PSYCH 406 (Psychopathology) - TikTok and Diagnosis

 Abstract

This essay discusses the trend of self-diagnosis for mental disorders by people consuming social media, such as TikTok videos. It then examines the complexity of proper diagnosis while discussing the challenges the DSM-5 faces in providing clear guidance on diagnosis. Lastly, it addresses the risks of self-diagnosis and steps people can take to not succumb to those risks.

Introduction

In the summer of 2022, my family was about to enjoy a much-needed vacation. But before we began the 1500-mile drive, we were slightly concerned about a noise from the family van. The van was dropped off at the local mechanic who regularly changes the oil in all our vehicles. Later in the afternoon, the mechanic called back and said the van would need a $7000 repair and even suggested buying a new car might be cheaper. Shocked by this diagnosis, we took the van to another mechanic we knew from buying a used car. After a day, this other mechanic said he had seen this problem in vans many times before and it would cost less than $500 to repair. Of course, we went with the second mechanic and the van is still working great to this day.

The risks and dangers of misdiagnoses can be significant, even for a mechanical car that is relatively less complicated than the human brain. In the case of our van, the misdiagnosis would have cost us significantly and the problem would still not have been fixed. However, for humans, the risks and dangers of misdiagnosing a mental condition can be even more substantial. 

With the widespread availability of information online and the broad reach of social media, the practice of self-diagnosis and sharing one’s story online has presented new challenges to the mental health community. The framework for diagnoses, including the use of the DSM-5, is intended to facilitate common understanding and nomenclature for psychologists and psychiatrists, as well as aid in predictions and information sharing and even guide therapeutic practices (Maddux & Winstead, 2016; David & Deeley, 2024). But despite significant research and debate, the DSM-5 is not perfect, which fact underscores the complexity of diagnosis. Even so, many unqualified and untrained people self-diagnose because of ease of access to the DSM-5 and because they hear others discussing their symptoms of disorders on social media. This practice has led to problems such as definition dilution and perceived absolution of responsibility for one’s actions (Cassata, 2024; David & Deeley, 2024). While self-diagnosis may have its place, individuals who choose this route should always seek professional assistance and remain open to the possibility that their self-diagnosis could be incorrect.

Self-diagnosis of Mental Disorders Via TikTok

Juliana Dodds (The Project, 2022) did not feel understood. In a search for answers, she turned to watching content on social media, including TikTok. When she heard others’ stories, she felt they could fully explain her perspective. Many people, like Juliana, are looking for answers as to why they act the way they do. For some people, the discovery of social media influencers explaining their symptoms becomes a launching point of self-discovery, which leads to a conversation with their psychologist and may confirm the diagnosis. However, not all cases are as straightforward as watching a video, talking to a therapist, and receiving confirmation of a diagnosis. Others may feel validated after watching social media, but when discussing the issue with a psychologist, and after being tested multiple times, the self-diagnosis is incorrect. Some patients become convinced they have a specific mental disorder despite what the psychologist says. Juliana falls in the latter category, and although her doctor diagnosed her with complex post-traumatic stress disorder, she is convinced she has attention-deficit/hyperactivity disorder.

The trend of self-diagnosis stemming from social media has become so pervasive, that a recent study was conducted to understand how accurate or inaccurate these influencers are. Cassata (2024) reviewed the study conducted by Drexel University’s A.J. Drexel Autism Institute and found that less than a third of the most popular autism-related content included correct information and that over 40% of those videos “were completely inaccurate.” The study further noted the extent of the misinformation, stating that many egregiously inaccurate videos had been viewed close to 150 million times. While the power and reach of social media grants millions of people access to potentially valuable information, which may kick-start them on the path to recovery, it nevertheless remains vitally important that proper diagnosis is applied. Often the diagnosis process takes time and can be very complex.

DSM-5 and Complexity of Diagnosis

The DSM-5-TR (American Psychological Association, 2022) contains over 1,000 pages of text, criteria, definitions, tables, and statistics. Countless hours of research and debate underlies the wide-ranging scope of mental diagnoses enumerated in the manual. In the section entitled “Use of the Manual” the authors both describe the extensive assessment that should be performed, as well as warn readers of the dangers of “simply [checking] off the symptoms” (p. 21, 2022). Indeed, case formulation should include a detailed clinical history and a succinct summary of the social, psychological, and biological factors that may have contributed to the development of a particular mental disorder. Even after all factors have been considered, ultimately, clinical judgment is critical in determining the relative severity and significance of an individual's signs, symptoms, and diagnosis.

Despite the numerous hours of research and effort poured into the DSM-5, a review of its history proves that this resource is not perfect. While great strides have been made to make it the valuable resource it is today, forthcoming editions and revisions will face difficulty in basing future additions on empirical support as well as managing the shift from a categorial model to a dimensional model (see Maddux & Winstead, p. 100, 2016).

With many research questions left unanswered, some take the approach of advocating for the addition of a disorder to garner attention so that empirical data could be collected on the disorder, as was the case with “severe irritability in youth” (p. 101, 2016). While perhaps a worthy cause, this practice has the risk of defining a disorder that does not truly exist. As to the shift in classification, more are beginning to recognize the consistent failures of the categorical model, and therefore the DSM-5 has begun the shift toward a dimensional model. Shifting to a dimensional model will allow for a continuum of mental disorders based on severity, frequency, or intensity, and will allow clinicians to provide a richer diagnosis as well as improved pathways to treatment.

In sum, the numerous considerations that should go into a diagnosis are guided by years of clinical training, as well as countless hours of research and debate to produce the DSM-5. Even with the critiques the DSM-5 faces, this situation further underscores the importance of a proper diagnosis by trained and qualified clinicians, and self-diagnosis from watching a TikTok video is fraught with peril.

Risks and Proper Use of Self-diagnosis

Virtually anyone can access the DSM-5. While obtaining this resource is easy, its use in diagnosing a disorder requires hours of training and practice. Many people will read the DSM-5 and begin to draw conclusions that they exhibit the hallmarks of a particular disorder. They may even take the added step of sharing their story on social media. Others follow proper channels and seek an expert to determine if the disorder warrants an official diagnosis. Two major risks of self-diagnosing are definition dilution (Cassata, 2024) and perceived absolution of responsibility for one’s actions (David & Deeley, 2024). While self-diagnosis, whether through reading the DSM-5 or watching a video on social media, may be the catalyst for the individual to get the help they need, they must not stop there. They ought to consult an expert and seek professional help.

One major risk of self-diagnosis is definition dilution. This means as more untrained people improperly explain a diagnosis on social media, the viewers of those misinformed videos also jump to inaccurate conclusions. The viewers, in turn, spread the misinformation, as well as become convinced they have a particular disorder. When a viewer visits a trained clinician and hears they may have a different disorder, the patient may become upset and even believe they are being gaslit (Cassata, 2024).

Another major risk of self-diagnosis is the perception that the patient is absolved of the responsibility for seeking a cure because fundamentally the self-diagnosing patient believes the symptoms they exhibit are normal and do not constitute a disorder. David and Deeley (2024) observed that self-diagnosis stems from “grass roots movements” such as the neurodiversity movement, which seek to “[reframe] several diagnostic categories as (mere) variations of normality” and even propose that these are not disorders (p. 1057, 2024). Once this concept (that a disorder is normal) is accepted (either individually or socially), the individual could assume an attitude that “the world needs to accommodate him and ‘his autism’” and he need not search for a cure or alter his behavior in any way (p. 1058, 2024).

There is room for allowing the potential for self-diagnosis, with several caveats. If a person has sought professional help and if in the course of exploring all possibilities, the patient discovers information on social media, and most importantly, if they discuss what they’ve learned with their trained mental health provider, then perhaps social media has a place in the diagnosis process. The Internet has connected billions of people. For some who may have limited resources and time, perhaps social media content might fast-track the diagnosis process. But the importance of not succumbing to naïveté cannot be emphasized enough. The patient should always keep an open mind when consuming social media and should generally be willing to trust trained experts. Cassata (2024) interviewed a trained clinician who wisely stated, “Social media, in and of itself, is not the enemy … the real threat seems to be our unquestioning, naïve relationship to social media and our belief that diagnoses can be self-made without consulting a professional.”

Conclusion

In conclusion, with the widespread availability of online information and the broad reach of social media, self-diagnosis and sharing personal stories online have posed new challenges to clinicians, psychologists, and therapists. The diagnostic framework, including the DSM-5, is designed to create a common understanding and lexicon for psychologists and psychiatrists. It also aids in making predictions, facilitating information sharing, and guiding therapeutic practices. However, despite extensive research and debate, the DSM-5 is not perfect, which further highlights the complexity of diagnosis. Nonetheless, many unqualified and untrained individuals self-diagnose due to the ease of access to information and exposure to stories influencers share on social media. This practice has led to issues such as the dilution of diagnostic definitions and the perceived absolution of responsibility for one's actions. While there may be a space for self-diagnosis, those who go down this path should always consult professional help and always keep an open mind that the self-diagnosis may be wrong. 

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders, text revision (5th ed.). American Psychiatric Association.

Cassata, C. (2024, April 11). Autism: TikTok Leading People to Inaccurate Self-Diagnosis (J. Peeples & J. Seladi-Schulman, Eds.). Healthline. https://www.healthline.com/health-news/autism-self-diagnosis-tiktok

David, A. S., & Deeley, Q. (2024). Dangers of self-diagnosis in neuropsychiatry. Psychological Medicine, 54(6), 1057-1060. https://doi.org/10.1017/S0033291724000308 

Maddux, J. E., & Winstead, B. A. (2016). Psychopathology : Foundations For A Contemporary Understanding (4th ed.). Routledge/Taylor & Francis Group.

The Project. (2022, December 6). Dr TikTok: People Using TikTok To Self-Diagnose Neurodivergent Conditions Such As ADHD Or Autism. Www.youtube.com. https://www.youtube.com/watch?v=qhx7PnHZ7cY&ab_channel=TheProject 

From Shipwreck to Fire

Remembering Heraclitus: Themes

If the dry, fiery soul is the wise, “enlightened individual” (Sweet, p. 59, 2007), then the damp, wet, or even drenched soul needs genuine, philosophical insight. And how curious to encounter this footnote in Remembering Heraclitus: “Ortega y Gasset in his Loss of Self in Art suggests that the philosophic impulse arises from ‘feeling shipwrecked upon things’” (Geldard, p. 96, 2001). The image is striking: a sopping-wet captain and his crew attempting to flee their ship that has crashed on craggy rocks! How far from being dry are those souls and in that sinking moment, when lives and fortunes are ruined, they are left wondering what has become of them. What twisted turn of events in navigation, reading bearings, and accounting of weather did they go afoul? They have become shipwrecked and now the process of recovery and the path to dryness and even fire begins – their first impulse to philosophy commences.

Perhaps the analogy can be further considered. Will the shipwrecked crew try again? Will they take the lessons they learned to heart to avoid a future shipwreck, or even despite their best efforts to avoid misfortune, will they nonetheless run aground unforeseen shallow rock? Is this never-ending cycle of flux their fate? Do their daimons lead them down this looping path to the point that their fate defines their character? And lastly, if they are to tread the endless path of flux, do they ever stop and wonder what their purpose is – what their telos is? Perhaps, like Zeno of Citium, a shipwreck offers transcendence and brings deep and fundamental discernment to the unfortunate soul, thus revealing their telos, and they never return to their former endeavor (see Long, p. 109, 1986). Is misfortune truly fortune? This essay will ruminate on these questions using Richard Geldard’s Remembering Heraclitus (2001) as the backdrop for the discussion.

Your Character is your Daimon

Fragment 119 is translated in various ways. Geldard (2001) notes that most translators translate it as “character is fate.” Sweet’s (2007) translation is “one’s character is one’s divine fortune” while Robinson’s (1991) is “a person’s character is his fate (divinity). As for Geldard (2001), he translates it as, “for human beings, character is the divine force.” There is a spectrum of interpretations for how one may grasp the meaning of this fragment. We may suppose our fate is entirely out of our hands and we seemingly resign ourselves to the fates the gods have doled out to us. Or we may interpret this fragment as a declaration of our freedom in which we get to control our attitude, narrative, and volition – we are the authors of our character. Geldard reviews various analyses of this fragment, one of which represents both ends of the spectrum as one and the same.

We have no say in the matter of which life we are thrown into. We don’t get to weave our DNA and choose our parents, nor even choose the best traits and aspects of our parents. In fact, we may even be chained with generational baggage, emotions, and “debt” if you take an Eastern philosophical view of the matter (see Geldard, p. 89, 2001). From this perspective of the fragment, our daimon is exerting destiny and fate upon us the moment our cells begin to replicate. But that is only one side of the coin, to reference the analogy Geldard uses. The other side of the coin represents the “so what?”

The character Andy Dufresne from Shawshank Redemption (Darabont, 1994) faced stacked odds against him, but how he responded to his fate (his daimon) ultimately defined his character. Indeed, our fate or perhaps our daimon, as our guardian spirit, senses the required obstacles we must face which act as catalysts for us to either succumb to defeat or to achieve a defining moment. From this side of the coin, then, we should not moan or gripe in the face of impediments, but rather we should thank the gods for showing us the way to finding our true character. As the well-known Marcus Aurelius passage teaches, regarding other people, the elements, and even wild animals, these are “hindrance[s]” and “obstacles” that indicate the “path” on which we can advance (Meditations 5, 20). In sum, our fate and impediments point the way to our character.

However, in a cosmos that never rests from change, we must be cognizant of the unending myriad of obstacles. We may think our character has been refined through the process of managing an impediment, but the reality is that the constant state of flux will demand we confront barriers endlessly.

Constant Flux

Fractals are intriguing mathematical constructs that exhibit self-similarity at different scales yet are vastly complex and ever-evolving. In other words, they are shapes that look similar or even identical depending on the focus and scale of the perspective. They're often intricate and detailed, yet they are built on simple repeating patterns or processes. Fractals can be found in nature, such as in the branching patterns of trees, the distribution of galaxies, the structure of coastlines, and even in the shape of clouds. Perhaps fractals are an apt metaphor for reality and existence as a whole: infinite, ever-changing, ever-evolving. Once set in motion, the math behind the fractal iterates and expands endlessly.

One of the major themes of Heraclitus is the nature of flux and the cause of it. According to Heraclitus, part of the process of acquiring wisdom is to be awake and conscious to comprehend “the thought that directs all things through all things” (Geldard, p. 46, 2001). Geldard then makes an interesting connection by quoting Anaxagoras who noted, “mind is infinite and self-sustaining, is unmixed, alone, and by itself …. [and] drives the whole revolution, so that it revolved initially, first in a small area and now more widely, and eventually more widely still” (p. 46, 2001). Could this description be applied to a fractal? Perhaps. And if this is the true nature of the Cosmos and as humans are intricately entwined in the details of the Cosmos, we must accept the idea that our own minds are tiny fractals in a larger fractal both of which are constantly changing and evolving and part of a massive chain which is infinite. Consider Fragment 45: “One would never discover the limits of soul, should one traverse every road - so deep a measure does it possess” (Robinson, 1991). Succinctly stated, change causes change and never ceases.

However, what does flux mean to the individual? First, the individual must heed the wisdom Heraclitus states. We must accept that change is constant and never-ending. To wail at the passing of every dead skin cell or formation of a wrinkle or to be overjoyed at the birth of a kitten or bloom of a rose is not wisdom. Implied in these overextensions of emotion is a desire for something to remain the same. A better reaction to change is to accept it and even embrace it.

Secondly, the individual must look both deeper into and take a wider perspective of the fractal. Upon further reflection of flux, and the more one becomes familiar with change, he will begin to note that there is a cyclical nature to existence. Seasons change; families shrink and grow; history seems both different, yet the same. If one becomes discerning enough, he will realize that feeling sadness or anxiety about change is folly, especially since he may have a chance to experience something anew. Spring flowers are never lost. Embracing a loved one on their death bed may seem to be final, yet sometimes we may feel we love the same soul in another person, such as the way a grandmother may have cooked a particular dinner is revealed again in the way a grandchild mimics the meal.

Lastly, for the individual facing endless change, perhaps the most important lesson for them to embrace is this: given the constant change and given the fact that the more change happens, the more we see similarity, then perhaps the long-term response to all flux and cycles is to live in harmony with the Cosmos – to live according to Nature as the Stoics would propose. One could argue that the individual should assume a long-term perspective and attitude about life. If change is constant and if we encounter repeat obstacles, then we ought to seek the choice that most aligns with the nature of existence. While an entire paper can be spent on this topic, instead of reading that essay, the reader may wish to watch and ponder two videos regarding the well-known economics game theory model called The Prisoner’s Dilemma. Video one (Agar, 2014) explains the prisoner’s dilemma, while video two explains the fascinating strategies employed while playing the game repeatedly (Agar, 2016). One, brief commentary on these videos is that the successful, long-term strategies used in iterative prisoner dilemma games are not unlike living a moral, virtuous life based on Stoic ethics.

Recurrence, to what end?

While applied ethics may be one reason to assume a long-term perspective, a related idea worth discussing would be the topic of ultimate ends for the individual. Geldard (2001) dedicates an entire chapter on telos and what we can learn from Heraclitus on this topic. This essay began by discussing philosophical and actual shipwrecks and how they are catalysts for change. The literal shipwreck must have been caused by one or many variables. Was the cause a faulty rudder, an incompetent navigator, or a lackadaisical captain, or were the elements – Nature – the sole causes of the ship crashing upon waves and rock? Were the captain and the crew completely helpless and only had God to blame for the crash? Once recovered on dry land or perhaps while drowning in the deep sea, they may have wondered: who’s in charge of all this or is it all chaos? What’s the purpose behind all this? Geldard contends that in Heraclitus’ perspective, there is “someone or something at the helm, which in turn implies a vessel with a rudder going somewhere” (p. 109, 2001). And with that implication, an aim for the individual could be found.

While Heraclitus does observe natural cycles and emphasizes constant change, he does not explicitly formulate a doctrine of recurrence or eternal return in the same way that later philosophers, like the Stoics and Nietzsche, do. However, there are a couple of gems found in Robinson (1991) and Sweet (2007) that indicate recurrence is a theme of Heraclitus and that with it, there is a heading to be found for the individual. Robinson quotes Aetius who wrote, “Heraclitus held that the recurrent fire is everlasting, and that destiny is a logos which fashions existent things through the contrariety of the directions in which they tend to run” (p. 173, 1991). Sweet, in his commentary on the themes of life, death, and the soul, discusses the dry and wet soul analogies of Heraclitus. He notes that Heraclitus proposes the soul gains power through wisdom and “becomes a dry soul” and “to the extent that it is identified with the universal fire” (p. 67, 2007). Furthermore, the truly wise person can attain such a degree of wisdom that their soul is unified with the universal fire and achieves a type of immortality. However, upon death, the wet or unwise soul turns to water and then earth and is merged into nature. While Sweet is not explicit, it could be assumed that the unwise person is reincarnated to try again, as it were.

Therefore, if it were assumed that flux is endless and recurrent and that individuals are tossed into the mix over and over again until they get it right and only when they become wise do they find an exit through unity with the universal fire, is this our answer to what our telos or aim in life is? One perspective Geldard brings into the analysis is that of Fowles. In this endless flux (what Fowles calls “The Situation”), “the only telos possible is an existential one” (p. 112, 2001). He quotes Fowles who writes, “To accept one’s limited freedom, to accept one’s isolation, to accept this responsibility, to learn one’s particular powers, and then with them to humanize the whole: that is the best … for this situation” (p. 112, 2001). In brief, one perspective is to simply accept existence as is. However, if this may seem distasteful, perhaps a more transcendental attitude of existence might invigorate life. Geldard offers the aim of unity with the Cosmos, or to be more precise, metaxy.

Fragment 10 focuses on the unity with the whole. “Seizures – wholes and non-wholes, being combined and differentiated, in accord and dissonant: unity is from everything and from everything is unity” (Sweet, 2007). Fragment 30 similarly notes, “this cosmos [the unity of all that is] was not made by immortal or mortal beings, but always was, is and will be an eternal fire, arising and subsiding in measure” (Geldard, p. 129, 2001). Geldard proposes that “the unity is the telos” of the human and that many texts from the same period of Heraclitus reflect this desire for transcendence away from the human existence Fowles describes and towards a metaxy or “in-betweenness” – a place between human existence and the Logos (p. 113-114, 2001). Geldard then reviews similarities between the teachings of the Old Testament prophet Jeremiah, the Buddha, and Lao Tse and the fragments of Heraclitus, all of which offer ideas for achieving unity.

Practice Again and Again

Since the individual finds himself in an endless flux that recurs, and his telos is to transcend into metaxy, what key lessons must he practice repeatedly to achieve his telos? Geldard notes similarities between Heraclitus and his peers of the time. The first is Jeremiah who calls the people, like a shepherd to his sheep, to “feed [on] knowledge and discretion” (p. 116, 2001). Geldard notes that this call to knowledge and discretion invokes a greater individual responsibility for people to come to God’s terms and perspective. In a similar vein, Heraclitus teaches that “to God all things are beautiful, good and just” (p. 116, 2001) and humans irresponsibly assume a narrow, closed-minded perspective. If we are to achieve our telos, we must practice abandoning our restricted point of view and practice embracing the perspective of the Cosmos.

Related to the practice of assuming a Cosmic attitude is the work of letting go of the ego and its related attachments and embracing the will of the Universe. Geldard references the Buddha’s doctrine of separating the selfish ego of one’s identity and in its place, assuming an identity equal to that of Divinity. When we cease being fearful of losing ourselves and cease the longing for fame and ego, we begin to break “the bonds of attachment” (p. 118, 2001). Heraclitus similarly admonishes in Fragment 2 that we must “obey the universal” and not be like common people who cling to their own “private understanding” (p. 119, 2001). To achieve our telos, we must practice relinquishing our selfish egos every day. Every flinch or snap judgment towards grasping at some portion of fame, or power or status should be met with practicing a desire to flow with Nature and being unified with the Nature of things.

Lastly, Lao Tse noted the tension of justice in the Universe by observing that tautness is needed for a bow to succeed. If there is no tension because the string is too long, then the string must be shortened and if there is not enough string, then it must be lengthened (see p. 120, 2001). A sage practices and demonstrates his knowledge rather than simply retaining it. True, divine understanding and judgment is not simple learning, but rather, being truly awake and aware and acting accordingly. To this end, Heraclitus teaches us to not heed him, but the Logos (Fragment 50) and that common humans do not have good judgment, but only divine judgment is good judgment (Fragment 78). Therefore, to achieve our telos, we must avoid the common and instead practice observing true wisdom. It will take skill to know when to apply a virtue and how much or how little for the right amount of tension.

Conclusion

The idea of a philosophical life beginning from a shipwreck is not novel. Many observers through the years have found the analogy quite compelling. Vidauskytė (2017) notes that not only is a shipwreck a metaphor for the initiation of a philosophical life, but that seafaring also signifies the human discontent with staying on land and the desire to transcend the human domain of land and venture out to the beyond. She rightly observes Diogenes Laertius commentary on Zeno of Citium, who survived a shipwreck and traded his lost cargo of purple dye for living a philosophical life on dry land. But not everyone’s fate is a shipwreck. Our character is defined by our fate, through the endless flux of impediments and obstacles. And sometimes, the monotony and recurring nature of existence forces us to wonder what our ultimate aim is. Perhaps after enough voyages and challenges, we arrive at true wisdom and begin to see the Cosmos as it really is – we lose our common ego and pivot to a desire to be at one with Nature. With enough practice of taking the Cosmic perspective, laying aside our ego, perhaps we achieve transcendence, return to land, and dry our soul by a flaming, wise fire.

References

Agar, J. (2014, October 4). The Prisoner’s Dilemma. Www.youtube.com. https://www.youtube.com/watch?v=t9Lo2fgxWHw&ab_channel=ThisPlace

Agar, J. (2016, July 2). The Iterated Prisoner’s Dilemma and The Evolution of Cooperation. YouTube. https://www.youtube.com/watch?v=BOvAbjfJ0x0&ab_channel=ThisPlace 

Aurelius, M. (2014). Meditations (M. Hammond, Trans.). Penguin Classics, An Imprint Of Penguin Books.

Darabont, F. (Director). (1994, September 10). The Shawshank Redemption. Columbia Pictures.

Geldard, R. G. (2001). Remembering Heraclitus. Lindisfarne Books.

Long, A. A. (1986). Hellenistic philosophy : Stoics, Epicureans, Sceptics. University Of California Press.

Robinson, T. M. (1991). Heraclitus : Fragments. University Toronto P.

Sweet, D. (2007). Heraclitus : Translation and Analysis. University Press of America.

Vidauskytė, L. (2017). Metaphor of Existence: Seafaring and Shipwreck. [Egzistencijos metafora: kelionė jūra ir laivo nuskendimas] Filosifija Sociologija., 28(1), 11-19.