In between their conniptions over the American election (the one where the majority doesn’t win), The Economist carried an article on ADHD. I’m seriously over ADHD (and elections) but there’s heaps of gold still to be mined in that particular field so it’ll be around for quite a while. This article, however, isn’t written by medical people looking for gold, so it doesn’t follow the usual line of "ADHD is everywhere but don’t worry, psychiatry will rescue you with its amazing drugs.” Instead, they give figures showing the rate of diagnosis is heading to the sky while prescription rates for stimulant drugs in the English NHS doubled in the five years to 2023. That’s doubled in 5 years. However, despite this excitement, they said “a growing number of experts … question whether it should be seen as a disorder at all.” Part of this is diagnostic: “The inner restlessness in ADHD can, itself, be easily mistaken for anxiety.” Another part comes from the fact that symptoms are very much dependent on the surroundings:
Children do better in life if parents and teachers provide a supportive, warm environment with structure and rewards for academic and behavioural achievements ... (for) adults, ADHD symptoms “go underground” when they are in jobs and relationships that play to their strengths …
That didn’t deter the nice people at Psychiatric Times, who cheerfully announced that ADHD is an “overlooked cause of persistent anxiety and depression in adults.” They started with a quick story on a 21yo man with a diagnosis of “treatment-resistant anxiety.” His symptoms “seemed to come out of nowhere when he was in middle school” (which is just what anxiety symptoms do) so he saw three different psychiatrists over the next 10 or so years. In that time, he had been given CBT and no less than sixteen different drugs, all with no benefit but lots of unpleasant and/or dangerous side effects (they didn’t mention his sexual interest but that would have gone too). The thrust of their article is that unrecognised ADHD actually causes anxiety, depression, drug and alcohol abuse and suicide bids (presumably some successful) so psychiatrists and everybody else must always be alert to make the correct diagnosis.
They point out that the symptoms of ADHD overlap with practically every other diagnosis in the book so patients should be given questionnaires to help make the correct diagnosis. Now this leads straight to a problem, because most questionnaires happily jumble symptoms of this, that and the other but, at the end, invariably pull the ADHD rabbit out of the hat. For example, the Jasper-Goldberg Adult ADHD Screen asks whether:
4. I have a quick temper … a short fuse.
9. My mood has highs and lows.
11. I easily become upset.
First, who doesn’t? Second, why are these symptoms of a brain disease called ADHD? Why is a quick temper not personality disorder or highs and lows not a problem with moods? Being upset, of course, could be anything from normality to psychosis, which helps explain a finding in another paper. Studying adult patients, the authors found that the rate of diagnosis of ADHD using DSM-IV-TR (from 2000) was just on 7%, but using the latest version, DSM-5 from 2013, the rate went up to 9.25%, one third more. Same patients, different diagnosis. The point is that the diagnostic criteria are so imprecise, so rubbery that what they think is “precision psychiatry” makes it possible to diagnose a ham sandwich with ADHD. Psychiatrists who are determined to find ADHD can easily do so without feeling guilty and it’s impossible to convince them they could be wrong. Those, of course, are central features of a cult.
Given all this vagueness, the article in The Economist is more reasonable. Of the search for the biological cause of ADHD, they conclude: the huge amount of research conducted at vast cost by innumerable teams of different specialists in so many centres of so many countries over so many years has yielded nothing worthwhile. Well, after all these years, it's nice to see they’ve come to their senses: just six years ago, they published an article on an enormous international project (a genome wide association study, GWAS) to find the genetic cause of ADHD and how this would transform treatment rah rah, but it’s now clear it came to nothing: “Scientists looking to simply (diagnose ADHD) with a checklist of biological markers have come up empty-handed.” As we’ve been telling them for years, but this forces them to confront a scary thought: perhaps we should stop saying that the symptoms of ADHD are necessarily evidence of a brain disease (especially one for which there is no evidence) and start to accept the astounding thought that humans, meaning children and adults, male and female, young and old, aren’t all the same? Just as humans are of different heights and weights and colours and shapes, perhaps they’re mentally different as well? OMG, pass the smelling salts, who could have expected that?
This epiphany leads to the radical idea that “one size fits all” may not be the best way to run our schools and training schemes and workplaces and so on. Rather than relying on drugs, perhaps we should look to modifying the environment so it suits the individuals better? For a child with ADHD symptoms, they suggest “a supportive, warm environment with structure and rewards for academic and behavioural achievements.” But isn’t that every child’s birthright? All they’re saying is that children with a good home and school will do better than those whose parents drink and brawl and whose school says “You’re sick, you’re weird, take these drugs and shut up.” It’s across the board: children who have a good home don’t suffer as many illnesses or injuries as children who don’t. That doesn’t mean there is anything biologically wrong with the unfortunates, it just says they’re not being looked after properly. The problem is clear: psychiatrists are determined to find illness in natural variation, they need it to justify their belief system.
It goes further than that, however, as the story of the 21yo in the Psychiatric Times article shows. He had previously been diagnosed as “treatment resistant anxiety” with “panic attacks and severe anxiety … inattention and hyperactivity since elementary school.” Because he didn’t get better with the sixteen drugs he was given, he was rediagnosed as having primary ADHD and secondary anxiety and given extra drugs (we aren’t told whether it helped or not). Two things scream out about this case: when it comes to making a diagnosis, psychiatrists can’t tell what’s primary and what’s secondary and, having made the diagnosis, they don’t know what to do.
Psychiatry has only a limited number of symptoms and it’s normal for people to present with symptoms from half a dozen diagnoses. That means the diagnostic system is at fault, not the individual. A person with social phobia is weepy and feels life will never improve, so may as well end it now. Somebody else believes people talk about him and spy on him so he stops going out and avoids people but then gets very unhappy. An person worries that people talk about her and are watching her for signs of abnormality so she tries to conceal it by being loud. This sort of thing is normal and the crucial question is: what came first? It’s essential to know the primary cause because that decides the treatment. But for mainstream psychiatry, the cause is always something biological. Mainstream psychiatry doesn’t deal in sequences of events and it certainly doesn’t accept that one mental disorder could itself be the cause of another. That would mean the whole thing is psychological, not biological, which they won’t accept. For example, the idea that a person with serious social phobia could get depressed because life sucks is not even considered: the anxiety and the depression have to be two separate and unrelated diagnoses because the genetic defect that causes anxiety can’t also cause depression. This is where the idea of “comorbidity” comes from, where people end up with half a dozen separate diagnoses, each of which requires its own drug treatment, all of which cause side effects, and nothing gets better.
The second screamer in the case vignette is so obvious the authors and editors of the article couldn’t see it: If a 21yo person with a common disorder like anxiety with panic attacks is given, one after the other or all at once, sixteen different drugs, then it is perfectly clear that none of the psychiatrists know what they’re doing. Res ipso loquitur, the facts speak for themselves: speaking as a chorus, buspirone, fluoxetine, escitalopram, phenelzine, mirtazapine, bupropion, aripiprazole, quetiapine, olanzapine, pregabalin, clonazepam, lorazepam, valproate, lamotrigine, lithium, and ketamine tell us: “We don’t have an effing clue what we’re doing.” It’s called blind poking: “Didn’t that work? Oh well, try this one, and maybe a bit of that as well. And something for side effects? Sure, this one.”
The ominous part of their story is that, from all the symptoms that a seriously anxious person could have, the authors extracted poor concentration and agitation as the only two that mattered, hung a diagnosis from them and gave the poor chap yet another drug but without dealing with his anxiety. For me, the very concept of anxiety includes poor concentration and physical agitation. If a person came in and said “I’m anxious but my concentration is steely and my hands are rock steady,” I’d say “Well, you’re not very anxious, are you? Get a job as a watchmaker, nobody will bother you.” ADHD is now being seen as the cause of every other mental disorder, especially the “treatment resistant” ones, but they’re “treatment resistant” just because the treatment is no good. This happens because psychiatry has no theoretical framework from which to hang the symptoms. With a bit of shoving and rearranging of symptoms, it’s possible to make practically any person fit any diagnosis. Note that: the person fits the diagnosis, not the other way around. This becomes very real where people are dragged before a tribunal and whatever they have said to anybody at any stage for any reason can be and often is used against them (important rule: never try to be funny with a shrink, or a nurse or … anybody).
So we see psychiatry go through its slow but predictable cycles of constantly slicing and dicing symptoms to come up with new diagnoses; an amazing treatment is announced; everybody rushes to prescribe it or get it; everybody talks it up; slowly the cracks start to appear in the story; then either a new treatment is announced (TCMS anybody? Ketamine?) or the symptoms are rearranged to give a new diagnosis which requires different treatment; and it’s off to the races. Today, everything is being blamed on ADHD, it’s the new universal cause of all mental woes. What’s missing in this saga is the essential idea of what sort of thing a mind is such that it can become disordered, because that tells us what to do.
One fine day, all this will come to a grinding halt but until psychiatry gives in and admits it doesn’t have that level of understanding, i.e. the fundamental requirement for any science, then blind poking will rule. Peoples’ lives will go steadily downhill (like the young chap in the article) until one day, they wake up and say: “This isn’t working, I’m out of here.” Then the psychiatrists will nod sympathetically and say: “Such a pity, we tried everything but nature won.” Yes, they tried everything except a new, self-critical approach.