ADHD. Again.

(Apologies for banging this drum again...)

I had intended to give ADHD a break for a while as I'm bored with it and I'm sure many readers are. However, this week I rather impulsively volunteered to watch a "masterclass" on ADHD diagnosis and treatment, sponsored by the college of psychiatrists. It consists of three one hour videos but so far, I've spent about five hours on just the first. There's an important point here, something I tried to publicise ten years ago, with no success. We'll come back to that point after a summary of the lecture (it's not generally available but times are shown as mins and secs).

The speaker was a full professor of Melbourne University who holds the "Financial Markets Foundation Chair of Developmental Mental Health, Depts of Psychiatry and Paediatrics." He gave the impression he had given this talk many times as he simply read from the powerpoint slides and added very little to what we could also read. He started with two excerpts from a children's book from 1845 which showed boys described as "fidgety" and "day-dreaming," to prove that ADHD has been around forever. He then gave statistics of the incidence and rates of diagnosis in different parts of the world. The general rate, he said, is 5.2% of children and 2.5% of adults but treatment rates vary dramatically, from 11%+ in many parts of the US (i.e. serious over-treating) to practically none throughout most of the world. Prescription rates in Canada are 8 times those of the UK, while Australia is twice that of New Zealand, even though the populations are identical and psychiatrists in each country are trained to the same curriculum.

At 12.00mins, he said: "I won't dwell on this last slide." It was soon clear why: 12 months after starting the drugs, 35% of children and 55% of adults have stopped taking them. At 5yrs, 81% of adolescents and adults have stopped them. He thought that was due to "lack of support ... how we support someone to continue with the drugs makes a big difference." That is, left to their own devices, people decide the drugs are no good. There was little doubt that "support" meant "pressure."

At 15.55, he asked: "So what is ADHD?" A fair question. I would have expected it in the first minute but we got the proof it exists before we got the definition. However, he didn't answer it. All he did was read the diagnostic criteria from the DSM5, which describe it but don't define it. So the whole session was on an undefined topic. There's an important point here that I've been making for years, with no impression. A definition consists of three parts: a name, a description, and a cause. For example: "Malaria (name) is a chronic relapsing febrile illness characterised by... (description) resulting from infection by the plasmodium parasite (cause)." There has to be some part of the definition that makes it unique. In malaria, it's not the fever that is unique, it's the specific cause. In ADHD, there is nothing unique in description, and the cause is "biological," which is too vague to count.

AT 18.50, he said: "In order to make this diagnosis, you need to be talking to someone, you can't just do this by questionnaire ... (22.30) Assessment for ADHD takes time." This is important because there are now "ADHD factories" that give people a few questionnaires, send them for an EEG or CT scan and then dish out the drugs, twenty minutes "work" in return for a few thousand dollars.

Who should be assessed for ADHD? Anybody with any sort of mental trouble, or a police record, or a history of drugs, alcohol, gambling, or a family history of ADHD... That covers about 80% of the population, although at 28.30, he conceded: "It is not uncommon to find somebody who appears too eager to have diagnosis of ADHD as a solution to problems that are not related to ADHD."

There were no examples of what could be a problem unrelated to ADHD but he segued easily into a list of celebrities "with ADHD." These included Mr Richard Branson, whose diagnosis, very late in life, was based on "several business failures," Mr Will Smith, based on "tax problems and relationship issues, and Ms Paris Hilton, based on "several issues." The speaker left no doubt that every time anybody stumbles in life, especially the rich and famous, and however briefly or explicably, it is due to undiagnosed ADHD for which they must rush to a sympathetic psychiatrist for urgent treatment. My daughter said that Ms Hilton only decided she needed a diagnosis when her ratings were falling and she saw how everybody rallied around Britney Spears in her saga.

He then showed lists that purported to prove that ADHD causes practically all human problems, including crime, drug and alcohol abuse, suicide, violence, gambling, anxiety, depression, school refusal, excessive time on TV or computer games, premature death from any cause, etc etc. It would seem that the only human follies not caused by ADHD are wars and paedophilia. Now we reach the crunch point because, at 39.30 he said: ADHD increases risk of all mental problems.

At 41.00, he said: "It is uncommon to see ADHD on its own." (i.e. without another diagnosis). If you have another diagnosis or social label, the chances that you will also have ADHD go through the roof. For example, if you are anxious, your chance of having undiagnosed ADHD is about 7%, or more than twice the norm. What he said was: "...there is odds ratio of 2.4 with just anxiety. I say just anxiety but I know anxiety is a, er, big problem when you have it... but it's not one of those severe and enduring mental illnesses that people often think..." I'm sure that was reassuring to all the people suffering anxiety but what does this mean?

43.10: "Everybody here (i.e. all the psychiatrists being educated) will be seeing patients with ADHD whether or not they're treating them and recognising them... Why do we have increased comorbidity with ADHD? There are several potential reasons... The symptoms of ADHD mimic other common mental disorders (because they share genes)... there is symptom overlap with other neurodevelopmental disorders, autism spectrum and specific learning disorder, and ADHD as a developmental risk factor for personality disorder, bipolar disorder, anxiety, substance abuse, depression, etc." This is crucial: because he had said ADHD is a genetic disorder, it necessarily precedes all of the above diagnoses. That is, he believes ADHD actually causes all these conditions.

Part of the trouble, he agreed, is that ADHD mimics other conditions, i.e. it has lots of the same symptoms. That means, he said, that people are wrongly diagnosed with anxiety or depression when they really have ADHD. The other part of the trouble is that psychiatrists aren't properly trained to recognise and treat ADHD. When a patient says "I feel depressed and suicidal," the psychiatrists don't understand that they are saying this because they have ADHD (the same ADHD that he hadn't defined). He confirmed this at 46.12: "That risk model...ADHD as a risk factor for the development of co-occurring conditions later in life, antisocial behaviour, addiction, depn, low self-esteem, anxiety..." (my emphasis). ADHD causes all these conditions. He then spent a few minutes showing how what we dimwits in the audience thought were anxiety and depression and bipolar disorder and so on are actually ADHD. That's why people don't get better, they're being misdiagnosed and mistreated by poorly trained psychiatrists. That's what he said.

At 53.00, he was asked a question on childhood trauma and ADHD.

Answer: "People with ADHD are actually much higher at risk of suffering from trauma and that includes trauma of sexual abuse, of physical abuse..." From the context, it seemed he was saying that pre-existing ADHD contributes to sexual abuse in the same sense it contributes to car accidents, drugs or criminal behaviour etc., i.e. it predisposes to impulsive, risk-taking behaviour. He could have said that having a mild or subclinical form of ADHD predisposes people to react badly to stressors, such as sexual or other abuse, because that would sound scientific even though, without a test to find "mild or subclinical forms of ADHD," the whole thing is pseudoscience, but he didn't say that. As it stands, the claim he seemed to be making is so outrageous (and totally unscientific) that I will contact him to clarify the point.

The message came through loud and clear: anybody who shows the cluster of symptoms of being restless and fidgety, with poor concentration, patchy memory, impulsivity and so on, just has the diagnosis of ADHD. It doesn't matter how these symptoms arose or what contributed to them, if you've got those symptoms, you're ADHD (as they say) and you must be put on drugs. Powerful and addictive drugs, with a lot of side effects. For life. Even though most people choose to stop them. And ADHD is a genetic disorder so it necessarily came before any life experiences and it must have contributed to them because ADHD makes people careless and impulsive. Like hanging around with people like Rolf Harris or Russell Brand?

The whole thing is becoming absurd. There is no doubt this professor believes heart and soul in ADHD and he wants everybody else to share his passion. There is also no doubt that he doesn't understand some very elementary points of logic, like inventing an extra diagnosis to account for symptoms that are fully accounted by the primary diagnosis. Anxious people are, of course, fidgety and restless and don't like waiting in queues and can't concentrate and don't remember what is said to them, just because they have the (very serious) condition called anxiety. That's what anxiety is, that's what anxiety does. There is no reason to invent a further diagnosis to account for those symptoms ... Or is there?

If we look at the larger picture, we see that some five million kids in the US, and many more elsewhere, are now taking addictive and expensive drugs in the long term. That market was saturated, so starting about 10 years ago, everybody decided they needed to worry about ADHD in adults. I mean, if you've got it at 16, it isn't suddenly going to resolve by 18, when the drugs had to stop. So there was a campaign to convince psychiatrists to find it in men, and now we're seeing the campaign spread to women and girls.

So back to what I said was an important point I tried to publicise ten years ago, with no success. It's true that there are people with personality disorders, lots of them, but modern psychiatry has no treatment for them. In three chapters published in 2012, I said that psychiatry is engaged in a long-term project of rediagnosing personality disorders as mental illnesses, for which it does have treatment (drugs, albeit terrible). The purpose was to spread psychiatry's influence, to make lots of money treating all these unfortunates who had been ignored for so long, and possibly to help sell more drugs for the drug companies that financed the research to show that ADHD exists and is a real problem and everybody needs their expensive drugs. What we're seeing is an extension of that project. Give more people more diagnoses so they take more drugs. This is Marketing 101: When a niche market is saturated, extend it to other sectors.

What's the professor's role? It's ironic that he holds the "Financial Markets Foundation Chair" because, as a True Believer, his passion is used to sway the unbelievers. He is, as Lenin didn't quite say, a "useful innocent," somebody who can be manipulated from behind the scenes to spread a message that the public wouldn't trust if it came from the people who are making all the money from this roadshow (i.e. the same "financial markets").

And I, for one, believe that anxiety is indeed very serious. But it certainly isn't improved by sticking everybody on amphetamines.

The whole thing is pseudoscience. I need a break before watching the other two videos. Grrrr.