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Opinion | We’re Thinking About Mental Health Diagnoses All Wrong

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Guest Essay

Credit...Yann Kebbi

Awais Aftab

Dr. Aftab is a psychiatrist and clinical associate professor of psychiatry at Case Western Reserve University.

My patients often ask if I think they have a particular psychiatric diagnosis, such as bipolar disorder, attention deficit hyperactivity disorder or autism. The way they ask suggests they believe that as their psychiatrist, I can identify hidden attributes in their brains, much in the same way one of my physician colleagues might diagnose a patient with a genetic mutation or bacterial infection.

The reality is messier and, in some ways, unsettling. When psychiatrists say that you “have A.D.H.D.,” what they really mean is something like this: After spending time listening to you, talking with people who know you and observing how you think and behave, I’ve made a judgment call that your experience fits a behavioral pattern we currently call A.D.H.D. It’s a cluster of problems and tendencies that travel together often enough that we’ve observed it, given it a name and studied it. Patterns like these are handy for picking treatments that might be helpful, but they don’t settle the deeper questions about how your brain works or what kind of person you are.

For decades, the public conversation about mental health has been routed through the categories in the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., the American Psychiatric Association’s official compilation of psychiatric disorders. Symptom-based categories have been convenient for professional communication, insurance billing and conducting clinical trials, but they have given the false impression that each mental disorder is a relatively distinct problem with clear boundaries and an essence that makes it what it is.

Scientific evidence accumulated from multiple lines of inquiry, including genetics, brain imaging and circuity, and measures of the brain’s electrical activity, shows that while there are biological irregularities associated with mental illnesses, the patterns we see in these scientific studies don’t neatly match up with diagnoses in the D.S.M. For instance, two people might have a similar genetic profile, but one will be clinically diagnosed with bipolar disorder and the other with schizophrenia. Neither genetics nor brain scans can distinguish a person with depression, A.D.H.D. or autism from one without.

That doesn’t mean that psychiatric diagnoses are meaningless labels or arbitrary symptom collections. They are practical tools that provide a shared language to describe very real patterns of distress and impairment and can help shape treatment. In practice, clinicians use them flexibly rather than rigidly.

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The problem is that when categories are the only language we have for talking about mental health difficulties, and when public discourse treats them as definitive explanations, patients and the public are left with a picture of the mind that is far too simple.

Here is what I want my patients to know:

1) Symptoms of mental illness exist on a continuum. Research has shown that they are distributed continuously in populations, similar to height, intelligence and temperamental features. This is one reason that some researchers have proposed replacing traditional diagnostic categories with alternative approaches that treat mental health problems more like a series of volume knobs than an on-off switch.

2) The symptoms of mental illness reinforce one another. An important theory in psychiatry, known as network theory, posits that mental health problems emerge from symptoms pushing and pulling on one another in self-reinforcing loops. Being unable to sleep can fuel daytime nervousness; nervousness can drain energy; low energy can lead to social isolation; isolation can worsen depressive rumination; and rumination can make it difficult to sleep. And so on. Symptoms are often triggered by life stressors, but once the symptom arrangement becomes self-sustaining, it continues on long after the stressor has disappeared.

3) At the start, mental health problems are open-ended and can evolve into various different diagnoses. Just as conditions like cancer and diabetes are seen as developing through stages, researchers are increasingly talking about stages of mental illness, from stage 0 (at risk) to stage 4 (resistant to common treatments).

The progression is not always linear or predetermined, especially in early stages. A 14-year-old presenting with anxiety could grow into a person with an anxiety disorder but could as easily develop depression, psychosis or substance abuse, or live a healthy life. Parents often want to know the precise diagnostic category for their child’s mental health challenges, but the truth is that the symptoms are inherently ambiguous and dynamic, and it is better not to force them into an ill-fitting fixed category.

4) Diagnostic labels are frequently blind to the collision between who people are and what their life demands of them. A woman prone to nervousness might struggle in a stressful work environment. A man diagnosed with A.D.H.D. as a child might have never needed stimulants until he started working two jobs to support his family and the chronic sleep deprivation made his attention problems unmanageable.

These are not straightforward cases of disorders internal to a person. They are mismatches between a person’s particular traits and capacities and what the individual’s circumstances require of him or her. They are also some of the most common problems in mental health care.

5) Understanding symptoms only in terms of disorder can obscure their meaning. We have forgotten that symptoms are not always diseases. Many uncomfortable bodily and mental experiences — pain, cough, fever, anxiety, low mood — are signals that evolved because they were useful to our survival in the course of evolution. Not being anxious in the presence of a predator is more costly than being anxious at rustling sounds that turn out to be just wind.

From an evolutionary perspective, sadness and worry are mental defenses against futile persistence and potential danger. Just as pain is your body’s signal that you are injured, sadness and worry can be signals that something in your life goals or situation needs to change. The problem is that these defenses can frequently misfire or get stuck, just as a cough can persist long after the infection is gone.

6) Personality shapes the expression and treatment of mental health problems. In my clinical experience, this is where some of the most important differences between patients lie. Two people may have the same symptoms of anxiety but for entirely different psychological reasons and with different treatment needs.

One person’s panic may be linked to a deep fear of abandonment; another’s may be tied to harsh self-criticism and shame. Some people are prone to self-blame and sensitivity to loss, while others crave connection and attention. Mental health problems are shaped by the interaction between these enduring personality patterns, as well as a person’s strengths and weaknesses in regulating emotions and impulses.

In my practice, I routinely see patients who have been diagnosed with depression and anxiety by one clinician, bipolar disorder by another and post-traumatic stress disorder by a third, at different points in their lives. They arrive confused and frustrated, asking: What disorder do I really have? The honest answer is: all of them and none of them. Each of these labels can capture something useful and inform treatment options, but none of them do justice to the dimensional and dynamic nature of mental illness.

Your mental health problems are not caused by a simple thing that you either have or don’t have. They are patterns shaped by who we are as people and that, in turn, shape the people we become. This is a more complicated story than “chemical imbalance” or “brain disease.” But it is closer to the truth. And an honest story is what you need to make sense of what is happening to you and to find your way through it.

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mareino
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"These are not straightforward cases of disorders internal to a person. They are mismatches between a person’s particular traits and capacities and what the individual’s circumstances require of him or her. They are also some of the most common problems in mental health care."
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Meet the candidates running to be D.C.’s delegate to Congress

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Want to meet the candidates for D.C.'s delegate to Congress? We're hosting a debate with SpotlightDC and The Washington Informer on Thursday, May 14. RSVP for free tickets — and find more info — here.
Meet the candidates running to be D.C.’s delegate to Congress

While D.C.’s mayoral race has been sucking up most of the proverbial political oxygen in the room, there’s another high-stakes citywide contest where the long-term incumbent isn’t running again and whoever replaces her will face a complicated, uphill slog. We’re talking, of course, of D.C.’s non-voting delegate to Congress.

Eleanor Holmes Norton has held that seat since 1991, and she only ever faced nominal opposition for re-election. That changed last year, as it was becoming clear that Norton – at 88, one of the oldest members of an already gerontocratic Congress – just didn’t seem up to the task anymore

Her public appearances dwindled as challenges to D.C.’s autonomy from the White House and Republican-led Congress were ramping up. Even while friends and former aides publicly urged her to retire, Norton gave conflicting answers on her political future before finally announcing in late January what everyone else seemed to see as inevitable – she would not run again.

Norton’s departure hasn’t just opened up her seat, but, as candidate Kinney Zalesne told us, sparked the first “serious conversation about what the delegate job is” in decades. That opportunity initially attracted more than a dozen candidates, though only five made the ballot for the Democratic primary: Trent Holbrook, Greg Jaczko, Brooke Pinto, Robert White, and Zalesne. 

While the push for statehood has been most prominent in recent years (the House twice passed a statehood bill six years ago), that’s not all D.C.’s delegate focuses on. Indeed, Norton gained such prominence because of everything else she did: negotiating with Republicans to temper their interference in local affairs, securing federal funding for city projects and initiatives, and waging symbolic battles big and small to try to ensure the District is treated like a state. 

Meet the Democratic candidates –  two sitting members of the D.C. Council, one of Norton’s recent staffers, a former nuclear regulator, and a prominent Democratic fundraiser – looking to succeed her. Whomever wins will go on to face non-Democratic candidates in the November election (there’s currently one Republican and one Statehood Green in the race, and independent candidates can jump in.)

Trent Holbrook

Norton hasn’t endorsed a successor, and it’s unclear if she will. But Trent Holbrook is approaching the race with the view that proximity to the legend is the next best thing.

The 40-year-old Dupont Circle resident worked for eight years as a legislative staffer in Norton’s Capitol Hill office (he left shortly after declaring his candidacy), a fact that he often reminds potential voters of. 

“I worked with Congresswoman Norton on this issue” has been a common refrain in recent debates. Whether it’s the statehood bill that cleared the House or the multiyear push to give D.C.’s mayor control of the National Guard, Holbrook says he knows not just the issues but also the politics and people involved in moving them forward – all by virtue of having sat alongside Norton as she waged those battles.

“I learned from the great while I was there,” he tells The 51st. 

He said Norton’s accomplishments – with him alongside her – are clear. Statehood became a cause célèbre among Democrats (after having failed to advance in the early 1990s), and over the years, many attempts to undo or change locally passed legislation were thwarted. “We’ve had a record number of attacks but very few actually stick,” he says. 

On the flip side, Holbrook says Norton didn’t only play defense; she knew what fights to pick on D.C.’s behalf and how to move them forward through the complex legislative process.  

“We had a great history in that office of knowing what moment we’re in, what’s moving, and what we could attach to it,” he says. “And that’s not something that comes to people, it takes years of experience.” 

Of course, it’s hard to tout proximity to Norton without having to answer questions about the controversy that dogged Norton for most of last year before she decided to retire: Did she hold on for too long as her mental and physical energy seemed to lapse? 

Holbrook answers that by saying he decided to jump into the race when “it was obvious” she wouldn’t run again, and while he didn’t directly address whether he and the rest of her staff was aware of her diminished state, he insists that she remained “one of the most effective lawmakers in American history.” (He adds, “I hope to be in her shape when I am 88.”)

Should he be elected to succeed his former boss, Holbrook says he would double down on pushing statehood. “One of the most important things the delegate has to do is continue to make it the national priority it should be,” he says. At the same time, he says he will keep up Norton’s history of fighting to defend and expand home rule and using the office to advocate for D.C. to be treated as an equivalent of a state for federal programs. 

He argues that the others running – especially his two competitors who currently serve on the D.C. Council – don’t have the right kind of experience to get the job done.

“This position is not like any position in government. You’re having to defend home rule and make advances on statehood. It’s not like being on D.C. Council where you are just working with Democrats,” he says. “It’s critical to have someone step in on Day 1 and start delivering.”

Greg Jaczko

We’re all aware of D.C.’s complaint that our residents suffer from the injustice of taxation without representation, but Greg Jaczko thinks far too much of the city’s fight has been focused on the latter instead of the former.

“We should make it no taxation until we get representation,” he tells The 51st.

The 55-year-old Tenleytown resident’s pitch is somewhat unexpected, but so too was his path into electoral politics. He has a doctorate in physics and came to D.C. 30 years ago for a science fellowship, eventually rising to serve as the chairman of the Nuclear Regulatory Commission under President Obama. He now has his own consulting firm on renewable energy. 

Jaczko says he was motivated to jump into the race because of how the Trump administration maligned and fired so many federal employees. “I didn’t see anyone in Congress really pushing back the way they should,” he says. “I thought, ‘I can run for office and make a difference or sit on my couch and complain about it.’”

If elected, Jaczko would push to be appointed to the House Oversight Committee, where he says he’d be best placed to fight for federal workers. “This country cannot function without the amazing people who work in the federal government,” he says. “We have to get them back and give them protections.”

Like everyone else vying to succeed Norton, Jaczko is a passionate supporter of D.C. home rule and statehood. But given the challenges of getting a statehood bill through Congress at this time, he is instead proposing to push a bill through that would exempt D.C. from federal taxation. (In 2024, D.C. paid $45 billion in federal taxes, more per capita than any state.)

“For the 30 years I have been here, we have focused on the representation part and not the taxation part. There are other jurisdictions like D.C. that are not states, and there the residents don’t pay federal taxes,” he says, referencing Puerto Rico. “We should use the power of the purse to make people recognize this injustice.”

It’s not a new idea – every now and again a D.C. resident pledges to withhold their federal taxes until the city is given statehood (the consequences for an individual doing so can be quite significant). It also interestingly has had at least some bipartisan support; the conservative Heritage Foundation once advocated for ending federal taxation for District residents. But Jaczko says now is as good a time as any to embrace it. 

“The goal is to get statehood, but this is a different tactical approach,” he says. ”It brings awareness because you have the rest of the country crying about unfairness. You reverse the discussion and it can move you closer to statehood.”

And, he adds, there’s a fringe benefit for a D.C. economy that’s been ravaged by Trump’s decimation of the federal workforce. “You can imagine if D.C. doesn’t pay a federal tax,” he says, “every corporation would want an office in D.C.” Charge them some higher local taxes, he adds, and voila: more revenue for the city.

“There is a degree of autonomy that comes from having more resources,” he adds.

Brooke Pinto

When Ward 2 Councilmember Brooke Pinto recently unveiled her first campaign ad this month, some were confused about why it focused on housing, an issue that she could just as well tackle by remaining in the council seat she has occupied since 2020.

Pinto doesn’t necessarily disagree. But she tells The 51st that while she is running for D.C. delegate to push for statehood and protect the city’s autonomy, she also wants to use federal leverage to focus on more practical daily matters. 

“I will be very focused on improving residents’ lives,” she says. “There are things to do locally [on housing]. But in Congress, this is an issue D.C. residents and Americans are facing that needs federal intervention.”

She wants to use that intervention to repeal the federal Height Act that limits how tall buildings can be; speed the transfer of old federal buildings and land to local control, so they can be used to build affordable housing; and declare more federal enterprise and opportunity zones, designated areas where investors are enticed with tax breaks. 

Pinto, 33, has most recently been known for her work on public safety on the council, where she shepherded legislation that increased penalties for gun crimes, expanded the use of pre-trial detention, and introduced the use of teen curfew zones to prevent so-called teen takeovers (advocates for criminal justice reform have often disagreed with her approaches). The Logan Circle resident says she’ll carry that experience with her to Capitol Hill, where Republicans often get involved in the city’s local affairs when it comes to crime.

“I’ve seen firsthand where the gaps are: the databases in our courts that are 50 years old, the gun control laws that are inconsistent in our region so we have illegal guns flowing in from Maryland and Virginia, our GPS monitors that run out of batteries,” she says. “All of those are federal functions where having someone who is an expert on public safety will allow me to move the ball.”

Pinto’s campaign has had a rocky go of things recently, though. Seeing White as her biggest competition, her campaign published unredacted opposition research on White and his family last month. The move sparked outrage from her council colleague; she ultimately apologized but refused to drop out of the race as he demanded. 

Pinto, a Connecticut native, has also had to fight off claims that she doesn’t know D.C. well enough to represent it in Congress. (Some of those out-of-town connections have helped her raise more than $1.2 million, more than any of her competitors.) But she rejects those arguments. 

“It’s the city I love, and it’s my home. It’s my life’s work to protect it. I think most people across D.C. get that, and they see that in my record, in my commitment,” she says. “We are an inclusive city that should be welcoming to everybody who comes here.”

That, though, brings her back to her focus on housing – and how the lack of affordable options is impacting longtime Washingtonians. “One of the biggest concerns I hear from Black residents is about displacement in large part due to the rising costs of housing, which is why addressing the affordable housing crisis is my number one priority,” she says.

Robert White

Up until last summer, At-Large Councilmember Robert White says he thought he would run for mayor, reprising his failed 2022 bid for the city’s top job. But, he tells The 51st that in early August “it became uncomfortably clear how under threat D.C.’s home rule is and that Congresswoman Norton was likely to retire.” A month later, White made the call: He was running to succeed her.

“There’s a unique historic opportunity to move D.C. statehood forward right now,” he says. “D.C. residents are much more active on local issues than they have been historically. We had been beaten on decade after decade, so there was never much of a reaction when Congress did things. That’s very different now. People are scared, and they are showing up.”

White, 44, is a known quantity in D.C. politics, having held a citywide seat on the council for a decade. He says that his tenure on the council – and that he’s a native Washingtonian and the only Black contender in the race – makes him uniquely able to connect to and mobilize residents. 

“There’s no one who understands the city better personally and professionally,” he says. “Residents in the city know me and they trust me. You can’t be negotiating and bargaining for a city you don’t understand.” 

White also served as legislative counsel to Norton from 2008 to 2013. And like every other candidate, he says he would marshal local and national forces to push D.C. statehood through Congress. But White says he’d also aggressively pursue a seat on the House Appropriations Committee, where he could better direct federal funds to the city and head off the usual budget riders that Republicans use to tell D.C. what to do (or not do.)

He wants to focus on stabilizing D.C.’s economy and thinks he could play a role by pushing to transfer federal lands around L’Enfant Plaza to local control and team up with regional partners to advocate for federal payments to make up for the significant impact of Trump’s cuts to the federal workforce. 

And, like Jaczko, White is interested in tax policy: He’d like to adopt a Puerto Rico-style system where businesses that move into the city don’t have to pay federal taxes on the money they make here. “That’s a model we can use to attract businesses to D.C.,” he says.

White touts endorsements from the Congressional Black Caucus, the Congressional Progressive Caucus, local unions, at least two council colleagues (Janeese Lewis George and Charles Allen), and Sen. Elizabeth Warren (D-Massachusetts). Still, his fundraising has lagged behind both Pinto and Zalesne, and he drew criticism for a social media post joking about the shooting at the White House Correspondents Dinner. (He later deleted it, calling it “inappropriate and insensitive.”) 

He’s bullish on his chances in the race, and on Pinto and Zalesne, pointedly argues that “this is not the time for a person that believes they can buy a seat or wants to learn in the position.”

Kinney Zalesne

If there’s a fringe beneficiary of the political mud that White and Pinto have been throwing at each other, it may well be Kinney Zalesne

The Cleveland Park resident was among the first to jump into the race for Norton’s seat, seeing an early start as vital to being able to introduce herself to an electorate that had likely never heard of her. Since then, Zalesne, 59, has raised more than $660,000 for the race, taking advantage of connections she built in her career in the federal government, leading a non-profit focused on helping D.C. kids get to college, at Microsoft, and, more recently, as a prominent fundraiser for the Democratic Party.

While there are five candidates in the race, Zalesne is pretty clear that she sees the real contest as being between her, Pinto, and White. And she seems more than happy to see the two of them battle it out in public; it buttresses her argument that being a local lawmaker doesn’t naturally make them more suited to be D.C. delegate.

“It’s not a step up from the D.C. Council,” she tells The 51st about the role of D.C. delegate. “That has never been the path. Because there is no vote, the power of the role is not in the position, it’s the person. Eleanor made it what she did because she had national networks and national experience. She turned her strengths into the role and served D.C. fiercely. I am aiming to do the same.”

Zalesne says her own “unusual mix of experiences” will lend itself to what she says would be her priorities if she were elected D.C. delegate: autonomy and economy. “Autonomy is statehood and everything on the way, and economy is about reimagining and recreating our economy to be less dependent on the federal government,” she says.

On autonomy, Zalesne would immediately call a “statehood summit” after the June 16 primary to refine the messaging and strategy around getting a statehood bill passed in Congress. She says her recent experience of fundraising for the DNC gives her relationships on Capitol Hill she could leverage to bolster the push for statehood. Zalesne also says more public education is needed; she envisions a broad advertising campaign targeting visitors, with the possible tagline, “Welcome to D.C., we’re the last colony.”

“We can launch a lot of new energy and creativity and discipline and focus,” she says. “Sharper, edgier, based on research, metrics-driven. Everything you want to do when you actually want to win, not just be indignant.”

Zalesne says she’d also push to create a Capitol Caucus in the House made of representatives from surrounding states, which could be a vehicle for diversifying the region’s economy. “If we collaborate better as neighbors, it would make a big difference,” she says.

As she continues her campaign, Zalesne is leveraging her time at the DNC to good effect; she’s touting endorsements from three sitting members of the House, among other figures. That may only go so far for most D.C. residents, though, so in late April she launched what she says is a “major six-figure multi-platform” advertising campaign that will last seven weeks. And she seems to hope that Pinto and White will keep taking shots at each other.

“They are unseasoned. They are not ready for the national stage. They are embarrassing themselves,” she says. “With those kinds of blunders, will they actually get us statehood?”

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mareino
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The Asteroid and the Meaning of Life

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The 2025 Metropolitan Sprawl Rankings | Center for Smart Transportation

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Top 10 Most Compact and Connected Metropolitan Areas (nationwide) in 2020

RankMetropolitan AreaIndex Score
1San Francisco-San Mateo-Redwood City, CA242.9
2New York-Jersey City-White Plains, NY-NJ227.4
3Philadelphia, PA220.8
4Miami-Miami Beach-Kendall, FL158.4
5Trenton-Princeton, NJ152.2
6Boston, MA145.9
7Chicago-Naperville-Evanston, IL145.1
8Santa Maria-Santa Barbara, CA143.3
9San Rafael, CA141.7
10Boulder, CO141.6

Top 10 Compact and Connected Large Metropolitan Areas (population of over 1 million) in 2020

RankMetropolitan AreaIndex Score
1San Francisco-San Mateo-Redwood City, CA242.9
2New York-Jersey City-White Plains, NY-NJ227.4
3Philadelphia, PA220.8
4Miami-Miami Beach-Kendall, FL158.4
5Boston, MA145.9
6Chicago-Naperville-Evanston, IL145.1
7Los Angeles-Long Beach-Glendale, CA137.7
8Detroit-Dearborn-Livonia, MI134.3
9Anaheim-Santa Ana-Irvine, CA132.7
10Oakland-Berkeley-Livermore, CA130.3

Top 10 Most Compact and Connected Medium-sized Metropolitan Areas (population of between 500,000 and 1 million) in 2020

RankMetropolitan AreaIndex Score
1Madison, WI126.3
2Bridgeport-Stamford-Norwalk, CT120.1
3Spokane-Spokane Valley, WA117.3
4New Haven-Milford, CT117.0
5Modesto, CA115.7
6Lexington-Fayette, KY115.5
7Stockton, CA109.6
8Omaha-Council Bluffs, NE-IA109.0
9Oxnard-Thousand Oaks-Ventura, CA108.5
10Scranton--Wilkes-Barre, PA107.8

Top 10 Most Compact and Connected small Metropolitan Areas (population of under 500,000) in 2020

RankMetropolitan AreaIndex Score
1Trenton-Princeton, NJ152.2
2Santa Maria-Santa Barbara, CA143.3
3San Rafael, CA141.7
4Boulder, CO141.7
5Champaign-Urbana, IL136.5
6San Luis Obispo-Paso Robles, CA135.4
7Springfield, IL135.2
8Erie, PA132.2
9Charleston, WV130.9
10Santa Cruz-Watsonville, CA130.6

The following tables present the list of the most sprawling metropolitan areas and divisions.

Top 10 Most Sprawling Metropolitan Areas (nationwide) in 2020

RankMetropolitan AreaIndex Score
224Rockingham County-Strafford County, NH65.1
225Jacksonville, NC63.7
226Greenville-Anderson, SC63.4
227Baton Rouge, LA62.5
228Myrtle Beach-Conway-North Myrtle Beach, SC-NC60.1
229Fayetteville, NC60.0
230Hickory-Lenoir-Morganton, NC57.9
231Nashville-Davidson--Murfreesboro--Franklin, TN57.4
232Atlanta-Sandy Springs-Alpharetta, GA57.2
233Riverside-San Bernardino-Ontario, CA54.3

Top 10 Most Sprawling Large Metropolitan Areas (population of over 1 million) in 2020

RankMetropolitan AreaIndex Score
208Jacksonville, FL73.0
211Montgomery County-Bucks County-Chester County, PA72.7
212Charlotte-Concord-Gastonia, NC-SC72.6
216Raleigh-Cary, NC71.0
217San Antonio-New Braunfels, TX70.7
219Houston-The Woodlands-Sugar Land, TX69.9
223Warren-Troy-Farmington Hills, MI65.2
231Nashville-Davidson--Murfreesboro--Franklin, TN57.4
232Atlanta-Sandy Springs-Alpharetta, GA57.2
233Riverside-San Bernardino-Ontario, CA54.3

Top 10 Most Sprawling Medium-sized Metropolitan Areas (population of between 500,000 - 1 million) in 2020

RankMetropolitan AreaIndex Score
205Columbia, SC73.8
210Greensboro-High Point, NC72.8
214Chattanooga, TN-GA71.3
218Jackson, MS70.2
220Knoxville, TN69.8
221Augusta-Richmond County, GA-SC69.4
222Winston-Salem, NC68.6
226Greenville-Anderson, SC63.4
227Baton Rouge, LA62.5
229Fayetteville, NC60.0

Top 10 Most Sprawling Small Metropolitan Areas (population of under 500,000) in 2020

RankMetropolitan AreaIndex Score
196Killeen-Temple, TX79.3
204Clarksville, TN-KY73.8
207Salisbury, MD-DE73.2
209Longview, TX72.9
213Huntsville, AL71.4
215Kingsport-Bristol, TN-VA71.2
224Rockingham County-Strafford County, NH65.1
225Jacksonville, NC63.7
228Myrtle Beach-Conway-North Myrtle Beach, SC-NC60.1
230Hickory-Lenoir-Morganton, NC57.9
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mareino
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DC is the #6 post compact county; Alexandria, Arlington, & Falls Church are #9, #11, and #12. But the rest of the DC region is waaaay down the list.
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NVIDIA Goes to Zero.

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On 10 December 2025, Cisco Systems closed at $80.25 - finally clearing its dot-com peak from 27 March 2000. And it only took twenty-five years, eight months, and thirteen days. Adjusted for CPI, the stock still trades at roughly half its real 2000 high; meaning anyone who bought at the top has waited a quarter of a century to break even in nominal dollars, and in actual purchasing power, they’re not there yet.

Cisco was arguably one of the most important companies of the dot-com era; routers and switches were the picks and shovels, and they sold the infrastructure everyone else had to buy. They were profitable, and they had actual revenue and customers. The boxes they shipped were as close to indispensable as networking gear got.

And the stock returned a generation of negative real performance.

Hold that fact in your head.

NVIDIA closed last week at a market cap hovering around $5 trillion. The stock trades at more than forty times trailing earnings and an enterprise value of about twenty-four times sales. In a year, the company has added more market value than the entire UK FTSE 100. Retail investors hold it in their pension accounts and their ISAs. Every algorithmic momentum strategy holds it, and so does every passive index fund.

The stock has started behaving like a vote on the future itself.

But if history is any guide, the short version of that future is this: a decade of expected real returns hovering near zero, possibly negative.

The dominant infrastructure provider in a capex supercycle returns less than people think over the decade following peak euphoria, sometimes by enormous margins. There’s never been a clean exception, and there’s no theoretical reason there should be one now.

So: the base rate.

The first great infrastructure capex cycle in the modern industrial era was the American railway boom. Between 1868 and 1873, more than 33,000 miles of track were laid. Steel rails, the air brake, signal telegraphy, federal land grants etc. It was the most ambitious physical buildout the still-young country had ever attempted. And those railways did remake the economy; New York to Sacramento compressed from six months to seven days. The integration of national markets that followed turned Sears, Roebuck and Standard Oil into empires.

But the railways themselves went bankrupt. The Panic of 1873 wiped out more than a hundred railway companies, and the Panic of 1893 took out roughly a hundred and fifty more. By the early twentieth century, the sector was a graveyard of bondholder workouts and federal receiverships. Over the following century, railway equity returns underperformed broad indices so consistently that they’re still considered textbook case of infrastructure value destruction.

The customers got rich, but the builders got hosed.

The 1920s electrification cycle produced the same outcome. Utility holding companies became the most fashionable equities in the world. They traded at multiples that made their cash flows look ridiculous, and once the crash started in 1929, electric utility holding companies lost more than ninety per cent of their value by 1932. Electrification was real; it changed agriculture and manufacturing.

The industrial value was generational, but the shareholders got hosed.

In the 1970s and 1980s it was mainframes. IBM was the indispensable compute provider of the post-war era. By the late 1960s it commanded the moat NVIDIA enjoys now; and through the 1980s and 1990s, IBM equity returns were a slow-motion disaster.

Between 1996 and 2000, telecommunications capex rose by more than seventy-five per cent cumulatively. Global Crossing, MCI WorldCom, Lucent, Nortel, AT&T, Qwest, and dozens of others laid roughly 80 million miles of fibre optic cable on the pitch that they were going to wire the planet. They had real customers, and Government policy was at their backs. Analyst models justified pretty much any P/E ratio you wanted.

Eighty-five per cent of the fibre sat dark for a decade. The cost of bandwidth fell by ninety per cent, and the telecom sector collapsed by ninety-two per cent. Twenty-five years on, the index still hasn’t recovered. Nortel went bankrupt. Global Crossing went bankrupt. Lucent had to be absorbed into Alcatel and then again into Nokia. The fibre that survived became the substrate Netflix and Facebook and Google and Amazon used to extract trillions in value.

The customers won, but the builders got hosed.

Cisco was supposed to be different; they were the picks-and-shovels play, a real business with real margins, selling real equipment to real customers. At its 2000 peak, Cisco traded at a P/E above two hundred and an enterprise value to sales ratio above thirty. The argument for those multiples was that Cisco was indispensable, that internet capex would compound for decades, and that nobody else could deliver what Cisco delivered.

All of that turned out to be true. The stock still hasn’t recovered in any real term.

The shale gas mania of 2010 to 2014 produced the same pattern at smaller scale. Fracking worked, the geology was real, the energy independence was real, and the equity returns for the upstream producers were a serial-killer chart. But Chesapeake Energy went bankrupt. Whiting Petroleum went bankrupt. Shale capex peaked, then collapsed, and then collapsed again.

The technology worked. The shareholders…well.

You understand.

You can run this exercise as far back as you want; canal mania in 1840s Britain, the bicycle craze of the 1890s, and the automobile boom that produced more than two hundred US car companies in the 1920s and a Big Three controlling ninety-four per cent of the market by 1955. Aviation in the 1930s. Photovoltaic cells in the 2000s. Each cycle had a real innovation and a defensible thesis for why the dominant infrastructure provider would compound shareholder value indefinitely; each cycle ended with that provider returning less than US Treasuries over the subsequent decade.

Capex cycles almost always overshoot; the economics of competitive bidding for productive capacity all but guarantee that capacity gets built past the point where the marginal unit earns its cost of capital. Builders capture the rents during the build phase, when demand outstrips supply. Once supply catches up, the rents collapse. The customers absorb none of the capex risk; they capture the durable value because they get the productive asset at clearance prices.

In its most recent quarter, four direct customers accounted for sixty-one per cent of NVIDIA’s total revenue; and just two customers accounted for thirty-seven per cent. The same disclosure existed at Cisco around 2000, where the largest customers were the very telecoms that subsequently went bankrupt. Concentration like this is what the late innings of a capex bubble look like; by that point, only a handful of buyers can write cheques big enough to matter, and those buyers know it.

Those four customers are projected to spend somewhere between $700 billion and $725 billion on capex in 2026 alone. To put that in perspective: US telecom capex peaked at roughly 1.2 per cent of GDP in 2000. AI hyperscaler capex is now on track to match that share in a single year, compressed into a sliver of the telecom cycle’s duration and concentrated among four buyers.

Fibre, once laid, lasted forty years. Railways, once built, lasted a century. NVIDIA’s H100 was state-of-art two years ago and is now a generation behind Blackwell. Blackwell will be a generation behind Rubin. Rubin will be a generation behind whatever follows. Hyperscalers are buying assets they’ll write down in three to five years. The capex is enormous and the asset life is short; that math can work for a few years, but it can’t work for a decade.

Google’s TPUs already handle a meaningful share of internal workloads. Amazon has Trainium and Inferentia, Meta has MTIA, and Microsoft has Maia. Broadcom is forecasting $100 billion in AI chip revenue by 2027. TrendForce expects ASIC-based AI servers to hit roughly twenty-eight per cent of shipments in 2026. The CUDA moat matters less for inference than it does for training, and the buyers know this; they’re spending billions to escape the supplier they currently depend on. Every one of them has board-level pressure to reduce NVIDIA’s share of their cost base.

This is the dynamic that killed Cisco’s premium. Customers built their own gear, standards commoditised the function, and white-box switching ate the margin. Cisco the company survived, but Cisco the stock didn’t.

When does the multiple compress on NVIDIA?

In Q1 or Q2 of 2027, one of the four mega-customers will say, on a quarterly earnings call, that its capex growth rate is moderating. They won’t call it a slowdown; it’ll be “rationalisation” or “improving capital efficiency.” That same quarter, MediaTek’s CoWoS wafer allocation from TSMC will have ramped from 20,000 in 2026 to 150,000 in 2027, which is when custom silicon becomes a credible second source. Broadcom’s AI revenue will be tracking towards its $100 billion target; and the market will see, for the first time, that the substitution is starting to happen at scale.

NVIDIA’s forward earnings multiple compresses from twenty-five times to somewhere around twelve to fifteen. Earnings themselves keep growing, possibly substantially, for another year or two. But the algorithmic strategies that bought NVIDIA on momentum will sell it on momentum. Passive flows that pushed it up via S&P 500 weight will pull it down via the same mechanism; and the stock falls fifty to seventy per cent over twelve to eighteen months.

The compounding math does the rest. Even if NVIDIA grows revenue at ten per cent annually for the following decade, an outcome that would still make it one of the great businesses of the era, and one of the greatest of all time, the de-rating from a premium multiple to a normal one eats every cent of that growth and most of the inflation. Actual returns through 2035 settle somewhere between zero and slightly negative.

This is, broadly, what the historical base rate looks like for the dominant infrastructure provider in any capex supercycle. The stock returns nothing while the underlying economy gets remade.

Half of you reading this think I’m wrong because NVIDIA is different. Cisco didn’t have CUDA. Railways didn’t have Jensen. IBM didn’t have a software moat compounding into robotics and simulation and the foundation models that will define the next decade of computing.

Maybe.

I’ll own that possibility.

I’d be a fool not to.

The other half will think I’m wrong because the bubble is bigger than I’m describing. The multiple compression is already overdue, and the customer concentration plus asset depreciation plus ASIC substitution mean the de-rating starts this year.

Also maybe.

What both halves should hesitate before believing is that NVIDIA’s stock will compound from here at the rate it has compounded so far; because the historical base rate for that outcome is roughly nil. Every previous capex supercycle has ended with the dominant provider returning less than cash for the decade following peak. There’s never been an exception, and there’s no theoretical reason there should be one now beyond “trust me, bro.”

NVIDIA’s customers will get artificial intelligence. And their shareholders will get to find out what twenty-five years of waiting feels like.


Selfonomics is published by my lab, Studio Self.

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Your Biggest Vulnerability is your Shitty Compensation

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My fourth month of unemployment. I'm fresh off an interview with a senior technical role advertised with a decent compensation range whose upper end would let me make median rent, and whose lower range would not. At the end of an excellent interview, I am informed that said compensation range, contrary to the Base Compensation tag in the job description, is in fact all inclusive, and that the role actually tops out below the living wage threshold for a three adult household for its base compensation.

I feel it's highly relevant to note that this was a role where I would own the entire technology estate for an employer. Every switch, every firewall, every database, every server, every phone, every laptop, every cloud, every badge system. All data, everywhere, at any time.

Everything.

For an employer in the public safety industry.

Seriously, this is a company first responders rely on for tech, and they want to pay below subsistence wages to senior technical people!

This is not the first time that compensation has been mismatched to the role, but it is the first time it's happened with a role so critically important to a company playing such an outsized role in as critical an area as public safety.

Which got me thinking: have employers just lost the plot on what compensation is actually for? What its intended function is? Because it seems to me that everyone thinks compensation is merely payment for labor and nothing more, a number to be driven down by any means necessary in order to keep more for those at the top.

And oh my god it is so much more than that.

We live in a society. This society has been arranged around using currency to purchase necessities, because some people decided that necessities are not guaranteed. You acquire currency by either investing currency you already have to compound it through the labor of others, or you labor in order to earn less currency than investors do.

Is that a gross oversimplification? You betcha, but I'm really trying to stay on topic and not fill this with reaction GIFs.

Author's Note: I failed.

Anyway, everyone needs currency to afford everything. Rent costs currency, food costs currency, electricity costs currency, water and sewage and garbage and healthcare and childcare and education all cost currency. Only after your essentials have been paid for, can you use excess currency to save for tomorrow - buying a home, or a car, or a retirement if you're really lucky.

Now at some point, the humans involved in handing out currency decided that too many people were living too nicely. The thinking was simple: trading time for currency in the form of labor was a sucker's game, and those with currency deserve more currency because they already had currency. Companies in particular deserved more money than the people who worked for the company, at least according to Powell.

Thus labor was reframed into those terms: wages were merely a payment to those who did labor, and labor was only to be paid the minimal amount possible in the marketplace for said labor, and not one cent more, regardless of external forces (like the cost of living). Minimum wages are bad, because wages should only ever go down relative to inflation and productivity, never up. Only those who own business deserve more currency, because they're the real workers.

Again, a gross oversimplification coming from an openly biased dinosaur. That's not the point.

The point is that wages aren't meant to merely compensate labor; they're also meant to protect the company.

Tony Soprano reminding you that this is a business.

I'll just be blunt: wages are also protection money. They're not just compensation for doing your job, they're compensation for not burning down warehouses, not going on strike, not sabotaging workloads, and not unionizing in the first place. It's the longest unspoken social contract dating back to pre-history: you pay me to live, or else.

Occasionally, employers will call labor's bluff. If twenty-thousand years of history is any indication, their temporary wins are always undone by the sheer ratio of workers to wealthy owners, though not before employers provoke and employ violence first. We are going through such a phase right now, if the above links are any indication.

Employers haven't paid their dues to labor in decades. Labor, kind as we are, have cut back on our lives as much as we're able to. We've given up homeownership, we're dropping out of healthcare, we're begging from food pantries, we're taking on gig work, and we've seen none of the wage gains from productivity our elders enjoyed. It's gotten so bad that, with workers having sacrificed our very ability to move up the socioeconomic ladder, the economy has gone K-shaped.

Despite this, employers seem to think there's more room for workers to yield. I say this because despite median wages being unable to afford median homes, I'm still finding employers offering lower and lower pay for work on their job descriptions. This isn't just economics anymore, this is a security risk, and employers are playing with fire.

Modern employers

Take your CPA, for instance, median pay of $81,680 a year and at moderate exposure to AI displacement according to Anthropic. These are people who know your books better than you. Where every penny goes, and where every penny can be silently swindled. They also audit your fancy new AI financial workflows, making corrections when it goes off the rails, and know where all your financial skeletons are buried.

Do you really want to pay your accountant so little that they can't make rent or buy a home? Do you really want them going to a food bank instead of a grocery store? They're excellent at judging risk, and know exactly what that pay gap is worth to them if the timing is right. Maybe it's blowing the whistle before you can fix an issue and leading to a costly investigation, maybe it's sharing your supply chain costs with a competitor for a higher paying job, or maybe it's committing outright embezzlement that they're sure your fancy AI tooling will miss.

Are you sure underpaying your accountant is a good idea?

Tech work, the last bastion of Middle Class employment, isn't doing any better. Take Computer and Network Architects, with a median pay of $130,390 per year; or the Computer Systems Analysts, median pay of $103,790 per year; or the Systems Administrators, with a median pay of $96,800 per year. These groups have the keys to your systems, your data, your endpoints, your real estate. They can see and do anything with a keystroke, including destroying billion-dollar businesses. The reason for the comparatively high wages was their comparatively high degree of trust.

Instead, employers outsourced to MSPs, then offshored overseas, then on-shored to underpaid and exploited H1Bs shackled to their employer's temporary sponsorship, then briefly hired North Korean spies, and are now attempting to replace the technical workers outright with AI that routinely drops production systems. All the while they lay off workers by the tens of thousands, over and over again.

I feel like there's an example of the consequences of not treating your technical experts with respect in popular media...

Dennis Nedry is a fucking asshole whose actions endangering personnel and guests were reprehensible, but he did repeatedly make it clear he felt undervalued relative to his contributions...

I'm not Dennis Nedry, but I've worked with folks like them before. Brilliant minds who can debug complex architectures and systems, who pour their lives quite literally into the work because they have a passion for it...and increasingly are all too willing to burn it to the ground when they feel slighted. Spend time around actual engineers and the like in most orgs, and you'll see patterns of ill-health: smokers, drinkers, chewers, vapers, over-eaters, out-of-shapers, poor posture, bags under eyes, thinning and greying hair, high amounts of stress, messy desks. All signs of humans sacrificing their own health for their employers, prioritizing work over life, overworked to an early grave.

Most folks aren't as egalitarian as I am, and as someone who has sacrificed physical, mental, emotional, and psychological health to the field for over fifteen years, I sympathize with where my peers are coming from. Most people aren't wired to "do no harm" no matter what, which means most people are a huge security risk if they're undercompensated.

Thing is, undercompensation isn't limited merely to your specialists and senior workers. Fast food workers will slow down lines to give themselves breathing room due to understaffing, and retail workers won't put in the added effort of store maintenance when they can't even maintain a roof over their heads. Office workers doing more menial tasks aren't going to follow through on security best practices if they're more worried about how to pay the electric bill this month while also affording insulin. Your contracted-out security staff aren't likely to pay close attention to camera feeds since they know they'll be replaced in three months before benefits kick in. Your MSP or offshored technical staff won't be invested in your long-term success when their KPIs only cover ticket counts and response times, and their competitors are already preparing to underbid at renewal anyhow.

The workers have been incredibly clear about their problems for twenty years, now, especially the younger cohorts. Employers haven't wanted to listen, believing one more technical control or one more AI system will finally give them the permanent, unassailable leverage they need to keep all the money and fire all the workers.

Fuck you, pay me.

I don't really have a positive way to end this. This is a warning, another canary in an increasingly smoke-choked mine. We're at the point that workers are quite literally burning down infrastructure and engaging in violence against leadership, and the response from those who can change things - our politicians, our corporate leaders, the investor class that's richer than ever in human history - don't really seem to give a fuck. There's this thick tension in the air between workers scrambling to survive, and monied classes who feel the demands of the workers are wholly unreasonable.

History paints a pretty clear picture of how this ultimately ends, but for what it's worth, I still feel like I should at least try to warn folks about the consequences of undercompensation.

Failing to pay your workers the money they need to live is breaking the social contract. It's the single biggest security vulnerability in your organization, and I promise you that there is not, and never will be, a technological control that can protect against it.

You gotta pay up, or you're going to get burned down.

Milton was right.

An addendum.

AI is making it faster and easier to brute-force security vulnerabilities at a time when open source is falling apart due to lack of funding and successors. Major companies are firing engineers to replace them with AI tooling, then hiring them back at lower pay packages when the AI fails, but still holding the AI Sword of Damocles over their heads. Software is expanding rapidly at a time when employers seek to eliminate the technical professionals who ensure their safety and prosperity, who can translate institutional processes and knowledge into cost-effective infrastructure.

Housing prices are up. Rent is up. Utilities are up because of AI datacenter builds. Food costs are rising due to global conflicts instigated by America. So too are energy prices, tariffs, inflation, and interest rates.

You, the employer, have a decision to make: do you start raising wages, working with policymakers to immediately address affordability, cease arbitrary layoffs, invest in worker futures, and promote regulatory schemes that reign in the worst myopic excesses of your peers for society's collective benefit?

Or do you take up smoking cigarettes while sitting inside a warehouse of loose gunpowder and dynamite, with a mob of torches and pitchforks right outside?

Coco has had it up to here with your bullshit.
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mareino
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