of action to ‘if you had a brake and then you had another brake that you stepped on to relieve the brake’6 — it inhibits the inhibitor, GABA, which triggers the release of excitatory glutamate, leading to a wide range of downstream effects, like neuritogenesis.7

This is called the ‘disinhibition hypothesis,’ and it marks a departure from the chemical imbalance theory of depression. It’s not about correcting a ‘balance’ of neurotransmitters, but using a drug to intervene on their action in a way that helps the brain change.

Biological mechanisms aside, another way of thinking about how psychoplastogens work is that disorder, for a moment, can be therapeutic. The psychopharmacologist Robin Carhart-Harris says they shift the brain into an “anarchic” state that is “highly entropic,” or more random.

If we think of depression and anxiety as pathologically stuck states, then this could be a ‘useful kind of scrambling up’, as Carhartt-Harris says:

“I’ve likened it to shaking a snow globe where, you know, the snow might get settled in a particular way, but once we shake it up, we can change things.”8

Central to this idea is the theory of the brain as a prediction engine.9 Rather than responding to experiences, this theory says that the brain is constantly making predictions about what we see in front of us for efficiency’s sake.

Depression could be seen as a negative prediction, a sort of neurological doomerism — things are bad, they will always be bad, and there is no hope. A psychedelic trip could disrupt this prediction for a moment, creating a window for change.

In Granta, the writer Sheila Heti describes her own experience of this window after two sessions of ketamine therapy. The drug removed the filter of social convention that she usually puts on herself, allowing her to actually be honest with a therapist about her fears of rejection. She worries to him that she is ‘dimming’ her partner, but also has the epiphany that relationships brighten, too.

In the days after her session, other possibilities became available to her:

“..in little ways, which are always big ways, I felt myself acting and thinking differently. For one thing, silence from other people didn’t seem like punishment. Unreturned emails felt like nothing. And I really paid attention to brightening, not dimming, Jack. Maybe I could wash his car? I thought, imagining other ways I might help him, for he was always, in practical ways, helping me. And so I did wash his car, and it was even fun. And he seemed happier, too.”

A participant in the 2021 ‘Ketamine and me’ project says something similar:

“I could see a future, I could see that I was capable of doing things…I didn't kind of feel the sort of the negative person sitting on your shoulder telling you that you can't do this there's a problem here…. It was almost as if…the angel and the demon on your shoulder, and all you could hear was the angel.”

A friend of mine is fond of saying that ketamine puts you ‘two steps away from the bitch in your head,’ which can be a huge relief when the bitch in your head gets way too loud. For me, being able to momentarily disconnect from my psych-ache is immensely therapeutic — dissociation allows me to directly experience that another existence is possible.10

However it works, ketamine reminds me that the neurons in my brain are shaped like the trees outside my window and the watershed around my house. It is fractals all the way up, to the level of galaxy and universe. Wherever something flows — water, oxygen, electricity — you will find a fractal system, rhizomatic.11

“Everything must flow,” Marcia Moore concluded after one of her trips. “This was to be lesson number one.”

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New year, new drugs!

I took bupropion for a month and it was fine, nothing terrible or amazing to report, but after the initial focus buzz wore off I just started getting agitated and taking a lot of klonopin, which is the opposite of what I want an antidepressant for, so on to the next one. My new year’s resolution is to systematically work through a pharmaceutical sample platter of four-to-six-week trials until I find a chemical that makes me less scared of everything.

It’s been one week on Lexapro, and I can feel it in my teeth. You know like, when you drop acid, and you can feel the inside of your teeth? (No?? Just me???) They say you’re not supposed to feel anything for like a month, but when I tried Zoloft years ago I definitely felt it in the first few days, so maybe I’m just a sensitive little freak.1

Lexapro, or escitalopram, is the product of what’s called ‘evergreening’ in the pharmaceutical industry, an almost exact copy of an older drug that went off-patent except for a tiny tweak that allows them to file a new patent, and make a bunch more money.

In this case, escitalopram has become one of the most commonly prescribed SSRIs in America thanks to marketing that said it worked better than its older, cheaper fraternal twin, citalopram. A 2023 review found that wasn’t true, and that the difference is in ‘potency, not efficacy.’

Still, it’s become a cultural phenomenon, embodied in the ‘Lexapro Girlie’ meme. Women have historically been a target demo for psych meds, starting with the Mommy’s Little Helper benzo era. But concerns about addiction made doctors more wary, and in the 2000s, SSRIs like Paxil and Lexapro got FDA approval for anxiety disorders, and prescribing practices shifted.

Now, women hashtag #LiveLaughLexapro on TikTok, and news outlets accuse them of glamorizing the drug as a ‘hot lifestyle accessory’ — a take that, in my opinion, misunderstands how the internet generations use irony to express sincerity.

Take this National Post piece from this month about ‘hot girls on SSRIs’, which weaves a narrative about a dangerous trend of overprescribing to people who aren’t really ill, and are just expecting a ‘magic pill’ to solve all their regular life problems.

But the only actual content creator in the piece contradicts this story, saying that she tried to ‘tough it out’ with ‘magnesium, meditation, deep breathing,’ before finally accepting that she needed to try meds. When asked why she talks about it online, she said:

“Because social media is so fake. I want to be real and honest and raw and show people, ‘This is real life.'”

This month I read the book Strangers to Ourselves by the journalist Rachel Aviv, possibly one of the best books on mental illness I’ve ever found. Aviv uses journals and unpublished memoirs to explore how people conceive of their mental distress and reconcile often conflicting narratives about it. In one chapter on Laura Delano and psych med withdrawal, she writes about her own entry into the world of the ‘Lexapro girlies’, spurred by an onset of social anxiety.2

I was struck by the existential way her psychiatrist described what the drug might do for her:

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Crochet is portable, so when the heat subsided and I could leave the house again, I brought little projects with me everywhere. I found that it helped me pay attention in conversations, talk more freely in therapy, and cope with all kinds of anxiety.

By the winter, I’d crocheted myself into RSI territory, but I couldn’t stop, so I decided to switch up my hand movements and try a knitting class at my local yarn shop last weekend. It was sold out, which is not surprising — yarncrafts are having a renaissance in the algorithmic age.

They’ve been framed as a pandemic lockdown cope, an antidote to doom-scrolling, and a new way of making third places during an epidemic of loneliness. These are fine explanations, but I’m always curious about the psychology of it all. Why had I become obsessed with yarn, to the point of injury?

Knitting and crochet, in essence, are just different ways of making loops inside loops with one continuous thread, until it eventually becomes fabric. The patterns are repetitive, and one hand-knit sweater, for instance, can contain upwards of 70,000 stitches, taking anywhere from 20-40 hours. This might not seem like an ideal craft for someone with ADHD, but it holds me still like nothing else.

In knitting class, as I was struggling to make loops with two pointy wooden sticks, the teacher peered over my shoulder and said: “It’s harder if you think about it too much.”

By which she meant: you only learn to knit by letting your fingers figure it out. The embodied cognition researcher and ceramics artist Camilla Groth calls this ‘making sense through the hands.’

Making, for Groth, is ‘a form of thinking through actions, tools, things, and materials.’1 Lambros Malafouris, an archeologist who studies how materials affect the mind, has a sillier name for this — he calls it ‘thinging’:

“Cognition and emotion are not realized in the brain but with a brain; that is, to think and to feel, we need more than a brain. Brain regions work in concert, but they are never alone; rather, they are always parts of broader systems extending beyond skin and skull.”

Malafouris and Groth are working under a set of theories called 4E cognition, which considers the mind to not just be inside the brain, but embodied (thinking with the hands), embedded (limited and shaped by the environment), extended (into tools outside the body), and enacted (or, arising through action).

Malafouris thinks that psychiatry has largely ignored how people think with — not just about — things. He argues that objects can act as anchors, or ‘material scaffolds.’ For instance, in dementia, personal possessions can become ‘biographical objects’ that help a person remember their life and reinforce their sense of self; in schizophrenia, working with a material like clay can help ground someone in time.2

Maybe yarn had become a scaffold for me, too.

Attention-crafting

In 2023 the New York Times ran a story about disabled knitters, many of whom had ADHD. One woman, a county councilor who had started knitting to cope with chronic illness, was called out for knitting during a public meeting — an offended colleague thought she was being rude.

Most of the article goes on to explain why it isn’t, because knitting can actually help some people pay attention. They quote Dr. John Ratey (of Driven to Distraction fame):

“Being involved with something will make a person with flagging attention be more attentive,” Dr. Ratey said. “You will turn on the prefrontal cortex if you’re doing something like knitting.”

But from an embodied cognition perspective, I think it’s a bit deeper than just pressing the on-button of your prefrontal cortex.

If cognition is embodied, then knitting with your hands is not just helping your mind attend, it is your attention. The tactility, the shifting gaze up and down again, even the tools and the yarn, are all part of attention, extended and enacted. They create the structure and rhythm a person might need to attend.

Needing to do two things at once to focus on one is a very common topic in ADHD circles, but often it’s attributed to ‘getting dopamine’ — another explanation that considers attention to be solely an internal process in the brain, rather than an embodied, enacted one.

What if attending through movement is not just a hack into neurotypical attention, but a style of attention in its own right?

A study on crochet and attention published last year found that the craft improved alerting and orienting on the Attentional Network Test. Researchers hypothesized that this could be because the motor skills required by the craft strengthen connections with attention networks in the brain.

Similarly, doodling during class has been found to help students retain more information and get better grades, and for ADHD students in particular, using a fidget spinner has shown ‘large immediate and sustained’ increase in time spent on a task.

I also use crochet to help me attend, but it depends what I am crocheting. Some patterns are simple and automatic, which are ideal for attention-scaffolding.3 Anything that requires counting or referencing a pattern, though, takes up too much attention, and then I risk slipping into immersion and blocking out the rest of the world.

Yarn crafts are dual-natured — they can facilitate attention outward or inward, depending on the complexity of the pattern.

Life-crafting

In a paper titled Why Our Brains Love Arts and Crafts, Huotilainen et al also look to the theory of embodied cognition to explain how manipulating materials with our hands can affect our mental states.

They note that tactile sensations, like feeling yarn slide through your fingers, can be stimulating, improving awareness and attention outward, but they can also be grounding, which helps people with a lot of internal chatter calm down:

“..it may appear that ‘the body knows how to relax’ with the simple craft activity and may override the negative, arousing, threatening thought loops circulating in the conscious mind.”

In 2024, researchers analyzed posts in a Ravelry group for knitters with mental illnesses called Knitherapy. One user wrote:

“While my hands are busy doing something, my mind slows to a crawl, and I am actually able to think about one thing at a time… rather than having 20-30 threads all going at once.”

The members of Knitherapy discussed all kinds of ways that knitting provided scaffolding in their lives.

Some used it as an alternative to taking anxiety meds; others as ‘a preventative measure’ to stop ‘a downward spiral.’ Knitting was also a kind of ‘diary’ — they could remember what they were doing and how they felt when they were making a piece, because those memories got embedded into the work, not unlike Malafouris’s ‘biographical objects.’

Knitting ‘stood for security, safety, assurance, strength, and stability.’ It was something they ‘could control in life even when other things seemed unfair and out of control.’ Crafting improved their self-efficacy — their belief that they could have an effect on the world.

There’s a lot that is ‘unfair and out of control’ right now, both a reality and a sense amplified by time spent plugged into newsfeeds. As digital life further alienates us from our work and from each other, people turn to crafting because doing something with your hands changes how you feel, and what you think is possible.

In researching this, I came across a psychological concept called ‘life crafting’:

..the conscious efforts individuals exert to create meaning in their lives through (a) cognitively (re-)framing how they view life, (b) seeking social support systems to manage life challenges, and (c) actively seeking challenges to facilitate personal growth.

I realize the word ‘crafting’ here is figurative, but literal crafting also checks all these boxes.

It offers ‘a safe possibility for failure’ — a practice that teaches, through tactile experience, how necessary failing is for growth.4 It brings people together around an activity to skill-share and make friends,5 and it provides an endless array of challenges in the form of new techniques and projects.

From an embodied cognition perspective, yarncrafting is life-crafting, too.

Groth writes:

“When we touch a material, we simultaneously feel ourselves and become aware of ‘being’. In this sense, making can be considered a way of being in contact with oneself.”6

I don’t see this trend as one of personal retreat, though. Many of the studies I read about yarncraft and well-being discussed the intensely social nature of the hobby — craft circles are popping up everywhere, online and off. Yarn can also be a scaffold for social cohesion. People want to weave together.

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Further Reading:

• A New Practice: How to Start Knitting, Madison Moore

• How to Crochet For Absolute Beginners, Hopeful Turns

• Making Sense Through The Hands: Design and Craft Practice Analyzed as Embodied Cognition, Camilla Groth, 2017

• Knitting Two Together (K2tog), “If You Meet Another Knitter You Always Have a Friend”, Court, 2019

• Why our brains love arts and crafts: Implications of creative practices on psychophysical well-being, Huotilainen et al, 2018

• Re-thinging Embodied and Enactive Psychiatry: A Material Engagement Approach, Malafouris & Rohricht, 2024

• How Knitting Transformed The Ancient World, Dr. Smiti Nathan

• Joy in Labour: The Politicization of Craft from the Arts and Crafts Movement to Etsy, Krugh, 2014

• A great video essay on cosplay crafting, private equity, and the fall of JoAnn’s that made me cry a little!!!

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It’s not the first time I’ve asked about antidepressants. I brought it up with my doctor last year but told her I was scared, because I’ve been on the psych med rollercoaster before, and it sucked ass. The stimulants made me angry and mean. The mood stabilizers did not stabilize much of anything. The only ones I like are the benzodiazepines, but I’m not allowed to take those everyday.

She ordered me one of those genetic tests that tells you which drugs you’re likely to metabolize best, to at least narrow it down and spare me some failure, but when I read the privacy policy, it basically said “We can sell your genome to the CIA if we want to!”, so I got paranoid and never sent in my spit.

It took me six months working with a therapist before I got the hang of distinguishing my intrusive thoughts from my valid concerns, and then some practice tolerating a little bit of uncertainty, before I could ask about antidepressants again. Why was I so afraid of them?

Well, partly because I went through a phase of psych med skepticism, informed by some critics who I no longer agree with. Over the last few years, I’ve been changing my mind — I mentioned this briefly in my piece on Sami Timimi’s new book, but I thought a more detailed explanation of how my thinking has evolved over time might be useful for my paid subscribers. (Maybe your ideas have changed too, and we can compare notes.)

It takes a lot for everyone to change their minds, but especially me, because my mind gets stuck on stuff and doesn’t want to let go. The researcher Sarah Stein Lubrano argues that nobody changes their mind just from reading a logically sound argument — actually, it takes experiences.

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“The idea that there are two types of brains, one typical and one divergent, is ridiculous!”

And, yes it is! We agree! Neurodiversity, at its core, is just the idea that there’s infinite neurological variation the world. So, actually diametrically opposed to the idea that ‘there are two types of brains.’ Neurotypical and neurodivergent describe social positions, not biology.

But another thing I don’t think critics realize is that there is also a lot of diversity in thought about the concept of neurodiversity itself.

In a paper from May this year, ten neurodivergent researchers attempted to map some of that variation — they wanted to explore their own ideas about ‘what neurodiversity is,’ and ‘what neurodiversity should do.’ Using a tactic called Q methodology, they sorted 200 of their own statements about neurodiversity into three viewpoints for each question:

What is neurodiversity?

1. ‘a social justice movement that requires a critical analysis of power’ / ‘grounded in a critique of capitalism’ / ‘intersects with other rights-based social movements’ / ‘inherently political’ / neurodivergence can also be a disability / the term ‘neurodiversity’ has scientific meaning

2. a recognition of neurodivergent peoples’ rights and benefit to society / not critical of capitalism, and actually thinks this could be antagonistic to the goal of pluralism / disagrees that ‘neurodivergence itself can contribute to disability’ / considers the term neurodiversity ‘scientifically meaningless’

3. ‘scientific knowledge about different types of, equally valid, mind’ / not necessarily political / science should lead, and politics follow

What should neurodiversity do?

1. ‘Proudly support neurodivergent people’s rights to what we need to be active and productive members of society’ / ‘promote pride not shame’ / ‘Embracing our own ways of being social, and becoming visible on our own terms’ / support people’s ‘right to live in the community’ / invest public funds in support and education / ‘Not looking for cures’ / ‘Avoid overextending the category’ and ‘getting hung up on politically correct’ terms

2. Be ‘a radical movement for broad based societal change in alliance with other progressive political activists’ / ‘part of a broader anti-disablist, anti-racist, trans-inclusive activist movement’ / includes psychiatric disabilities as neurodivergent, whereas #1 does not

3. Focus on ‘genuine social inclusion’ / emphasizes ‘right to belong within society and not be excluded’ (ie through institutionalization) / does not tend to consider mental illness as neurodivergence, like #1, but does include intellectual disability / ‘falls somewhere between the ‘radicality’ of [2] and the ‘pragmatism’ of [1]’

All of these perspectives agreed that neurodiversity is ‘simultaneously a biological fact, a framework of values and a social movement,’ but there were genuine disagreements about who is included in the neurodivergent umbrella and what the political goals of the movement should be.

The social justice view considers autistic people, the mad and mentally ill, and the intellectually disabled to be united by a ‘shared social/political marginalization’, whereas the liberal rights view thinks this ‘risks watering down’ the focus on ‘recognising the needs of people living with known and observable developmental differences.’

Where the social justice view wants to change society in radical ways which would benefit more than just neurodivergent people (that include the structure of the economy, Sami!), the liberal rights view wants to focus on meeting the needs of neurodivergent people ‘to facilitate their productive contribution’ in society as it is.

It’s a familiar political fault line, one that critics on the left often gloss over when they reject neurodiversity as just idpol Canva infographic slop that is ‘gentrifying’ disability.

This frustrates me to no end, as someone who agrees that neurodiversity is a critique of power and capitalism, that the umbrella is wide, and that it should intersect with other movements seeking to change society.

For paid subscribers, a deeper dive into neurodiversity’s evolutions via three more papers that came out this year. The first one adds a dash of history, my favorite!

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At the beginning of the year, I started a series critiquing Russell Barkley’s concept of executive dysfunction, which I have (ironically, or I guess, fittingly), left unfinished. Digging into Andrew’s idea is part of that work, though, because I don’t think man can live on critique alone.

We need alternatives, other possibilities and avenues for sense-making, and I love this one because it takes ideas about ADHD that already exist and weaves them into something new. The response over on Youtube has already been really great — one commenter even said it made them tear up!!!

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Something that keeps surfacing in reactions to this idea is the question of how it relates to monotropism, the attention tunnel theory of autism that a lot of ADHDers also find relatable as hell. Personally I like both theories and see no issue stacking them on top of each other, but I do also see how they might seem totally opposite.

Univocity is a philosophical reframing of attention. In the neurotypical sense, attention is usually described in terms of parsing and prioritizing. You look around and select one thing to pay attention to, ignoring the other things in view. But univocity describes a style of attention where you can’t easily parse one thing out from all the other things.

It’s difficult to distinguish one thing from all the other things, but that doesn’t necessarily mean that you’re multi-tasking, or that your attention is broad. You could still be doing deep, monotropic dives into your interest(s), it’s just that you don’t really see that interest as separate and discrete from everything else.

Actually, psychology researchers think that nobody is truly multi-tasking, just task-switching, which takes a lot of brain energy. Monotropic people struggle more with switching tasks — it takes more energy to change tracks, because of the intensity with which they focus on something.

Similarly, a univocal style of attention would mean that you have to do extra cognitive work to parse and prioritize the attentional field, which you are experiencing as one unified stream. Maybe univocal could describe the philosophy of your attention, where monotropic could describe its intensity and explain your behavior.

The relationship between the two ideas is definitely something to ponder more! I think there’s room for multiple frameworks, and that, like Andrew says at the end of the video, there doesn’t have to be One Theory to Rule Them All.

Last month for my critique of Sami Timimi's work, I read a book on Kant, who said that every theory is an abstraction. Scientists abstract sensory information into concepts so we can understand it, but those abstractions can only ever approximate truth. Kant thought it wasn’t really possible to fully know the true nature of the world, because we have to filter it through our limited frameworks of thought.

ADHD, autism, neurotypical, monotropic, univocity — these are all just abstractions that help us make sense of the chaos that is conscious awareness. Theories are just tools, and you’re allowed to have a whole kit of them! Fill it with the ones you like the most!

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Other things connected to this thing:

In a global study from 2016, 5.8% of people reported having a psychotic experience at least once in their life, and 2% in the prior year. OpenAI’s most recent numbers claim that .07% of users each week show signs of either psychosis or mania, which is not really surprising in context. Actually, it seems a bit low!

All kinds of really ordinary stuff can trigger a psychotic experience — not getting enough sleep, taking certain drugs, being super stressed out, giving birth, losing a loved one, and even just spending 25 minutes in a sensory deprivation tank. Brains make patterns, so of course linking your brain up to a statistical prediction machine that can make patterns a million times faster than you can have some intense effects on your mind.

There’s a lot we don’t know about this phenomenon, though. Journalists have been calling it ‘AI psychosis’, but experts seem kind of annoyed by that term, because it’s not really the best description of what’s going on.

Almost all reported cases solely involve delusions (false beliefs), which is just one part of the psychosis constellation. And not everyone who’s experienced these delusions are using a pathological lens to understand it — for some, it’s akin to a spiritual experience or a psychedelic trip.

Quite a few papers have come out in the last few months on ‘AI psychosis’, so for paid subscribers, I’ve compiled a few of my favorites, supplemented with some good video essays, a lived-experience podcast project, and a relevant Mad Studies text.

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Timimi is a child psychiatrist in the UK who seems perpetually embarrassed of his own chosen profession. Why does he keep working in it, you have to wonder?? This man has never met a psychiatric diagnosis he liked, and he is working tirelessly to define mental illness out of semantic existence.

His previous titles include The Myth of Autism: Medicalising Men’s and Boys’ Social and Emotional Competence and Insane Medicine: How the Mental Health Industry Creates Damaging Treatment Traps and How you can Escape Them. I have not read these books, but I did once recommend a collection that he edited, Rethinking ADHD, because it was one of the only critical books on ADHD I could find.

After reading his new book, though, I have realized: critical for me means, let’s ask more questions about who gets to call the shots. Critical for Timimi means, if there’s not a specific biomarker that correlates with a specific diagnosis, then you’re all just having a collective hallucination!

So What Is Timimi’s Whole Deal?

If I had to pick a thesis statement in Searching for Normal, it would be this:

“Mental health ideology may be the biggest and most powerful cause of mental health problems today.”

In other words, the way that we think about mental health is actually giving us mental illness. ‘The problem is the problem’, he writes — we are all victims of a cursed tautology. What does he want instead?

“I call for a radical shift, a revolution no less, in which there will be no more use of psychiatric diagnoses, a dramatic decrease in the use of psychiatric medication, and the promotion to the public of a narrative that will help rehabilitate emotions back into the sphere of the ordinary and/or understandable.”

Timimi thinks that we have all been duped by psychiatry and neoliberal capitalism into believing that any negative emotion is a bad-feeling brain disease, and that what we really need to do is stop trying to control or get rid of those feelings, because they are ‘understandable human reactions’ to life in a capitalist hellscape.

Sure, that means we need ‘a more socialist-orientated economy,’ but that ‘by itself would not be sufficient’. We also need to change our mindsets, and learn to accept that suffering isn’t illness, it’s just a regular-degular part of life.

As an example, Timimi brings up his own struggle with insomnia, which is not a mental illness, but we’ll go with it:

“I used to get insomnia frequently and would struggle with it. Then one day my wife said, ‘You do like to make a fuss about your sleep.’ It was just a throwaway comment. It must have played on my mind because I recall a few days later having something of an emotional epiphany (I don’t know how else to describe it). I understood, at a level beyond language and intellect, that my struggle with insomnia was because I was struggling with insomnia. I understood how after a while insomnia causes insomnia, and to interrupt that process, I had to stop taking it so seriously and refrain from trying to find a solution to it.”

He decides that it’s fine, actually, and people don’t need that much sleep to function, anyway, because ‘people are resilient’ — which is definitely not ‘a flawed Western theory of suffering aligned with neoliberal ideology’!

Through his own recounting of case studies with young people in his practice, we learn that instead of diagnosing them or prescribing them medications, he gives them a little resilience training, and sometimes, unsolicited gender opinions.

In one scene, a trans, autistic, and ADHD college student named Andrew comes into his office looking to try medication. He’s having severe mood swings, and episodes of paranoia where he feels like he’s being stalked by a girl about his age.

Timimi ignores his request for meds and instead engages Andrew in a Socratic dialogue that was probably as annoying to experience as it was to read. He gives Andrew an etymology lesson about the word resilience,1 before suggesting that the girl he feels is stalking him could be his past female self who ‘wasn’t ready to die yet’ and ‘felt betrayed’.

At this, Andrew ‘seems shocked’, and then requests to see someone else. Good for him! Not sure why you would tell on yourself like that in your own book, unless of course, you never once stopped to consider you could possibly be wrong!

But that’s just some fun little color to warm you up for my cold hard analysis. (I promise I have serious analysis!) Come with me as we jump ahead to Chapter 12: NOW That’s What I Call Gender-Critical, Greatest Hits Edition.

Wait, no, I’m sorry: Neurodiversity, Gender, and New Human Typologies.

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Teaching Your (Autistic) Grandmother To Suck Eggs

In 2016, Timimi had an extended email debate with the critical autism studies scholar Damien Milton, in which he demands that Milton provide specific biological evidence for autism to justify his own identification with the term. He doesn’t understand why autistic people would use a word for themselves if there wasn’t a clear biomarker that showed it was actually a real thing (or, as the philosophers say, a ‘natural kind’).

Milton tells him that he knows autism is a social construct, he has been studying and publishing on it for years, but he still recognizes there are ‘dispositional’ differences in autistic people that translate into real struggles in life, and need some kind of label to make things like community-building, culture-making, knowledge-creating, and political organizing possible.

Timimi responds with like 800 word essays where you can almost hear him spitting his incredulity all over the keyboard, repeating his demand for biological evidence, reiterating that it has no essential nature, and arguing that, under neoliberalism, it is sold to the public as a ‘brand’.2

All of this Milton agrees with, at one point joking, “The term ‘teaching your grandmother to suck eggs’ springs to mind.”

As in, yeah, we know. Autistic people have been sucking these eggs a lot longer than you! Okay that’s a weird idiom,3 I’m going to switch to another one. You’re preaching to a choir that had the hymns memorized before you even graduated seminary!

This is, as you can imagine, supremely annoying. The most annoying thing ever, probably. What’s even more annoying is that, almost ten years later, Timimi still refuses to listen to input from the people in the categories he’s critiquing, and is instead expanding his argument to the scapegoat-du-jour: the transgenders.

Despite his ‘socialist-orientated’ leanings, Timimi makes a hard right turn at trans youth, citing the sketchy Cass Review against gender-affirming care in the UK, a Finnish doctor who practices conversion therapy, and the president of the anti-trans group Society for Evidence Based Gender Medicine.

He repeats fear-mongering rhetoric about ‘atrophied genitals’, suggests that ‘the construction of trans identity has emerged from ongoing homophobia’, and wonders if transition is just ‘an iteration of consumer capitalism’ urging people to re-invent themselves in order to be happy.

It’s aaaaall a neoliberal psy-op, basically, and those of us who identify as autistic or trans are victims who have been duped. Again, it doesn’t cross his mind that we could use psych labels and psych meds while also having critiques of psychiatry, or that there could be neurodivergent and/or transgender Marxists who despise the elite capture of identity politics as much as he does.

No, he’s really out here calling us sheeple in the subtext!

In A Critique of Critical Psychiatry, Robert Chapman is not surprised when diagnosis-criticals like Timimi turn on trans people:

“…the routine marginalization of both disabled and trans identities and voices follows much the same reasoning: each relies on the commitment that identities (whether gender or disability) must map on to biological essences to be real.”

Timimi’s argument hinges on the assumption that real = biological, and he says ‘the political problem’ for him is ‘disembodying the idea of ADHD or autism from any need for correspondence in material reality’. (Why this is a bigger political problem than structural ableism, state violence, and bodily autonomy, I do not know!)

He claims:

“Through social looping and contagion these constructs (ADHD, autism, neurodiversity, trans) come to be viewed as real, and become a naturalised category. This makes them ideal for commodification and profit mining.”

The Pokémon media franchise has made $113 billion dollars in revenue, which is like 10x more than the market share of autism (or something, I can’t do math), so not really sure how a thing being a natural kind makes it uniquely ideal for profit mining, but he suspects that ‘the profitability of gender-affirming care’ is driving the spread of trans identities like he suspects pharmaceutical sales are driving ADHD diagnoses.

This makes little sense when you look at what drugs are actually the most profitable. Psych meds and HRT don’t even make the top ten list this year — number one is Keytruda, a cancer drug, number two is Eliquis, a blood thinner, and number three is Ozempic. Yes, profit-mining our health is a huge problem, but it’s not unique to psychiatry or trans medicine, and it’s strange when your ‘socialist-orientated’ analysis doesn’t locate them inside this bigger picture.

How Many Ways Can A Thing Be Real?

Because science has not been able to pinpoint a specific biomarker that can differentiate autism or ADHD from the general population, that means, for Timimi, they cannot exist. We are merely ‘imagining it to be so’, and then it is ‘made real’.

Anti-trans types make a similar argument about trans people, claiming that chromosomes are the truest form of ‘biological reality’, and then accusing trans people of being totally divorced from it. But if you stop to think about this argument for like more than two seconds, it doesn’t make a ton of sense.

First of all, unless you work in a genetics lab, you will never directly interact with a chromosome. You only know it’s real because it’s a concept you learned about in science class. You can, however, directly interact with a trans person, whose real body and personality and behaviors you will really experience.

What, then, is more real? And what is a medical transition if not a direct reckoning with your own flesh?

As Chapman points out, the idea that mental illness doesn’t exist because psychiatry isn’t based on hard bio-facts like the rest of medicine comes from one Thomas Szasz, and it lives on in the work of many critical psychiatry figures from the UK.4

Even though I don’t think he shares Szasz’s right-wing politics, Timimi’s book is very clearly part of his intellectual tradition. He tries to paint psychiatry as a subjective branch of medicine that has unique problems with social injustices which other branches of medicine do not, because they’re objective and evidence-based.

But this is very plainly not true — all branches of medicine have been, and continue to be, all kinds of fucked up,5 because medicine is a human social practice, so it reflects social biases and injustices.

As an example, Timimi contrasts depression with the supposedly-objective diagnosis of diabetes. But, as Chapman writes, this is not a great argument, because ‘the concept of diabetes has continually fluctuated in relation to racialized biases’ and who gets diabetes is ‘still determined largely by factors related to race and class.’

When Timimi uses diabetes as an example of an objective medical diagnosis, he’s sanitizing the truth that all of healthcare under capitalism is an unjust, for-profit enterprise, in order to make it seem like mental illness is a myth. He also overlooks the fact that the structure of ableism exists independent of psychiatric diagnoses.

Psychiatry did not invent ableism by labelling people with mental illnesses. Historically, it offered a way to control and manage people who were already being disabled by the economic system’s demand for productive bodies.6

If we got rid of diagnostic categories tomorrow, ableism would remain — disabled people would still be more likely to get arrested, experience twice the violence,7 be more likely to live in poverty, and have much higher healthcare costs, but worse access to healthcare.8

All of this seems like some serious material reality to me, and we don’t really need a biomarker to know that these populations are experiencing it!

We do, unfortunately, need diagnoses if we want to access treatment and accommodations, so unless we, I don’t know, got stuff like universal basic income and truly socialized medicine, and designed a system where everyone could get the material support they needed without having to navigate some bureaucratic maze designed to deny as many resources as possible, deleting psychiatric diagnoses and calling them ordinary would only fan the already-raging flames of ableism.

Is it possible for diagnoses to be useful and scientifically rigorous without being tied to a specific biomarker? The autistic researcher Sam Fellowes thinks yes. This year, he put out a book called In Defence of Psychiatric Diagnoses,9 which draws on modern interpretations of Kant, an 18th century philosopher who was trying to settle an argument between the rationalists and the empiricists.

Rationalists said knowledge comes from thought, and empiricists said knowledge comes from the senses. Kant was like, obviously, it’s both, but also, the true nature of the world can’t really be known by us, because we have to apply our own constructs to our sensations so we can make them make sense. Fellowes writes:

“His clearest example is when he argues that things in themselves do not exist in space and time. Rather, space and time are imposed upon the world and we cannot help but see them as existing in space and time. Space and time are concepts we apply to the world…

..Any attempt to see things which exist outside us will require imposing space and time upon them. Consequently, we cannot see them as they are in themselves but only as they appear to us.”

For Fellowes and the Neo-Kantians, this applies to all of science. None of our models of the world reflect its true nature, because it’s all coming to us through the concepts we created to be able to understand the mish-mash of shapes, sounds, colors, and smells bombarding our brains:

“In relation to psychiatry, we see one person exhibiting one set of symptoms, a second person and a third person exhibiting different overlapping sets of symptoms, and unify these together by positing the psychiatric diagnosis of autism. We take different people and abstract those differences by unifying them under the thought object of autism. The legitimacy of unifying these different people under autism depends upon applying principles to the data. These principles are what convey scientific legitimacy to the thought objects (assuming that the data we apply the principles to is reliable) because the principles themselves are based in reason.”

Where Timimi thinks of diagnosis as scientific only if it’s based on a ‘causal and physiological framework’, Fellowes bases it on the systematic application of reason. But there’s another way of looking at them that doesn’t require an extended philosophy lesson.

Philosopher Sanneke de Haan frames diagnoses as ‘disorders of sense-making’. In a talk last year, she explained:

“..our sense making is no longer attuned to the situation but is stuck in a certain groove. If, for instance, we are anxious without the situation giving us any reason to be anxious, if we feel hopeless even when we do things that we normally enjoy, or if we see deeper meaning in coincidences like the letters on a driver’s plate, if our sense-making is biased in a certain direction, so to speak, and if this happens not just once but structurally, and if we or our loved ones suffer from this bias in our sense-making, then I think we can speak of a mental illness.”

This way of looking at mental illness includes brain chemicals without reducing a person to them, and it leaves a lot of room to consider their social context and personal history, but it’s meaningfully different than Timimi’s ‘understandable/ordinary human reaction’.

An ‘understandable reaction’ is a bad day, but an illness is a re-organization of your entire lifeworld.10 Collapsing all mental distress into the ordinary erases this difference and denies the reality of disablement.

Squishy Lenses

I don’t think the kids are brainwashed victims of ‘mental health ideology’. I think they are probably more critical than we give them credit for.

Some research bears this out. A 2020 paper by Linholm and Wickstrom explored how young people interact with labels like anxiety and depression, and what they found was that, although they use clinical words, when asked to explain what they meant, they didn’t talk about chemical imbalances, but instead social pressures:

“Rather than reproducing a sense that the battleground is inside young people’s heads, they locate the battleground in their social and structural context of managing school, their social relations, and norms and ideals of society and their peer groups.”

The authors point out that if teenagers are using diagnostic words in cultural ways, and adults are using them in medical ways, this could lead to a misunderstanding — adults focusing too much on clinical issues, when the kids are actually more worried about their social world.

In the metamodern age, we use multiple lenses at once, toggling between them like tabs in a grand narrative. I’ll give you an example from my own intellectual journey with anxiety.

At first, I placed the lens of ‘brain disorder’ over my life, but over time I found that it didn’t work for me. Discovering the neurodiversity movement made me realize I could take off that lens, and try on a new one. The autism lens and the ADHD lens clicked a lot of things into place.

Then I started getting into critical psychiatry, where I tried on the trauma lens and the human reaction to capitalism lens and the existential lens.

All of these lenses allowed me to view my anxiety in different ways, and learn new things about it. I had a deeper, more complex understanding, but anxiety was still dis-ordering my sense-making as much as ever. So this summer, I dusted off the brain disorder lens, and started seeing an OCD therapist.

But I didn’t so much circle back as I spiraled up, retaining all these lenses I acquired in my thought-detours. When my therapist tells me that I ‘have’ OCD, and asks me to speak about it like an entity in my head, I understand this now as a psychological technique, not a literal claim.

OCD is a lens I can use when it’s useful, but it doesn’t preclude all my other lenses, and it doesn’t make me a victim tricked by psychiatry into ignoring politics. It’s an imperfect, abstracted model, as all models in science are, but in concert with my other lenses, it’s helping me make sense of a disordered pattern and weave a new one.

If Timimi truly wants ‘a radical shift, a revolution no less’, dismissing mental illness as a myth is a mistake. The experience of illness puts you in personal, daily contact with ableism, which often reveals far more about politics than it obscures.

For some people, this could be the first thread they begin to pull, leading them to unravel the curtain that has hidden how capitalism and power are at work in their lives. If you tell them they’re just having ordinary reactions to life, to be resilient and get on with it, you could just be drawing that curtain closed.

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More in this series:

So, I reached out to Andrew and asked if he would be down to explain his work a bit for the class, and we had a really interesting chat last week.

I’m working on putting together a video about it now, but in the mean time, paid subscribers can scroll to the end for a short preview of our conversation. I would love to hear what ya’ll think about the theory as I work on this script!

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The Univocity of Attention is an attempt to explain what ADHD is, outside of the pathology paradigm, but in a way that also counters the critique that ADHD is just an overmedicalization of ‘normal human behaviors’.

Andrew argues that because ADHD behaviors are so similar to ‘the general state of humanity’ under capitalism, it’s vulnerable to skepticism and dismissal, as in: Everybody has a hard time concentrating now, because of those damn phones!

ADHDers tend to respond to these kinds of critiques by doubling down on biology and talking about genes and brain scans, but there are a couple problems with this:

1. reliable biomarkers for ADHD have yet to be found, which is an easy win for the skeptics’ argument1

2. it circles right back around to relying on psychiatry’s definition of ADHD, which is one of negation: ADHD is not normal function, it’s dysfunction, disinhibition, disorder. This leaves non-ADHD professionals in charge of defining ADHD, rather than ADHDers themselves.

So, is there a way to explain ADHD in the affirmative, not as a negation of ‘normal’ functioning, but as a way of functioning in its own right? That’s the problem Andrew tackles in his dissertation.

To start, he identifies misrecognition as ‘the predominant form of ADHD harm.’ He writes:

“ADHD individuals—as is the case for any disability—must create new norms for themselves to adapt to their environment.. When these new norms are not recognized by others, ADHD behaviours are inevitably misinterpreted or misread..”

This is different from stigma, which is more about the label itself causing scorn; misrecognition is like misreading the neurodivergent room.2

The neurodiversity movement has actually lessened the stigma of labels quite a bit, he argues, but it hasn’t done much to solve the problem of ADHD norms being misrecognized as character flaws.

Take, for example, the ADHD struggle with linear time. Neurotypicals tend to read my lateness as bad character, but my ADHD friends understand that time is a bit squishy. We all know that “come over for dinner at 6” means the chicken isn’t going in the oven until 7, and we just factor that into our plans.

Interpersonally, misrecognition might just mean losing friends who deeply value punctuality, but professionally, it can have worse consequences:

“In a study of career outcomes of ADHD individuals with a post-secondary degree, it was found that they are still at least twice as likely to be laid off (33% to 13%), 1.5 times as likely to be fired (61% to 43%), and earn $8,900-$15,400 (USD) less per annum than their non-ADHD counterparts of equal educational background.. They are also four times less likely to hold a “professional job” than those without ADHD who hold a similar degree..”3

Misrecognition is another problem The Univocity of Attention sets out to address by outlining an ‘ADHD logic’ that could help self-advocates more clearly explain what ADHD is and why a behavior relates to it, instead of just attributing it to Russell Barkley’s theory of executive dysfunction.

Actually, Andrew takes a bit of inspiration from Barkley’s theory, at least in its structure:

“Barkley begins with one basic deficit, and shows how it unfolds into another deficit; in turn, this second deficit unfolds back into the first deficit. Its end is also its beginning. The logic of ADHD, for Barkley, is this specific immanency, this specific giving-rise-to-itselfness.”

It’s kind of like a big ADHD ourobouros?

Barkley starts with disinhibition, which he says leads to working memory deficits, since a kid who doesn’t stop and think before acting is a kid who’s also not practicing their memory skills. This reinforces the disinhibition, which leads to problems with planning and goal-directed behaviors.4

This theory has been so successful in public discourse, Andrew argues, not because it’s actually ever been scientifically validated, but because it logically separates ADHD from ‘normal human behaviors’:

“Barkley’s theory shows, against the skeptics, how garden-variety distraction that every human experiences is not ADHD because it does not unfold from this specific, immanent process.”

Andrew’s theory attempts to do something similar, but by starting with attentional difference rather than dysfunction. ADHDers are being misread because we’re viewed through a neurotypical lens that understands attention as something that ‘must be stratified and prioritized’, but that might just not be how we attend.

Below, we talk about equivocity vs univocity of attention, and how the latter could offer an alternative explanation for commonly-discussed ADHD traits like high creativity and emotional dysregulation:

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I also could not find a history of POTS anywhere, so I made one — it starts at 20:08.

Here are a few of my favorite sources from the making of this video:

🔬Autonomic Neuroscience Special Issue on POTS, 2018

• This is a super comprehensive collection of papers on every aspect of POTS, from autoimmunity to headaches to stomach problems.

• I used this paper on the patient perspective in particular, because O’Sullivan’s argument that people are being made sick by diagnosis-run-amok doesn’t track with what POTS patients are actually experiencing, which is years of being symptomatic without a label, multiple misdiagnoses, severe lack of knowledgeable physicians, and traveling hundreds of miles to get care.

📖 Disjointed: Navigating the Diagnosis and Management of hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders, 2020, edited by Diana Jovin

• Tbh I didn’t really know much about hEDS before developing POTS, but it’s basically impossible to research POTS without also learning a bunch of stuff about hEDS, because they’re such ‘common co-travelers’.

• O’Sullivan is confused at how hEDS, POTS, MCAS, Chiari malformations, migraine, IBS, autism and ADHD could all be clustered together in so many of her young patients, and she even says that these patients are ‘a major reason’ she wrote a book arguing that overdiagnosis is making people psychosomatically sick!

• The Dysautonomia chapter of Disjointed offers a counter to this in the form of what pediatric cardiologist Andrew J. Maxwell calls ‘the Pentad super-syndrome’

  

• Maxwell proposes several ways these seemingly disconnected conditions could all be linked together and cause further issues. It’s speculative and definitely needs more research, but why wouldn’t you at least be a little bit curious about the possibility that there is something going on we just don’t understand yet, rather than concluding it must all be psychological?

📝 Long COVID Is Not a Functional Neurologic Disorder, Davenport et al, 2024

• A collection of the current evidence against the claim that LC is psychosomatic

• The authors actually list all the conditions from the pentad above as things that are commonly misdiagnosed through a psychosomatic lens.

• They argue that ‘two divergent scholarly and clinical paths’ began with the diagnosis of neurasthenia in the 19th century. One, focused on biology, produced the diagnosis of ME/CFS, and the other, focused on psychology, led to Functional Neurologic Disorder.

📝 Defining the Chronic Complexities of hEDS and HSD: A Global Survey of Diagnostic Challenges, Life-Long Comorbidities, and Unmet Needs, Daylor et al, 2025

• One of the most interesting things I learned at the Dysautonomia Conference this year is that a lot of people with hEDS can recall a ‘triggering event’ that either kicked off or worsened their symptoms — 70%, according to this paper!

• The researchers wonder if thinking of hEDS strictly as a connective tissue disorder is missing the bigger picture, as the most-reported symptoms go far beyond joint issues, encompassing a ‘high prevalence of immune, neurological, gastrointestinal, and autonomic dysfunctions’

There are a lot of bits and pieces in the video from stuff I’ve written this year, so if you want to retrace my steps, check out these posts:

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It starts with heaviness, like my insides are made of ultra-dense rock.

A distance stretches out between me and the world. Comprehension ceases. Despair drops in, then those physically painful, full-body sobs. I start to think about where all the knives are in the house, dig my fingernails into my arm instead.

This lasts from thirty minutes to an hour, and I tend to find the nearest bathroom, turn off the lights, and lay on the cold tile until I’ve cried so much that I am tired enough to sleep. I wake up the next day feeling like I’ve been hit by a bus.

It’s not exactly a panic attack — I’ve had those too, and there’s a difference (numb hands and face, that rollercoaster drop feeling in your stomach). But the suddenness is very similar, and benzodiazepines help, too, so I call them sad attacks.

I’ve been having sad attacks since I was young, but managed to hide them from almost everyone except my live-in partners. When I finally started seeing psychiatrists in my late 20’s, I felt if I just told them everything, if I just gave them enough information, they would know what to do.

But actually, none of them knew what the fuck I was talking about.

I wondered if it had anything to do with being autistic, so one day I googled ‘autism sad attack reddit’, and a post came up titled Who has heard of depression attacks?

A depression attack (as mention to date only reported amongst autistics, and only recently), is much like a panic or anxiety attack but with despair. A very accute, very intense state of depression. As such is dangerous. Even though usually only around 30mins in duration, the individual is at high risk of self harm or an impulsive suicide attempt (ie: no planning or means). From my own experience and those I've heard from other most of us isolate and spend the attack fighting the desire to end it all. After it passes you feel back to normal so really easily mistaken as being attention seeking or overly dramatic if you try to get help in the moment or discuss it after. Obviously, this makes future attacks even more dangerous because you don't seek help. Verbal and aural communication becomes virtually impossible. It also seems most people don't remember much afterwards. They know they had one but if someone asked what someone said to you and your response the memory just doesn't seem to be there. Written communication doesn't seem to be affected in the same way as verbal. Though anything much beyond yes/no questions still may be a problem.

In a follow-up post, OP attributes the concept to the British autism researcher Tony Attwood,1 who wrote a CBT self-help book in 2016 for autistic people struggling with depression.

Attwood writes that the depression attack2 could be caused by a combination of suppressing emotion and struggling to be aware of your own feelings, which then build up and acutely explode:

“…there is no prior warning. The overwhelming despair may occur as a catastrophic emotional overreaction to what appears to be a relatively innocuous negative experience, such as making a minor mistake, being late or being teased. However, there may have been a backlog or build-up of despair over a long time that was not cognitively recognized by autistic adult or others. This final, simple event or trigger releases the pressure that has been building for so long. The cap could not stay on the bottle any longer. The resulting conspicuous despair is very deep and genuine, and entirely unanticipated.”

I did some more digging, and found that Attwood is not the only doctor to notice this phenomenon.

A Japanese psychiatrist named Hosinobu Kaiya had a similar idea in 2016. He wrote up a case study of five patients who suffered from what he called ‘anxious-depressive attacks’, which one subject described like this:

“I was attacked by a sudden emergence of loneliness and sadness without any reason, followed by bad memories from the past. My mind was occupied by an idea that I must pay for my sins with my death. I felt my heart pounding. I was looking at my left wrist and visualizing myself cutting it. The image made me cry aloud “No! No! No!” I began to feel that I was nearly going mad.”

There is no mention of autism, although some of the cases describe what many would recognize as autistic traits:

• “As an infant, she…exhibited severe fear of strangers. In junior high school, she experienced social anxiety, avoided public speaking, and was ridiculed by her classmates.”

• “she had a tendency to develop social and generalized anxiety and had trouble in adjusting to her surroundings”

• “she coped with the [attack]…by going through her favorite books”

Kaiya writes that the anxious-depressive attack consists of three things, in order:

“sudden outbursts of negative emotions incongruent to the conditions of the place, rumination of intruding unpleasant memories, and finally, behavioral reactions to these painful feelings and thoughts, including self-harm.”

He also notes that, while patients rarely bring up these attacks, when asked directly if they experience them, it’s not uncommon, affecting 43% of patients in the anxiety clinics where he conducted his research.

Rumination is a central feature of Kaiya’s anxious-depressive attacks, and in more recent work, he has also linked them to rejection sensitivity. Contrary to the claim that it’s unique to autistic people, Kaiya writes that it’s ‘trans-diagnostically seen’ in everything from depression to OCD to schizophrenia.

I always hesitate to say something is unique to autistic people, since human behavior exists on a continuum, and we are just humans, after all — but if sad attacks are tied to rumination, it would make a lot of sense that people with sticky, perseverative brains are more likely to experience them.

Over the years, I’ve learned to distract and sedate myself to cope with sad attacks instead of self-destructing.3 This is more or less the advice that Attwood gives when he recommends making a safety plan for these dangerous attacks of sudden despair:

• reach out to someone so you’re not alone

• use a special interest as ‘an off-switch’ for the sad attack

• retreat to a safe, quiet place

• give yourself time to move through and process the emotions

He also includes a few recommendations for supporting someone through a sad attack:

• don’t try to make conversation

• don’t try to fix it

• don’t ask what’s causing it

• validate and listen

• remind them that it will pass soon

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Three Mental Illness Memoirs To Read Instead of Unshrunk

In March I critiqued Unshrunk by Laura Delano, and it has so far been one of my most popular posts of the year.

Since I personally love the mental illness subgenre of memoir, I thought I would follow up with a few favorites from my shelf that offer some interesting counterweights to Delano’s work, too.

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Last year I wrote a piece about why we scroll that touched on the theory of the predictive brain, which says that the brain doesn’t just react to the world, it’s actively creating models that predict it, top-down-like.

I wondered how this theory would apply to autistic people, who are said to process bottom-up. Well, this week I came across a book-length answer to that question:

Basically: uncertainty sucks. We all want to know what the weather is going to be like tomorrow,1 and predictions are the brain’s way of coping with the excruciating uncertainty of being conscious.

The predictive brain theory is kinda hard to grasp at first because it goes against our old input-output computer metaphors for the brain, according to Vermeulen, who prefers sports metaphors instead.

In tennis, for instance, the ball moves too fast across the court for a player to see where it’s going and then react to it; instead, they must predict where it’s going first.

As the theory goes, this is basically what our brains are doing all the time about everything — predict first, then react to errors in our predictions by updating our models of the world. These models are generalized — like, most of the time when the ball is hit from that angle, it goes over there, but sometimes there’s a fluke, and it flies off in a different direction.

Not every prediction error warrants a change to the model — sometimes a fluke is just a fluke. But Vermeulen argues that autistic people have trouble disregarding prediction errors when they’re not important — instead, everything is relevant and warrants an update to the model, which means that we can end up with super specific models that don’t generalize well (aka ‘rigid thinking’).

According to Vermeulen, where allistic people tend to rely on their predictive models when perceiving the world, autistic people rely on sensory information — we ‘first see, then believe’.

This can sometimes be a good thing — it means autistic people are often less biased,2 more logical, and more accurate in our observations3 — but it’s also overwhelming, and way, way less efficient. Sluggy as hell, if you will.

It means that we need more time to adjust, and we get stuck bouncing around in a perpetual stew of prediction errors that most people just ignore. This makes the world seem ‘far more VUCA4 – volatile, uncertain, complex and ambiguous’.

And you might say, well, the world is volatile, uncertain, complex and ambiguous, so that’s just correct! And I agree! But being confronted by this fact all day long is very stressful! The illusion of predictability shields most people from this ‘uncertainty stress’, as Vermeulen calls it.5

This is an idea about autism from someone who is not autistic, so I am sure there are critiques to be made, but I appreciate Vermeulen’s insistence that the way to help autistics with uncertainty stress is not some kind of special brain training or whatever — it’s just giving autistics more details, and where possible, more control over our sensory world:6

“It should also be remembered that offering certainty and predictability requires almost no time and no effort. You don’t need to follow an expensive training course to be able to do it. In fact, anyone can do it. And you can do it anywhere. What’s more, it benefits everyone, and not just people with autism.”

Next up, a very important history lesson, as public discourse continues to entertain the idea that Long Covid is psychosomatic:

📝 From Long Flu to Long Covid: A Brief History of Post-Viral Illness by Emily Mendenhall and Philip Finkelstein

• The first widespread recognition of post-viral neurological effects was ‘influenza nervosa’ in the Victorian era (although post-viral illness had been described waaay before that by Hippocrates)

• There was also a massive spike in post-viral illness across the world after the Spanish Flu of 1918, but one historian argues that nobody remembers it because it got overshadowed by World War I

• Post-viral illness also appeared during polio times in 1934, when a fatiguing illness took out a bunch of medical staff in LA. Most were women, and some were TREATED WITH HYSTERECTOMIES dEAR GOD.

• In the 50’s, there was the famous Royal Free outbreak in a London hospital, where Dr. Melvin Ramsay argued it was a viral issue, and the term myalgic encephalomyelitis was introduced.

• But then, in the 70’s, a couple of psychiatrists shot back, arguing that it was all just a mass hysteria. This is a debate that survives to this day, such as in my hateread of 2025!

• “Society cannot afford to dismiss long COVID as a niche or exaggerated condition, or ignore its striking parallels to the secondary symptoms of the Spanish flu and postviral syndromes that have emerged throughout the centuries.”

I touched briefly on the term ‘medical gaslighting’ in a recent post after finding that it’s a top concern for patients this year. But what is it, and how does it happen? Here’s a deeper dive:

📝 Medical gaslighting as a mechanism for medical trauma, Devora Shapiro & Anna Hayburn, 2024

• This paper presents two case studies (both of whom have POTS!) to illustrate the traumatic effects of being dismissed by medical providers. TLDR, they argue that including medical trauma under the PTSD umbrella could improve care.

• One case is overt — a patient overheard a doctor accusing them of faking — while the other case is more subtle, illustrating how a patient with a difficult-to-diagnose condition can end up with the label of ‘factitious disorder’ in their records, leading to a pattern of suspicion and dismissal in their encounters with the healthcare system

• The authors argue that this is not merely personal harm, but an example of ‘testimonial injustice’ — a term from the philosopher Miranda Fricker for when a person’s credibility is viewed as suspect because of their gender, race, disability, class, etc.

• “..medical gaslighting is the process of chipping away at the testimonial authority of the patient’s experience in the context of the medical encounter, as legitimately ill and in need of medical treatment.”

• This can lead to medical trauma, causing ‘significant anxiety, anger, irritability, hesitation, and/or guardedness when engaging with medical providers’ and ‘may lead patients to avoid health care associated tasks or services’

• “Each time a patient presents with difficult to diagnose symptoms, or they are misdiagnosed and consequently fail to respond to treatment, trust in their accounting of symptoms may decline; when a patient presents again with similar complaints, rather than suppose the medical institution has failed to identify and treat the patient’s problems, providers may instead assume the patient has failed to comply with treatment, or exaggerated their symptoms.”

• “…the patient’s gaslighting is the result of more than any individual provider: it is the product of a complex network of knowledge-producing structures (medical institutions and authorities), which culminates in an institutionally supported narrative that the patient’s limited testimonial authority is unable to counter.”

📝 Experiences of Autistic Joy, Elliot Wassell, 2024

• Autistic4autistic research that adds a necessary counterweight to the focus on disaster and pain that is usually found in both autism research and public discourse

• Autistic people frequently discuss and write about their joy, but this can be seen as proof that they aren’t really autistic, because in the public imagination, autism = bad bad pain/tragedy: “..as Yergeau argues, autistic people are often stereotyped and essentialised and face a rhetorical double bind whereby if they enjoy being autistic then they cannot really be autistic.”

• Wassell asked autistic participants about their experiences of joy, sources of which include: sensation, repetition, and complete absorption

• Participants said ‘the people and place need to be right’ to experience such joy; to be in control, to feel safe, and sometimes to be alone

• Participant 28: “I think one of the easiest, zero-cost things that neurotypicals can do to support autistic joy is to TRULY accept that our ‘special interests’/passions give us happiness and fulfilment to a degree that simply does not exist for neurotypicals. No matter how ‘weird’, ‘age inappropriate’, or ‘useless’ our passions might seem to them, for us, this is what makes life worth living. Autistic people shouldn’t have to hide our special interests.”

Vermeulen calls special interests ‘islands of predictability in an ocean of uncertainty.’ Currently mine is making tiny knots over and over and over again until they look like plants:

3

ok this is a really interesting example, from a study where they asked allistic and autistic kids to identify emotions in images where they didn’t match the context:

Apparently most of the neurotypical kids in the study said this woman is happy, because that is the expected context of Christmas!!! whereas 7 out of 10 autistic kids accurately identified her as sad, because that is what the visual information of her facial expression is giving us.

Earlier this week, he made an appearance on FOX Business, where he brought the host a carrot cake to celebrate the 60th anniversary of Medicaid — a perfect symbol of how the Right is sugarcoating the cruelty of Trump’s reconciliation bill, which is projected to strip millions of poor and disabled people of their healthcare while pouring billions of dollars into a secret federal police force that is kidnapping our neighbors.

Here’s the gist of his insidious spin: Oz claims that he loves Medicaid, that Medicaid is precious, and that it must be protected from ‘fraud, waste, and abuse’ — all the ‘able-bodied people’ on Medicaid who he claims are spending ‘6.1 hours a day’ playing video games and watching TV.

In order to preserve our noble and righteous Medicaid, they had to create what he brands a ‘community engagement’ requirement — 80 hours of work, school, or volunteering per month to keep your healthcare. They’re not cutting Medicare at all (he lies) — actually, they’re going to spend $200 billion more dollars on it!

It’s unclear where he got this number, but it doesn’t match the Congressional Budget Office’s projections, which show a reduction in spending to the tune of $1 trillion. Maybe he’s doing that annoying thing where you argue from a technicality because you know that, in general, you’re wrong?

They’re not cutting by directly pulling funds from Medicaid, but rather by weaponizing paperwork — or, in bureaucracy-speak: ‘procedural disenrollment’.

Medicare recipients will have to prove their 80 hours of work per month twice a year to keep their healthcare. Administrative burdens like this have previously shown to produce high rates of disenrollment from Medicaid, either because people miss their deadlines, or because their cases close automatically while agencies lag behind under backlogs of paperwork.

Also: most people on Medicaid have jobs. Oz’s ‘able-bodied people’ playing video games for ‘6.1 hours per day’ comes from a post by the conservative think tank AEI, and he actually couldn’t even get the figure right. The study found 6.1 hours was the time spent on all socializing, where TV and video games accounted for 4.2 hours. But that’s not even the worst part!

Four public health experts responded to AEI’s analysis by saying it ‘contains a basic flaw that makes its findings and conclusions virtually useless.’

The dataset only included people who receive SSI — which automatically qualifies a person for Medicaid in most states — but also only represents ‘about 14% of low-income individuals with disabling conditions’. SSI is very hard to qualify for, and many disabled people who can’t work but do receive Medicaid are not on SSI.

Also, some people on SSI work, too. Also, it is possible to play 6 hours of video games a day while having a job!2 This stat is just bullshit spin with bad numbers that scapegoats poor and disabled people. The goofiest part of this interview, though, is when Oz fumbles over his little ‘MAHA Medicake’:

“We’ll be there for you, the American people, when you need help with Medicaid and Medicare, but you have to stay healthy as well, be vital, do the most you can do to really live up to the potential — your God-given potential — to live a full and healthy life. Don’t eat carrot cake.”

The host laughs in confusion. “[But] that’s what you’ve given me!”

Bringing Back Health Patriotism

Urging people to change their eating habits for God and Country is actually an old American tradition. In Modern Food, Moral Food, historian Helen Zoe Veit dug through 380,000 letters that Americans had sent to the US Food Administration in the late 1910’s to understand historical attitudes about food, and what she found tells us a lot about the rhetoric Oz is calling up once again.

The US Food Administration was a temporary agency created by Woodrow Wilson in order to export food to European allies whose enemies were trying to starve them out during the first World War. They needed to send stuff that kept well in a transatlantic trip and was nutrient-dense, so they focused on creating a surplus of ‘beef, pork, white flour, butter, and sugar’ by propagandizing the American public to forgo these foods and eat alternatives.

Veit writes:

“Administrators asked Americans to eat one meatless—meaning no red meat—and one wheatless meal each day, and to observe a completely meatless day on Tuesday, a porkless day on Saturday, and a wheatless day on Monday. Wartime pamphlets, posters, and cookbooks instructed Americans how to cook and eat what were to many people unfamiliar wartime substitutes like oatmeal, peanut butter, skim milk, cottage cheese, and pasta.”

Even though the government had the legal power to impose rations, they chose to encourage voluntary food conservation instead by tying it to morality and patriotic duty. This was seen as a kind of American exceptionalism — European nations had to enforce their rations, whereas Americans had the self-control to do it of their own accord.

Much of this food propaganda was directed at housewives, who were seen as serving a noble function in feeding the nation’s children. While wealthy white women wrote into the agency demanding ration cards that told them what to cook, poor and working class letter-writers mocked rationing as a privilege they couldn’t afford:

“The choice to live more ascetically was a luxury, and the notion of righteous food conservation struck those with nothing to save as a cruel joke.”

This rhetoric was also tied to the temperance movement, which spread the message that using wheat to make alcohol during wartime was a shameful waste. The idea that Americans had become soft, gluttonous, over-indulgers was everywhere during the Progressive era (as it still is now!), and making better food choices was seen as a way to be an honorable, patriotic citizen:

Hoover wrote a special message to Americans telling them to “go back” to a simpler way of living, one he implied that they had recently abandoned:

“Go back to the simple life, / Be contented with simple food, / Simple pleasures, simple clothes. / Work hard, pray hard, play hard.”

In a 21st century echo of this Progressive era propaganda, Oz told Dasha Burns of Politico that their ‘major goal’ is to get moms ‘energized’ to ‘get their kids healthy’. He has previously stated that he believes educating people about nutrition and walking 20 minutes a day are the best ways to achieve that patriotic healthiness.

But do these messages of personal responsibility really make people healthier? Cayce J. Hook and Hazel Rose Markus don’t think so. In a 2020 paper, they argued that they actually make people sicker by increasing their stress over controlling health problems that individuals cannot fully control. They write:

“Many everyday environments in the United States make healthy behaviors difficult, expensive, time-consuming, or counternormative, whereas unhealthy behaviors are often cheap, convenient, widely promoted, and normative..”

Take walking 20 minutes a day, for example. American towns have been designed to be car-centric, making their infrastructure hostile and dangerous for pedestrians.

And, just as choosing to eat fish and cheese instead of beef and flour was financially out of reach for many poor Americans during World War I, all the food nutrition in the world means nothing if you live in a food desert or a food swamp, or you have no money for groceries because Dr. Oz and co. cut food stamps, too.

Hook and Markus explain that a culture of personal responsibility limits the health policies that can be enacted to simply providing more information and more choices — two pillars of the MAHA movement. These policies ‘may help the rich get richer’, as ‘education campaigns tend to disproportionately benefit people with the greatest education and financial resources’.3

More choices are not necessarily good for you — they can actually increase anxiety, causing people to ‘agonize over decisions’ and to tie their choices to their identities, raising the stakes of every decision.

Telling the chronically ill to eat less cake for America is absurd, but health patriotism endures across the ages because it allows policymakers to project a facade of concern about real social problems, while shifting the responsibility for those problems onto you.

Responsibility is part of your personal health, but it’s far from the only thing that determines it. Your health is inseparable from everyone around you, and as Hook and Markus emphasize, it’s not just your own life that you have the agency to change, but the society that you live in, too.

For paid slugscribers this week:

Um, shit is bad! You probably don’t need me to count the ways — I’m sure you’re overwhelmed by all the shitty news on your feeds, too. So instead, here’s a few ways I am coping — personally, politically, and existentially — with this current, terrible moment.

Read more

I once polled my audience and a reader asked if I would do round-ups but for research papers, and I thought that was a very good idea, since I am always sifting through papers for some reason or another and finding interesting stuff.

These aren’t necessarily going to be new papers, although some might be, but, you know..

Do Stims Make Your Brain More Wrinkly?

I haven’t done a social media debunk in a while and I know it’s always a crowd-pleaser, so here we go: this video came across my fyp recently, claiming that a new study has now proven that ADHD meds “can actually improve brain structure.”

This is not really what the study found or what the researchers concluded, and I actually had a very different takeaway after reading through it. The study is called:

📝 How psychostimulant treatment changes the brain morphometry in adults with ADHD, Ghozy et al, 2025

• Researchers pulled the brain scans of 26 ADHD adults from a pre-existing database. Half of them had been treated with stimulants, and half had never taken them — they compared these groups’ brain scans and symptom scores.

• The group of 13 people that had taken stimulants included three different types, various dosages, and also different durations, from 1-5 years.

• They found that the medicated group had more wrinkles in their brains (higher gyrification index), deeper wrinkles (increased sulcal depth), and more complex shapes on their brain surface in the frontal lobe (higher fractal dimension).

• But, the untreated group also had more complex brain surface shapes, just in a different part of their brains.

• The only clinical difference they found was higher ‘venturesomeness’1 in the untreated group.

• Despite finding differences in the brains of the medicated group, they did not find any changes in their symptom scores.

This is a crucial point that the researchers state in their abstract, but the creator failed to mention. They suggest showing this study to people who argue that ADHD medication is ‘bad for the brain’, but I actually think that could hurt your case, because this particular study found that stimulants were associated with brain differences, but not improved symptoms!

Which, of course, doesn’t mean they’re not extremely helpful for some people, sometimes!2 But it makes me think of something Awais Aftab wrote recently about this:

Don’t take stimulant medications because you believe that you have a defective brain and you need the medications to fix that. That’s a terrible reason to stay on stimulants! If you were told that by a clinician, you were told an oversimplified story that you should give up. Take stimulants if they meaningfully improve your life and allow you to function better — regardless of whether ADHD is a “medical disorder.” Take them as long as they do, and if you find that your life is better without them, that’s okay.

What is ADHD Consciousness?

While we’re on the subject, I found this ADHD4ADHD theory very interesting. It’s by a psychotherapist with ADHD, and it’s an alternative to deficit-based, cognitive behavioral theories based on interviews with ADHDers about their experiences:

📝 The Creative Awareness Theory: A Grounded Theory Study of Inherent Self-Regulation in Attention Deficit Hyperactivity Disorder, Champ et al, 2024

• Champ found that the ADHDers she spoke to described being in constant motion between two states: chaotic attention and hyper focus: “..it was difficult for them to describe one state without relation to the other.”3

• The paper outlines three different self-regulation strategies that are used to navigate these two states of ‘ADHD consciousness’: self-absorption, self-transcendence, and creative awareness

• Self-absorption strategies try to deal with chaotic attention through masking and (maladaptive) coping mechanisms

• There’s a sense of the self as ‘dysfunctional’, ‘broken’, ‘ a failure’, lots of ‘self-blame, shame, and rumination’, and ‘anxieties around rejection and lack of hope’

• “Participants aimed to gain a sense of self-control by actively engaging in negative self-criticism, withdrawal, and isolation”

• While these strategies do sometimes help manage chaotic attention, they cost a lot of energy and harm a person’s self-esteem

• Self-transcendence strategies attempt to deal with hyperfocus by letting it take over and using it to finish tasks, or relying on ‘crisis generation’ like deadlines or high-pressure situations for motivation.

• This can lead to crashes, overwork, and self-neglect (ie not eating or peeing because you’re stuck in the focus tunnel). These strategies also use up a lot of energy and neglect a person’s needs.

• Creative awareness strategies exist in the sweet spot between self-absorption and self-transcendence, basically becoming aware of ADHD traits and learning to accept them, using curiosity and mindfulness as tools to navigate the two poles of attention, and developing an ‘authentic inner compass’ in order to cultivate intrinsic motivation, not goals that come from outside.

How Does Chronic Illness Change Your Life?

Intellectually, I’ve been on a bit of a chronic illness kick lately (coping mechanism), and in a book on contested illness I explored last week for paid slugscribers, I discovered the work of disabled philosopher S. Kay Toombs, who writes about how chronic illness is fundamentally different from acute illness, and what that means for the doctor-patient relationship:

📝 The Metamorphosis: The Nature of Chronic Illness and Its Challenge to Medicine, S. Kay Toombs, 1993

• In chronic illness, ‘the body opposes the self’

• Most of the time we don’t have to think about our bodies, but in chronic illness, you gotta think about your body everyday. There is a sense of being ‘inescapably embodied’.

• Toombs argues that chronic illness is different from acute illness because it is a kind of metamorphosis where ‘the experience of bodily disruption becomes one’s normal expectation and non-disruptive moments appear as only fleeting anomalies’

• Chronic illness disrupts both space and time: ‘One can never be certain, from one day to the next, as to the extent of one’s physical capabilities’

• In acute illness, disease is seen as an ‘external threat’ that has to be ‘defeated and banished’, but this doesn’t work for chronic illness, where disease ‘becomes an intrinsic element of one’s being’

• “The goal for chronically ill patients is to learn to live disordered lives”

• Chronic illness also challenges the typical doctor-patient relationship, where a patient gives control over to the doctor to heal them. Patients often have had to learn a lot about their bodies and their illnesses, which means ‘each must trust the other’s knowledge as they work together in the therapeutic endeavor’

• “Healing is a mutual act”

• Toombs recommends that doctors don’t just focus on the disease process, but that they also ask patients questions about their ‘life-world disruption’ (ie ‘what is the most difficult aspect of your illness?’ and ‘what do you fear most about this illness?’)

• These conversations can be therapeutic, because they can prevent the patient from feeling ‘abandoned’ by medicine or ‘beyond help’

Okay, that’s it, short and sweet and full of bullet points like a newsletter is supposed to be. Let me know if you like this segment, and I’ll keep doing them!

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