Many people—scientists, psychologists, journalists, bloggers—distinguish between solitude and isolation. The binary is simplistic: solitude, good; isolation, bad. By definition, solitude and isolation are more nuanced than the good-bad binary makes them out to be. Solitude isn’t all purity and fortitude. By definition, it’s merely “the quality or state of being alone or remote from society” and can be “a lonely place.” Isolation isn’t necessarily punitive. The verb “to isolate” denotes the voluntary act of separating from others. It’s benign, even positive: “occurring alone or once.” Yet isolation is seen as a punishment, thrust upon us and never entered into by choice. The word connotes solitary confinement and incarceration—two tactics rooted in prejudice. The common remark that someone with a peaceful mind can enjoy isolation as monkish solitude whereas someone with a troubled mind will suffer solitude as imprisonment misses the fact that a monk typically isn’t in a forty-eight-square-foot cell, could not possibly have been arrested as a result of racial profiling, and is free to leave at any time.

I could leave but never went far. No vacation. No quick road trip out of the city. I rarely went outside a five-mile radius. Same bed. Same breakfast, lunch, and dinner table. Same desk. Same walls.

My apartment stopped suiting me. It wasn’t a refuge anymore. No relief came at being alone each time I walked through the door. That small space no longer provided solitude. Solitude slid into isolation and isolation tipped over into loneliness. I blamed the claustrophobic lack of square footage, the oppressive brick wall. Even before I walked in the door, I felt a crushing weight.

The essayist Michel de Montaigne would have disagreed. Physical space doesn’t determine our emotions; the mind does: “Our disease lies in the mind, which cannot escape from itself.” Montaigne would have told me to keep a “back shop,” a private room within the self, where others can’t enter. Plaster and wood have nothing to do with it. We must have “a mind pliable in itself, that will be company.” Finding contentment in solitude requires self-reliance. But my inner back shop had transformed from a citadel of solitude to a penitentiary of isolation and loneliness.

Like the solitude-good, isolation-bad calculation, a similar binary is applied to solitude and loneliness, except loneliness isn’t just bad, it’s dangerous. In the US, it’s an “epidemic” that affects teenagers and the elderly most acutely. It’s a health threat on par with smoking, contributing to heart disease and increasing the risk of stroke, Type 2 diabetes, dementia, and suicide. Loneliness affects how we work, making us less likely to succeed and take pleasure in what we do.

But loneliness isn’t threatening. It means “being without company.” Only the tertiary and quaternary definitions emotionalize it as “sad from being alone” and “producing a feeling of bleakness or desolation.”

Loneliness, like any difficult emotion, gets its power from the conviction that we’re the only ones feeling it. As a defense, we reassure ourselves that others feel it, too. We join loneliness meetup groups and form people-haters clubs. Thousands of us like the books cited on the loneliness-quotes page on Goodreads. Eleven thousand people liked a passage from Jodi Picoult’s bestseller My Sister’s Keeper: “Let me tell you this: if you meet a loner, no matter what they tell you, it’s not because they enjoy solitude. It’s because they have tried to blend into the world before, and people continue to disappoint them.” The loner, the lonely one, isn’t to blame; it’s other people.

Discomfort is, by nature, uncomfortable. Days spent in my apartment were jarring. Even my solitary walks became unnerving. But I didn’t call my discomfort symptoms.

The change didn’t come as a chrysalis moment. Not an instant of blossoming. It came as a slow unraveling facilitated in part by a book. I entered my pathological life through one book—The Best Little Girl in the World—and exited it through another—the DSM.

It’s unclear why I suddenly wanted to know the source of my diagnosis. Maybe it was the solitude. Or the discomfort. My doctoral program taught me to rely on primary sources. I hadn’t been doing that.

I wish I could say my first real encounter with the DSM took place in the dim, dusty stacks of a medical library, but I was in my tiny apartment in the blue light of my computer screen. My desk lamp was lit. A half-nibbled square of chocolate sat on a paper towel beside my keyboard. An internet window was open to the library portal of the university where I taught. I typed DSM in the search box and filtered for online access: Diagnostic and Statistical Manual of Mental Disorders: DSM-5. American Psychiatric Association. DSM-5 Task Force. c2013.

I clicked and scrolled past the purple cover to the introduction. The sense that, if I kept reading, it might contaminate me and I might somehow fall back into that world of diagnoses and Dr. Ms and PHPs almost made me stop. But I clicked on the Bipolar and Related Disorders chapter. It was all there: short paragraphs describing each disorder followed by numbered and alphabetical symptoms lists followed by codes and specifiers and “diagnostic features.”

People complain that these lists and categories are what’s wrong with the DSM. But to me they were beautiful. Clear. Orderly.

Then I found other books warning against accepting DSM diagnoses. In Saving Normal: An Insider’s Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life, Allen Frances writes, “[New] diagnoses in psychiatry are potentially much more dangerous than new drugs because they can lead to massive overtreatment (with all the possible side effects).” In The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder by Allan Horwitz and Jerome Wakefield, they state: “Pathologization of normal conditions may cause harm, and avoidance of such pathologization may decrease such harm.” I read Edward Shorter’s A History of Psychiatry and How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown. And Hannah Decker’s The Making of DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry. And Anne Harrington’s Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness. And Thomas Szasz. And Robert Whitaker. And Erving Goffman.

And The Book of Woe, in which Gary Greenberg eviscerates the DSM. He asks psychiatry for one—just one—“slam dunk” diagnosis: “the psychiatric equivalent of strep or diabetes, a single diagnosis that indicated a single pathology and a single treatment. But I would have settled for less, one solid example of the value of a diagnostic system.” Spoiler: He never finds one.

The truth was everywhere but nowhere. Most people I knew still believed in the chemical imbalance theory. They talked about their “depression” and “anxiety disorder” as actual illnesses and took medication and saw psychiatrists and psychologists and therapists (though how many would if they didn’t have insurance and had to pay out of pocket?), all without knowing what the acronym DSM even stood for. The truth was in plain sight (but hidden [bracketed]).

Excerpted from PATHOLOGICAL by Sarah Fay. Reprinted with permission from HarperOne, an imprint of HarperCollins Publishers. Copyright 2022.


  • Sarah Fay is an author and activist. Her writing appears in many publications, including LongreadsThe New York TimesThe AtlanticTime Magazine, The New RepublicMcSweeney’s, The Believer, and The Paris Review, where she served as an advisory editor. She’s the recipient of the Hopwood Award for Literature, as well as grants and fellowships from Yaddo, the Mellon Foundation, and the MacDowell Colony, among others. She’s the founder of Pathological: The Movement (, a public awareness campaign devoted to making people aware of the unreliability and invalidity of DSM diagnoses and the dangers of identifying with an unproven mental illness. For more, visit