Diagnosis Is Dimensional, Not Binary
ADHD and PTSD are not entities you have or do not have — they are surface phenomena on a continuum, and the labels are artefacts.
- Difficulty
- Easy
- Time to result
- ~weeks to results
- Steps
- 4
- Confidence
- 92%
Confronted with the surge in ADHD diagnoses — roughly 11% of US children aged 3 to 17 by 2022, a twentyfold rise in UK adult diagnoses between 2000 and 2018, a near 300% rise in Australian medication over a decade — van der Kolk reframes the entire question. These are not binary conditions. The capacity to focus, pay attention and be flexible in attention is dimensional: some people cannot sit still at all, others can under certain conditions. Underneath the same surface behaviour sit many possible causes — genetic, toxic exposure in utero, or trauma, and he notes that just about every traumatised child he has seen meets ADHD criteria because trauma wrecks the capacity to focus. So ADHD is not an entity like a gallbladder cancer or an astrocytoma; it is a network-level way of organising the mind, and the diagnostic system, he says flatly, sucks. He should know: he helped create the DSM in a minor role and describes it as an artefact of people sitting in a room forty years ago making up little lists, with no scientific validity, PTSD being among the more reliable of them. His explanation for why the field has not moved on is institutional rather than scientific: the focus is not on helping people but on funding successful financial organisations.
Origin
Bartlett raises his own ADHD diagnosis and observes that other diagnosed people have drastically different symptoms — he can focus intensely for long periods on things that interest him. Van der Kolk validates the confusion, saying everybody serious about this knows the diagnostic system totally sucks, and recounts an insurance-company head who told him privately he was not interested in getting people better but in maximising subscribers.
Core principles
- 01Attention capacity is dimensional, not binary.
- 02The same surface behaviour has genetic, toxic and traumatic causes.
- 03Almost every traumatised child meets ADHD criteria.
- 04These configurations are not stable — people grow out of and through them.
- 05The DSM is a forty-year-old artefact with little scientific validity.
- 06The obstacle to updating it is financial, not scientific.
How to run it
- 1
Ask what dimension is affected, not which box applies
Van der Kolk's replacement questions are functional: how well is your brain able to filter out irrelevant information, how well is it able to be still and quiet, how well are you able to take on a task and complete it.
Pro tip Functional questions produce targets that can actually be trained.
Watch out A label produces no intervention target, which is why he calls labels little crutches that never quite capture the suffering.
- 2
Enumerate the possible causes
He refuses Gabor Maté's framing that ADHD is specifically a response to early childhood stress, saying it could be genetic, could be toxic, could be trauma. His own son met ADHD criteria without being particularly traumatised — real organic issues, which he later outgrew.
Pro tip Multi-factorial framing keeps both the biological and the relational routes open.
Watch out Collapsing all attention problems into trauma is as reductive as collapsing them all into genetics.
- 3
Treat the brain organisation, not the label
His neurofeedback framing generalises: this is not about trauma, it is about brain organisation. Trauma leads to disorganisation, but you treat the disorganisation.
Pro tip His concrete example: when you close your eyes the back of the brain should produce slow, peaceful waves; in traumatised people it produces faster ones, generating agitation.
Watch out Targeting the diagnosis rather than the measurable dysfunction leaves you with nothing to train.
- 4
Expect configurations to change
Van der Kolk insists these things are not stable — they are configurations you can grow with over time, surface phenomena rather than fixed entities. His son's profile changed substantially.
Pro tip Both his children turned out to be very different people from who he thought they were.
Watch out A permanent-identity reading of a diagnosis forecloses the change the evidence says is normal.
In the wild
Van der Kolk's son was neuroatypical, very out of control, highly reactive, bright, staying in bed playing computer games. People wanted to put him on medication, but van der Kolk was a psychopharmacologist who had studied the drugs and could see they were not helping.
→ Because he was a doctor he did not have to submit to authority as most parents would. His son grew up to be one of the most loving, thoughtful adult parents you could hope to meet. He also flags privilege: he had the money and time to explore alternatives, which a family in a housing project would not.
The head of an insurance company took van der Kolk's neurofeedback training and pulled him aside afterwards.
→ He said that as head of an insurance company he was not interested in getting people better, he was interested in having as many subscribers as possible. Van der Kolk uses it as the concrete form of his claim that the focus is on funding financial organisations rather than helping people.
Common mistakes
Medicating children as a first move
Van der Kolk warns that drugs given during developmental phases can change how the brain is formed. Suppressing the reactions may prevent the brain learning the adaptations his own son's brain learned. He also cites that children from low-income families are around four times more likely than the privately insured to receive antipsychotics.
Treating the label as an explanation
Labels are little crutches that never quite capture what someone is suffering from. Bartlett's own experience — sharing a label with people whose symptoms are drastically different — is the practical demonstration.
Assuming the diagnostic categories are scientific
Van der Kolk, who helped write the DSM, calls it a total artefact of people making up lists in a room forty years ago with no scientific validity, and says everyone who knows science knows we should move beyond it.
Is it for you?
Best for
Anyone carrying a diagnosis that does not seem to describe them, and parents weighing medication for a child.
Not ideal for
Situations where a diagnosis is required for access to support or accommodation — the critique does not remove the practical function of the label.
From the transcript
“these are no binary issues so this capacity to focus to pay attention to be flexible in your attention is a dimensional issue”
“just about every traumatized kid I've ever seen met criteria for ADHD because trauma really messes up your capacity to focus and concentrate”
“our diagnostic system totally sucks”
From the episode
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Bessel van der Kolk