This has been a busy week for the merchants of ADHD. According to our good friends at Psychiatric Times, we are "...amid what is being called the “crisis of our time” in terms of children’s mental health," namely, the fact that over 3million US children have been made dependent on stimulant drugs. Now, the pigeons are coming home to roost as forty years of relentless propaganda about the need to drug "deviation" in children means that (wait for it)... the drug companies are running out of drugs. This is true. You would expect that they would simply crank up the machines but for some archaic administrative reason, producers are restricted to last year's supply of ingredients to make this year's batch of drugs. However, over the pandemic, the numbers of people taking prescribed stimulant drugs jumped by an implausible 8% in a year. As a result, pharmacies across the US are out of these highly addictive chemicals just as children start the new school year.
We are now moving into surreal territory. It's one thing to beat up a moral panic (defined as: "a widespread fear that some great evil threatens the values, interests, or well-being of a community or society") about a brain disease in children, it's something else again to say "Sorry folks, we got it wrong, there's no treatment after all." For the wealthy, whose sprogs go to select private schools, it's not a problem as they can simply pay the difference between generics and name-brand drugs and problem solved, but for ordinary people, and for those on Medicaid (for the poor), it has the makings of a catastrophe, as one senior psychiatrist described:
When children fail to get their prescribed medication for ADHD, their symptoms become more prominent and may become difficult for them and their parents or teachers to manage. There are psychological ramifications for the child because they will be experiencing difficulties with completing tasks they are used to doing, and they may become anxious or depressed as a result. I have seen several patients whose grades dropped in school and whose behavior worsened at home to the point where they were in crisis...
This effect is, of course, better known as "drug withdrawal," but nobody is allowed to say that. The obvious question is "Why are so many people taking these drugs?" Why did prescriptions for stimulants explode by 8% a year during the pandemic? Can we possibly blame those crafty Chinese in their Wuhan lab for this, too? Probably not. In a completely unexpected confession, former president of the American Psychiatric Association and well-known propagandist for biological psychiatry, Jeffrey Lieberman said:
I think the problem is not so much that we have a shortage of medication, but instead an overdiagnosis of the condition. There is no way that ADHD, as reflected by prescriptions for psychostimulants, can be multiples in frequency to what they are in western Europe and in other parts of the world. The question is: How and why is this happening?
Of his penetrating insight, we could say "Better late than never," but the answers are probably that having to look after their little darlings all day in apartments, unable to go out and play, drove the parents mad so they had their children drugged to slow them down. As for the adults, because the increase is mainly among young adults, same again: unable to go to rave parties and the like, they did what young adults do today, reach for the pill bottle. But this is entirely a social phenomenon, not medical in any way except society now reacts to any social problem with a medical solution. Granny's lonely stuck in her little flat all day? Give her antidepressants. Shy teenager? Antidepressants. Can't sleep due to worrying about work? Hypnotics, followed by antipsychotics when they wear off. Erratic and impulsive teenager? Aha, here the story gets a bit complex, because they may have not one but two or even more diagnoses, for which they need lots and lots of drugs. For life.
A story from 2021 in Psychiatric Times (again) said that children with a diagnosis of ADHD had ten times the rate of a diagnosis of bipolar disorder (that's 1,000%) than other children. The first response to this news is "Well, that's what those drugs do, they make people go mad," but that's excluded. According to DSM5, what most of us would call "adverse drug reactions," such as "manic switches," are not due to the drugs at all (p124, p133), they are due to the drug "uncovering the pre-existing illness." About 15% of all people prescribed SSRI antidepressants will experience bouts of intense and unpleasant physical and mental agitation but with stimulants, the risk is higher.
What this says is that a person (of any age) who can't concentrate for whatever reason will quickly end up on a swag of drugs for life, because (a) they're all addictive, (b) they all cause severe side-effects which are labelled as separate diagnoses, (c) nobody provides information on how to withdraw from them and (d) forget that psychosocial stuff, it's all biology. And as the shortage of drugs in the US shows, abruptly stopping powerful psychoactive chemicals will always result in severe withdrawal effects:
... after her twin 7-year-old daughters with severe ADHD had to go without their medication, a mother reported they were “hitting teachers, throwing dirt, and destroying the classroom.” She added it caused “hell” in her family.
So it was with mounting excitement this week that I waited for a Zoom lecture from the college of psychiatry on Personality Disorder and Neurodevelopmental Disorders: is there a link? This brings up the concept of "comorbidity," meaning a person has two or more distinct diagnoses which need treating. It's a bit like general medicine, you can have rheumatoid arthritis and pneumonia as separate, unrelated conditions, each of which needs treatment. Former director of the US NIMH, Dr Steven Hyman, said "comorbidity bedevils clinical practice" [1], meaning they can't work out what to do with the idea.
When this lecture was announced a few weeks ago, I lodged my application within a few minutes as well as my question, so my question must have been very close to the top of the list, if not there. The speaker, a professor with a paragraph of qualifications and appointments, was introduced with the rather touching acknowledgement of, among others, "all our neurodiverse listeners." Unfortunately, even though I was listening closely, I did not detect a definition of that term or of "neurodevelopmental." According to DSM5 (p31), these are "a group of disorders with onset in the developmental period." There is no explanation of where the "neuro-" bit comes from, or why stuttering is lumped with intellectual handicap.
The speaker conceded there is very considerable overlap between the concepts of personality disorder (PD) and neurodevelopmental disorder (NDD) and referred us to DSM5. There has been a massive increase in diagnosis of autism spectrum disorder (ASD), from 1/5000 in 1975 to 1/60 today (about 8,500% increase). This is also true of other NDDs such as ADHD, specific learning disorder (SLD), Childhood-Onset Fluency Disorder (SOFD) (stuttering, for older readers), Social (Pragmatic) Communication Disorder (SPCD) (a new one) and so on. "Why the increase?" he asked. "Is there an epidemic?" Good questions. Partly, he said, the increase is due to changes in diagnostic criteria (which Allen Frances, chairman of the DSM-IV committee, says was a grievous mistake). The new concept of a "spectrum" means that there's a place for everybody in the queue (it used to be called a 'continuum' until that term was shown to be nonsensical); constant publicity about mental disorders; controversy over the role of the National Disability Insurance Scheme (NDIS) in such conditions; the availability of special purpose funding for schools and other agencies and, finally, huge increases in school diagnosis of NDDs and, of course, self-diagnosis with Dr Google.
What do PD and NDD have in common? Everything, it seems, whereupon the speaker lost me in a welter of abbreviations before he surfaced again with ADHD and ASD. These show 60-80% comorbidity, after which the thrust of the talk changed, via a case report of fairly awful neglect and abuse of a child by the parents, to show that the problem is somehow the child. It seems that having an odd child can convert "good enough" parents into critical, dismissive and generally hostile/neglectful parents. Why is the child odd? Because s/he/it has a neurodevelopmental disorder, and because it's "neuro," it had nothing to do with the quality of the family life, except to make it worse. Somehow, he sequed into comparing ADHD and something called "Rejection-Sensitive Dysphoria," a new one for me, which is:
... 'unbearable' pain as a result of perceived or actual rejection, teasing, or criticism ... a brain-based symptom that is likely an innate feature of ADHD. Though the experience of rejection sensitive dysphoria can be painful and even traumatic, RSD is not thought to be caused by trauma.
This was accompanied by a Powerpoint slide of boxes and arrows of almost Byzantine complexity which led to rapid-fire discussion of Borderline Personality Disorder (BPD), mind-blindness, hypermarginalisation, psychopathy, ADHD, ASD, Theory of Mind etc in BPD... After 45 minutes of this, I scrawled in my notes: "I can't stand this. He is simply reciting unrelated facts with no model to hang them on." Then followed a discussion of transcranial magnetic stimulation (rTCMS) in BPD, ASD, PTSD and various others until the speaker was interrupted to thank him for a "wonderful, fascinating presentation" and to remind him it was nearly time to finish and be sure to leave time for questions. Aha, my question must have been at the top of the list. At 6.51pm, I scribbled "I have to wait to the end of this to be able to say they wouldn't answer my question."
The rambling continued except for one gem, a mention of "the pandemic of overdiagnosis of childhood bipolar disorder in the US." Other than that, I commented "He is talking inconsequential nonsense but it gives the impression of great scholarship. In fact, it is bullshit." As I had fully expected, my question didn't get a mention, which is why I submitted it:
"What is the name of the model of personality you use in your practice, teaching and research? How does it lead to a model of personality disorder?"
Of course he wasn't going to answer that question. He can't answer it because, as a fully mainstream academic psychiatrist, he doesn't have any theory of mind, any model of personality or any concept of personality disorder as it flows from that model. All he could do was rattle on about DSM5, which is a categorical classification of personality disorder, not a model. The difference is critically important: the DSM system sorts mental disorders into groups or categories, which are supposed to be completely separate and distinct. It gives unique diagnostic criteria for each distinct mental disorder so there is no overlap between the different diagnoses. That way, different psychiatrists can see the same patient and reach the same diagnosis. That is called "reliability," meaning the diagnostic criteria reliably sort the patients into their groups.
The purpose behind this is that each diagnosis should map down on to the genome, yielding a specific genetic defect for each disorder. Then the Brave New World scientists will come up with a particular drug for each diagnosis and the problem is over. What this approach doesn't address is the question of "validity," whether the specific diagnoses are, in fact, real things. For example, is stuttering a biologically distinct condition from all the other signs of anxiety in children (and adults)? No, it's not. The DSM system doesn't bother about validity, that's something else again. It is about description, not about explanation, which is why we can state so confidently that the idea
that so-called Rejection-Sensitive Dysphoria "is not thought to be caused by trauma" is pseudoscientific rubbish. They can't say this because they have no explanatory model, no concept of how this thing (if it is actually a thing) comes about. They say it because it fits with their ideology of mental disorder as a biological condition, not because they have any understanding of what people feel about events in their lives. How can I be so sure of this? Because their concept of science actively excludes any mention of minds, feelings, beliefs, hopes, etc. It is a psychiatry stripped of the very mentalism that separates us from zombies.
I had more stuff to mention but that's enough. A day after enduring that lecture, my "certificate of attendance" arrived, allowing me to claim points for continuing education. Fortunately, I'm beyond all that now but it has to be understood that the process of education in modern psychiatry has nothing to do with the central concept of scientific progress, criticism. It is about uncritically absorbing what the "key opinion leaders" say must be absorbed in order to become and remain a member of a movement that does not have any of the features of an empirical science, let alone the features of an empathic, human-centred service.
As for the relationship between personality disorder and "neurodevelopmental disorders," the reason Dr Hyman can't make head or tail of it is because he has no explanation for mental disorder beyond "chemical imbalance of the brain." He simply can't comprehend that a person could be anxious and irritable as a result, or angry and miserable as a result. For him, one of the main architectsof the biological drive in psychiatry, they have to be distinct, genetic conditions. But that's what happens when you don't understand humans as thinking, feeling critters reacting to events in their lives. You end up treating them like cattle.
1. Hyman S. New Evidence for Shared Risk Architecture of Mental Disorders.
Published Online: January 16, 2019.
doi:10.1001/jamapsychiatry.2018.4269
Prof. Dainius Puras, former Special Rapporteur on mental disorder for the UN Human Rights Commission, is visiting Australia this week to speak at a conference in Adelaide. The Critical Psychiatry Network managed to get him to slip in a brief presentation on Tuesday 15th August. I will be watching on Zoom and will report back. I would love to ask him his view of Australia's refusal to allow the UN Subcommittee on Prevention of Torture to visit our mental hospitals in October last year but he can't comment on such matters. I still haven't received an answer from the Qld Attorney General over why the visit was blocked.
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