ADHD: why so much difference between US and rest of the world?

[Dmytry]

Or for psychiatry in general, its full of non-diagnoses.

That happens with physiological symptoms all the time. A specialist trained to interpret symptoms from a single perspective is of course going to diagnose from their specialty first.

Yes of course, but the issue is that it is like you have a surgeon that can diagnose that a specific bone is broken, and get you in a cast, and you have a kinetiatry specialist that diagnoses 'low mobility disorder' based on checklist regarding your walking difficulties, and can prescribe a motorized wheelchair at best or sports doping at worst. That's what it is like with neurology and psychiatry.

edit: I mean, if you are a neurologist/infectious disease specialist and you do everything correctly you can't diagnose encephalitis when there isn't encephalitis, but if you are a psychiatrist and you do everything correctly you can diagnose encephalitis as schizophrenia. It's not symmetrical.

 

[Virogtheconq]

That's not quite the same thing, since the broken bone is one of several types of "low mobility disorders."

It still doesn't address the core issue, which is when a presented set of symptoms can result in different diagnoses (or maybe not even a diagnosis per se, but merely a recommendation of symptom treatment) depending on the specialist. Bringing the mental vs. neurological dichotomy isn't particularly relevant.

 

[Dmytry]

That's not quite the same thing, since the broken bone is one of several types of "low mobility disorders."

It still doesn't address the core issue, which is when a presented set of symptoms can result in different diagnoses (or maybe not even a diagnosis per se, but merely a recommendation of symptom treatment) depending on the specialist. Bringing the mental vs. neurological dichotomy isn't particularly relevant.

Well, some of what is unavoidable. The issue in my example is that psychiatric diagnosis is a recommendation of a symptom management, but is often mistaken for actual diagnosis, with sometimes dire consequences (death or brain damage if it was encephalitis). There seem to be some sort of thought fallacy where people mistake label for explanation. I.e. you have kid doing badly at school, if it is because of lack of sleep, that is actual cause, but if it is 'because' of ADHD, that is like saying kid is doing bad at school because kid is doing bad at school, except cycle is disguised through clever use of a label. This sort of explanation-by-labelling is some sort of historical carry-over from back in the day when medicine was almost 100% sham. It's not useful at all. If kid is doing badly at school, call it what it is, maybe even prescribe stimulants to help kid learn, no need for BS pseudoexplanations, they only stop people from looking into actual causes such as lack of sleep or what else.

edit: Or someone is psychotic and you don't know why, call it what it is, the person is psychotic, you may give anti-psychotics to manage the symptoms, and send him to MRI to see why he's psychotic, you may not find any obvious causes, in which case, the symptom management is all you can do, trying to lower the doses of anti-psychotics perhaps in hope that unidentified underlying issue has resolved. That's how it should be. Bad labels are dangerous. Back when medicine was almost 100% sham, the doctors needed to say something profound about anything, it seems that got ingrained in the culture. We poorly understand workings of the brain and subsequently the worst anachronisms that were banished from any other areas of medicine remains there.

 

[samantha_cs]

You seem to have this idea in your head that for most or all ADHD sufferers, there is some simple underlying cause, like sleep deprivation, that explains the symptoms.

Why do you think that?

 

[andgarden]

You seem to have this idea in your head that for most or all ADHD sufferers, there is some simple underlying cause, like sleep deprivation, that explains the symptoms.

Why do you think that?

He still hasn't said whether he thinks depression is a real medical condition.

 

[Dmytry]

You seem to have this idea in your head that for most or all ADHD sufferers, there is some simple underlying cause, like sleep deprivation, that explains the symptoms.

Why do you think that?

You seem to have this idea in your head that making strawmen furthers your argument.

My point is that ADHD is defined badly enough so that sleep deprivation would be 'diagnosed' as ADHD, and subsequently not treated. Sleep deprivation is probably fairly common. A study I linked in OP finds link between being younger in class and ADHD, another simple underlying cause. In so much as you haven't provided evidence for some insanely complicated underlying cause underpinning majority of ADHD, or even hypothesised at what such cause might be, it seems prudent to assume the ADHD might be explainable by what we already know. That's called scientific method. When you see some new phenomena you try to explain it with what's known. And you consider simpler hypotheses more likely (or preferable over more complicated hypotheses), something known as Occam's razor.

Furthermore, the official hypothesis is that ADHD is caused by low arousal, which is a very simple underlying cause, that can have a variety of other very simple underlying causes.

re: Depression being a 'real' medical condition, what it has to do with anything? People end up in life situations that make them feel down or feel better, one could manage that with drugs that improve mood, albeit the efficacy of such drugs is very dubious because of selective publishing and un-blinding. I'm all for soma, ala brave new world, provided it works.

 

[samantha_cs]

My point is that ADHD is defined badly enough so that sleep deprivation would be 'diagnosed' as ADHD, and subsequently not treated. Sleep deprivation is probably fairly common. A study I linked in OP finds link between being younger in class and ADHD, another simple underlying cause. In so much as you haven't provided evidence for some insanely complicated underlying cause underpinning majority of ADHD, or even hypothesised at what such cause might be, it seems prudent to assume the ADHD might be explainable by what we already know. That's called scientific method. When you see some new phenomena you try to explain it with what's known. And you consider simpler hypotheses more likely (or preferable over more complicated hypotheses), something known as Occam's razor.

Let me handle these one at a time. First, the link you posted in the OP about school-aged children having a much higher rate of diagnosis is entirely reasonable given the DSM criteria which state that the disorder must affect at least two separate areas of the individual's life: School and home, Work and home, Work and school etc. Since children who have not yet started school may not have two separate areas yet, they cannot be responsibly diagnosed with ADHD.

Second, while some, maybe even a significant portion, of individuals with ADHD are actually suffering from sleep deprivation - a hypothesis which is still being researched - it does not explain all cases of ADHD. Indeed, the primary researchers looking at that link say, explicitly that "No one is saying ADHD doesn't exist", something i pointed out before. Now that there is clear research indicating that sleep deprivation might be misdiagnosed as ADHD, professionals are more likely to investigate it before giving the ADHD diagnosis, just as they investigate depression and personality disorder as alternative explanations for the symptoms.

Third, if you would bother to educate yourself even a little bit on the actual state of the research into ADHD, you would see that it is, in fact, quite complex. For example, one of the primary factors associated with ADHD is heredity Link. Additionally, you continue to ignore demonstrated population differences in brain structure and activity between individuals with ADHD and the normal population.

And finally, Occam's Razor is not and never has been a scientific principle. The correct scientific response to the question "Which of these two explanations for the observations is correct?" is not "The simpler explanation". The scientific response is "What experiment can i perform to distinguish between these two explanations?" Falling back on Occam's Razor to draw conclusions is lazy thinking. Furthermore, Occam's Razor only applies to explanations which fit all of the available evidence, and i highly doubt your hypothesis fits all of the available evidence.

You're correct that i haven't presented a thesis paper detailing the state of ADHD research. i'm not an expert, and i don't have that kind of time. If that's what it would take to convince you, i suggest you start reviewing ADHD literature extensively, rather than spouting off ill-informed opinions based on extremely limited data.

Furthermore, the official hypothesis is that ADHD is caused by low arousal, which is a very simple underlying cause, that can have a variety of other very simple underlying causes.

What simple underlying causes for low arousal have not been, in your opinion, adequately researched as causing ADHD?

Also, since you believe the DSM criteria for ADHD are insufficiently rigorous, how would you improve the definition?

 

[andgarden]

re: Depression being a 'real' medical condition, what it has to do with anything? People end up in life situations that make them feel down or feel better, one could manage that with drugs that improve mood, albeit the efficacy of such drugs is very dubious because of selective publishing and un-blinding. I'm all for soma, ala brave new world, provided it works.

You've said everything I needed you to say right here. Your views on mental health are way out of the mainstream.

 

[Jim Z]

After discussing it with my GF

ah, well, no greater authority on the subject than Dmytry and his GF.

 

[Dmytry]

My point is that ADHD is defined badly enough so that sleep deprivation would be 'diagnosed' as ADHD, and subsequently not treated. Sleep deprivation is probably fairly common. A study I linked in OP finds link between being younger in class and ADHD, another simple underlying cause. In so much as you haven't provided evidence for some insanely complicated underlying cause underpinning majority of ADHD, or even hypothesised at what such cause might be, it seems prudent to assume the ADHD might be explainable by what we already know. That's called scientific method. When you see some new phenomena you try to explain it with what's known. And you consider simpler hypotheses more likely (or preferable over more complicated hypotheses), something known as Occam's razor.

Let me handle these one at a time.

First, the link you posted in the OP about school-aged children having a much higher rate of diagnosis is entirely reasonable given the DSM criteria which state that the disorder must affect at least two separate areas of the individual's life: School and home, Work and home, Work and school etc. Since children who have not yet started school may not have two separate areas yet, they cannot be responsibly diagnosed with ADHD.

You didn't understand the cut off issue. Within, say, 3rd grade, the kids that are youngest in the class get substantially higher rate of diagnosis (up to 2x) than kids who are oldest in the class. Nobody's comparing kids outside school with kids inside school. The one year lower maturity can result in doubling of the cases. Maturity is a major factor, apparently.

Second, while some, maybe even a significant portion, of individuals with ADHD are actually suffering from sleep deprivation - a hypothesis which is still being researched - it does not explain all cases of ADHD. Indeed, the primary researchers looking at that link say, explicitly that "No one is saying ADHD doesn't exist", something i pointed out before. Now that there is clear research indicating that sleep deprivation might be misdiagnosed as ADHD, professionals are more likely to investigate it before giving the ADHD diagnosis, just as they investigate depression and personality disorder as alternative explanations for the symptoms.

I'm not saying it doesn't exist, I'm saying that the sleep deprivation ought to be listed as cause of some of ADHD. And kid being youngest in class as another cause of some of ADHD. And so on.

Third, if you would bother to educate yourself even a little bit on the actual state of the research into ADHD, you would see that it is, in fact, quite complex. For example, one of the primary factors associated with ADHD is heredity Link. Additionally, you continue to ignore demonstrated population differences in brain structure and activity between individuals with ADHD and the normal population.

And the study I cited in OP found a very strong correlation between ADHD and age relatively to rest of the class.

And finally, Occam's Razor is not and never has been a scientific principle. The correct scientific response to the question "Which of these two explanations for the observations is correct?" is not "The simpler explanation". The scientific response is "What experiment can i perform to distinguish between these two explanations?" Falling back on Occam's Razor to draw conclusions is lazy thinking. Furthermore, Occam's Razor only applies to explanations which fit all of the available evidence, and i highly doubt your hypothesis fits all of the available evidence.

Do you have a link to evidence that the observed phenomena is not adequately explained by known mechanisms? No? The first step in making a hypothesis is seeing if you don't need any. In this particular case, well, some kids do badly at school. We know a zillion of things that can make kids do badly at school (and those seem to be correlated with "ADHD", even when its something as trivial as age relatively to the class). There are also unknown reasons why kids may do badly at school. We can't just assume based on no evidence that most of kids must be doing badly at school because of some single unknown complicated reason and all those known reasons must be only minor contributor.

You're correct that i haven't presented a thesis paper detailing the state of ADHD research. i'm not an expert, and i don't have that kind of time. If that's what it would take to convince you, i suggest you start reviewing ADHD literature extensively, rather than spouting off ill-informed opinions based on extremely limited data.

You wouldn't even read what I link.

Furthermore, the official hypothesis is that ADHD is caused by low arousal, which is a very simple underlying cause, that can have a variety of other very simple underlying causes.

What simple underlying causes for low arousal have not been, in your opinion, adequately researched as causing ADHD?

Also, since you believe the DSM criteria for ADHD are insufficiently rigorous, how would you improve the definition?

Well, not defining it as full diagnosis could be a start, like 'cough' is not a full diagnosis but a symptom (which you can manage on it's own)

 

[Dmytry]

re: Depression being a 'real' medical condition, what it has to do with anything? People end up in life situations that make them feel down or feel better, one could manage that with drugs that improve mood, albeit the efficacy of such drugs is very dubious because of selective publishing and un-blinding. I'm all for soma, ala brave new world, provided it works.

You've said everything I needed you to say right here. Your views on mental health are way out of the mainstream.

How so? It's fairly mainstream view that depression is usually triggered by some life events, I mean, just google 'causes of depression'. It's also mainstream that it can be managed with medications. It is also relatively mainstream view that those drugs are not very effective compared to placebo, and have significant undesirable side effect. And of course there's individual/genetic variability, some people feel worse when facing same events, some few might go depressed for no external reason but that's an exception.

 

[andgarden]

No more games: do you accept that clinical depression as understood by 21st century psychiatry is a real medical condition?

 

[sciencegeek]

There are new diagnostic criteria for ADHD in DSM-V which is supposed to be out in early 2013. In the US there is a new diagnostic test (Quotient test) to assist in ADHD diagnosing and it is FDA approved. Can't really say if the US has a higher treatment rate because of over diagnosing or if the rest of the world doesn't bother with it.

Can sleep issues overlap ADHD symptoms? Yes. Most psychiatric disorders overlap with each other and can be influenced by physical factors as well. Sleep, hormonal problems such as thyroid, tumors, etc. What a good doctor would do is to start eliminating possible problems like those listed above then proceed towards an ADHD diagnosis.

Stimulant medications are safe. They have an extremely long history of use in medicine. Can stimulants cause long term health problems? Sure they can. I'm willing to bet that prescribed doses of amphetamine or methylphenidate are much less harsh on the body than the massive amounts of "junk" stimulants people use to self-medicate on a daily basis (caffeine and nicotine). As long as a patient also keeps their health monitored with periodic physical exams to make sure everything is fine in the cardio and metabolic areas then there isn't much to worry about.

 

[Dmytry]

No more games: do you accept that clinical depression as understood by 21st century psychiatry is a real medical condition?

Yes. For that matter, I do accept that ADHD is a 'real medical condition'. What I do not accept is the next step which typically follows after proclaiming it a "real medical condition": assuming by association some features of most but not all real medical conditions, such as being well understood, having effective treatment strongly superior to placebo, having predominantly single cause, having necessarily physiological rather than psychological prime cause, and so on.

 

[Dmytry]

There are new diagnostic criteria for ADHD in DSM-V which is supposed to be out in early 2013. In the US there is a new diagnostic test (Quotient test) to assist in ADHD diagnosing and it is FDA approved. Can't really say if the US has a higher treatment rate because of over diagnosing or if the rest of the world doesn't bother with it.

Can sleep issues overlap ADHD symptoms? Yes. Most psychiatric disorders overlap with each other and can be influenced by physical factors as well. Sleep, hormonal problems such as thyroid, tumors, etc. What a good doctor would do is to start eliminating possible problems like those listed above then proceed towards an ADHD diagnosis.

Precisely. Wouldn't it be more sensible then, though, not to create a diagnosis which is essentially a confident sounding name for "we don't know what is causing this" (and should ideally only be reached after ruling out all the causes), but instead have "ADHD-like condition" (symptoms manageable with stimulants) which forks off into such causes, and if none is identified, "unknown cause", which would correspond to current "ADHD"? There needs to be an integrated diagnostic manual, where you note the 'ADHD symptoms' and from there you fork off into possible causes to treat, or if none apply, stay there with 'causes unknown' and manage the symptoms with stimulants (clearly an inferior option).

Stimulant medications are safe. They have an extremely long history of use in medicine. Can stimulants cause long term health problems? Sure they can. I'm willing to bet that prescribed doses of amphetamine or methylphenidate are much less harsh on the body than the massive amounts of "junk" stimulants people use to self-medicate on a daily basis (caffeine and nicotine). As long as a patient also keeps their health monitored with periodic physical exams to make sure everything is fine in the cardio and metabolic areas then there isn't much to worry about.

Hmm, I'd agree with that for adult use, but the 2..4 years olds... it is rather common that otherwise safe medications cause long term problems when used at early age, and in this case the safety was not properly studied. Also the amphetamines seem to have far more potential for abuse than caffeine, for what ever reason.

 

[samantha_cs]

You didn't understand the cut off issue. Within, say, 3rd grade, the kids that are youngest in the class get substantially higher rate of diagnosis (up to 2x) than kids who are oldest in the class. Nobody's comparing kids outside school with kids inside school. The one year lower maturity can result in doubling of the cases. Maturity is a major factor, apparently.

Point taken. i didn't read your initial link carefully.

Do you have a link to evidence that the observed phenomena is not adequately explained by known mechanisms? No? The first step in making a hypothesis is seeing if you don't need any. In this particular case, well, some kids do badly at school. We know a zillion of things that can make kids do badly at school (and those seem to be correlated with "ADHD", even when its something as trivial as age relatively to the class). There are also unknown reasons why kids may do badly at school. We can't just assume based on no evidence that most of kids must be doing badly at school because of some single unknown complicated reason and all those known reasons must be only minor contributor.

"The exact cause of attention deficit hyperactivity disorder (ADHD) is not known"
Scientists are not sure what causes ADHD, although many studies suggest that genes play a large role.
While the exact cause of ADHD remains a mystery, brain scans have revealed important differences in the structure and brain activity of people with ADHD.
As with all mental disorders, the exact cause of attention deficit disorder (ADHD) is unknown, so parents should not blame themselves for this problem.
Shall i go on? i realize that citing the mainstream opinion of the scientific community is effectively an appeal to authority, but since neither of us is experts, i think that appeal is fair.

Your following diatribe betrays a continuing misunderstanding of how ADHD is diagnosed. It is not just "kids doing badly at school." In fact, if that is all that was observed a diagnosis of ADHD would be contraindicated. According to the DSM IV guidelines, disfunction must be present in at least two separate areas of the individual's life. Furthermore, ADHD is not a diagnosis if the "kids doing badly at school" aren't doing badly for a relatively narrow set of behaviors. You're right, there are zillions of reasons kids might be doing badly, but not all of those reasons would trigger a suspicion of ADHD, nor would most of them support a diagnosis.

You're correct that i haven't presented a thesis paper detailing the state of ADHD research. i'm not an expert, and i don't have that kind of time. If that's what it would take to convince you, i suggest you start reviewing ADHD literature extensively, rather than spouting off ill-informed opinions based on extremely limited data.

Well, not defining it as full diagnosis could be a start, like 'cough' is not a full diagnosis but a symptom (which you can manage on it's own)

Or perhaps including a line that ADHD should not be diagnosed where other conditions explain the symptoms better? A line saying something like " The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder" i'll agree that line of the DSM could be expanded, but there is such a recommendation already in place.

i'll also note that the current DSM IV criteria were written in 1994. Obviously, we've learned a lot about ADHD since then.

 

[samantha_cs]

Oh, and since you were railing about a brain scan test...

Here is a candidate

 

[ChrisG]

"Subsequently, support vector machines (SVM) were used to develop classification models based on the extracted features."

I have an office mate who's using SVMs to classify physiological states. They're not what they're cracked up to be, by a million miles, IMHO. Part of the testing of the SVM involved feeding variants of it with a "test" datasets. Every single time, when each SVM was presented with the same dataset repeatedly, it generated an entirely different classification matrix in response. I wouldn't touch them with a bargepole.

 

[sciencegeek]

Yeah I would be hesitant to give a 2-4 year old medication. That is just me though.

Yes amphetamines (adderall & dexedrine) and methylphenidate (ritalin) have potential for abuse, hence the C-II drug scheduling. The vast majority of people with ADHD rarely abuse them though. The non-ADHD people that take them either for recreation or for study purposes are the ones that typically run into addiction problems.

Whether anyone wants to believe ADHD or any other psychiatric disorder exists is up to them. Some brains are just wired differently is my theory. Some more serious than others. For ADHD, data has shown that when patients are treated with medication (usually stimulants) there is a rapid decrease in the problem areas. Balancing out the dopamine and NE (which is what stimulants do) makes a big difference.

I will disclose that I am treated for a few things such as ADHD and depression but I'm trying not to be completely biased. I've been taking amphetamines for years, have excellent blood pressure, my cholesterol has dropped to normal levels because of amphetamines and my craving for caffeine all but disappeared. I rarely take the amount I'm prescribed and get zero euphoria. I don't really get how people want to take stimulants for fun but who knows.
I've taken a ton of different SSRI antidepressants over the years and they didn't do jack for me. I kind of skeptical if they work that well at all but that is my own personal belief. What works for one may or may not work for another. Actually the one thing that has worked well is lithium. Funny that lithium has been the only proven thing that actually reduces suicide in patients. A naturally occurring element that is dirt cheap.

 

[Dmytry]

Yeah I would be hesitant to give a 2-4 year old medication. That is just me though.

The issue is that it is not quite clear why the symptoms should be managed in 2..4 year old kids, nor is there really a guideline to diagnosis for kids that age, nor can you assume safety. It can hardly be anything other than malpractice.

Yes amphetamines (adderall & dexedrine) and methylphenidate (ritalin) have potential for abuse, hence the C-II drug scheduling. The vast majority of people with ADHD rarely abuse them though. The non-ADHD people that take them either for recreation or for study purposes are the ones that typically run into addiction problems.

Well, people with ADHD do have higher drug abuse rate but that may be simply because of failing to do some things.

Whether anyone wants to believe ADHD or any other psychiatric disorder exists is up to them. Some brains are just wired differently is my theory. Some more serious than others. For ADHD, data has shown that when patients are treated with medication (usually stimulants) there is a rapid decrease in the problem areas. Balancing out the dopamine and NE (which is what stimulants do) makes a big difference.

I agree that some brains are wired different, but on top of this you have all the other differences, including age within the class, where 1 year of maturation at age of 10 or so apparently can cause 2x difference in rates of diagnosis. That's ten percent difference in maturity, you can easily get more than this from different speed of maturation (which is btw heritable). Strong dependence of diagnosis in the class on the month of birth is a big red warning sign, and a huge problem because there's larger still difference due to speed of maturation.

I will disclose that I am treated for a few things such as ADHD and depression but I'm trying not to be completely biased. I've been taking amphetamines for years, have excellent blood pressure, my cholesterol has dropped to normal levels because of amphetamines and my craving for caffeine all but disappeared. I rarely take the amount I'm prescribed and get zero euphoria. I don't really get how people want to take stimulants for fun but who knows.

That seem to differ a lot between people. Many can't give up nicotine or caffeine, even though those are quite weak.

I've taken a ton of different SSRI antidepressants over the years and they didn't do jack for me. I kind of skeptical if they work that well at all but that is my own personal belief. What works for one may or may not work for another. Actually the one thing that has worked well is lithium. Funny that lithium has been the only proven thing that actually reduces suicide in patients. A naturally occurring element that is dirt cheap.

I think this may be precisely because depression is not a 'real disease' but a symptom of, likely, a plurality of different neurological disorders and conditions, for some of which the SSRI may be ineffective or even worsen the symptoms.
I can't stop being amazed at how easy it is to insert implicit assumptions into sentences in English, such as an assumption that it is fundamentally 1 disorder or close to such. Normally such a claim would need really good empirical support, but you can put such claim into two words like "real disorder", or "the cause". Evidence is especially wanted when it overlaps with multiple known disorders and those had to be excluded via a list.

 

[Chuckaluphagus]

if you are a psychiatrist and you do everything correctly you can diagnose encephalitis as schizophrenia.

If you are a psychiatrist practicing according to current standards of care in the United States, and you don't first rule out neurological causes as the basis for symptoms in your patient, than you are not "doing everything correctly". The psychiatrist in your example, who diagnosed schizophrenia when the real issue was encephalitis, was negligent. A story of an incompetent psychiatrist does not make the entire field of practice suspect, or a disorder nonexistent.

 

[sciencegeek]

Read this website and all your answers may be answered.

http://thelastpsychiatrist.com/

 

[Dmytry]

if you are a psychiatrist and you do everything correctly you can diagnose encephalitis as schizophrenia.

If you are a psychiatrist practicing according to current standards of care in the United States, and you don't first rule out neurological causes as the basis for symptoms in your patient, than you are not "doing everything correctly". The psychiatrist in your example, who diagnosed schizophrenia when the real issue was encephalitis, was negligent. A story of an incompetent psychiatrist does not make the entire field of practice suspect, or a disorder nonexistent.

Diagnosing neurological causes is not within the area of competence of psychiatrist, that's the issue, afaik the guy didn't have high fever at the point where the temperature was taken, or some other doctor had been negligent. He also got unlucky with how his brain was affected by the swelling and the like, in that it resembled sudden onset SZ.

The big picture issue is that there are various neurological diseases and heritable conditions, some of them known, some of them unknown. The encephalitis is one of those known neurological diseases. The schizophrenia and other mental disorders are old, traditional collection of symptoms of the unknown. I fully expect that eventually this ground of the unknown will be divided into neurological diseases which would not at all correspond to the taxonomy that was made up long ago without employing the scientific method. Roughly, I would expect that we would eventually discriminate between presently unknown disorders A,B,C,D... many of which can randomly result in symptoms of different currently-recognized psychiatric disorders depending to which areas of the brain are affected.

 

[Chuckaluphagus]

if you are a psychiatrist and you do everything correctly you can diagnose encephalitis as schizophrenia.

If you are a psychiatrist practicing according to current standards of care in the United States, and you don't first rule out neurological causes as the basis for symptoms in your patient, than you are not "doing everything correctly". The psychiatrist in your example, who diagnosed schizophrenia when the real issue was encephalitis, was negligent. A story of an incompetent psychiatrist does not make the entire field of practice suspect, or a disorder nonexistent.

Diagnosing neurological causes is not within the area of competence of psychiatrist, that's the issue

No, that's not the issue. Diagnosing neurological causes is what neurologists are for. The psychiatrists I know (and, due to circumstances, I know quite a number socially) all require new patients to be sent for a neurological screening to rule out such causes before they're ever evaluated for psychiatric issues. I've even heard them fume about screw-ups where patients aren't sent for the neurological evaluation first, because the psychiatrists can't get started until they know that any symptoms aren't being due to a neurological cause.

The psychiatrist who misdiagnosed the encephalitis patient wasn't competent to diagnose encephalitis, but that isn't the point; he or she shouldn't have been seeing the patient until someone who was competent had already ruled out such things. The tragedy is not a failing of psychiatry at all, just a failing of that psychiatrist and/or that medical facility.

 

[Dmytry]

if you are a psychiatrist and you do everything correctly you can diagnose encephalitis as schizophrenia.

If you are a psychiatrist practicing according to current standards of care in the United States, and you don't first rule out neurological causes as the basis for symptoms in your patient, than you are not "doing everything correctly". The psychiatrist in your example, who diagnosed schizophrenia when the real issue was encephalitis, was negligent. A story of an incompetent psychiatrist does not make the entire field of practice suspect, or a disorder nonexistent.

Diagnosing neurological causes is not within the area of competence of psychiatrist, that's the issue

No, that's not the issue. Diagnosing neurological causes is what neurologists are for. The psychiatrists I know (and, due to circumstances, I know quite a number socially) all require new patients to be sent for a neurological screening to rule out such causes before they're ever evaluated for psychiatric issues. I've even heard them fume about screw-ups where patients aren't sent for the neurological evaluation first, because the psychiatrists can't get started until they know that any symptoms aren't being due to a neurological cause.

The psychiatrist who misdiagnosed the encephalitis patient wasn't competent to diagnose encephalitis, but that isn't the point; he or she shouldn't have been seeing the patient until someone who was competent had already ruled out such things. The tragedy is not a failing of psychiatry at all, just a failing of that psychiatrist and/or that medical facility.

I brought it up to demonstrate how psychiatric diagnoses - even for widely accepted 'real diseases' where something is clearly wrong with the patient - are very different from every other type of diagnosis, in that they represent the non-diagnosis by other medical professionals rather than positive identification. They are a dustbin for the cases where no-one actually knows what it is. And there is some evidence that the 'treatment' of such symptoms has negative effect on the recovery rate:
http://ajp.psychiatryonline.org/article ... leid=98965
I may be a bit biased as engineer in my disdain for trying to fix what you don't understand. The worse understood areas of medicine remind me of ignorance driven home repairs. The lights now work, but the fuse has been hot-wired with the thickest wire the idiot could find. The gas heater is now working, but is an enormous explosion hazard because gas shut off has been overridden. And so on. And there's no one who knows better, and only the most severe and common of the failings have been so visible as to get noticed and measured.

 

[Virogtheconq]

I may be a bit biased as engineer in my disdain for trying to fix what you don't understand. The worse understood areas of medicine remind me of ignorance driven home repairs. The lights now work, but the fuse has been hot-wired with the thickest wire the idiot could find. The gas heater is now working, but is an enormous explosion hazard because gas shut off has been overridden. And so on. And there's no one who knows better, and only the most severe and common of the failings have been so visible as to get noticed and measured.

So it's better to not even try to treat the symptoms before positively identifying a source? It's not like any of these conditions are considered a solved problem, and there is active research on identifying causes.

 

[Dmytry]

Read this website and all your answers may be answered.

http://thelastpsychiatrist.com/

Ohh, this is surprisingly good. Seems a bit on the ranty side but as far as I can tell he knows his stuff, and the position on issues is quite nuanced.

 

[Dmytry]

I may be a bit biased as engineer in my disdain for trying to fix what you don't understand. The worse understood areas of medicine remind me of ignorance driven home repairs. The lights now work, but the fuse has been hot-wired with the thickest wire the idiot could find. The gas heater is now working, but is an enormous explosion hazard because gas shut off has been overridden. And so on. And there's no one who knows better, and only the most severe and common of the failings have been so visible as to get noticed and measured.

So it's better to not even try to treat the symptoms before positively identifying a source? It's not like any of these conditions are considered a solved problem, and there is active research on identifying causes.

Whenever it is worth to treat condition A with method B, that's up to scientific studies on the effects to say, not up to general ideology... given presence of unpublished studies and how common that is, I'd think it is safe to guess there are enough cases where the whole body of evidence says that yes it is indeed better not to try particular treatments, while the cherry picked set of studies says it is better to try, and the actual approach is to do it even if patient barely responds. Plus, people have a strong cognitive bias against inaction.

 

[samantha_cs]

Regarding unpublished studies, this article looks interesting.
http://pharmacy.ucsf.edu/news/2012/01/20/1/

In more than 90% of the 42 outcomes, the inclusion of the FDA’s unpublished trial data in revised meta-analyses changed the estimates of a given drug’s efficacy.
But, contrary to the researchers’ hypothesis, those changes were decidedly mixed: Estimates of drug efficacy increased as often as they decreased (for 46% of outcomes each). Another 7% of the outcomes in the revised meta-analyses showed the same drug effectiveness.

The revised meta-analyses did not find that any of the drugs were ineffective (i.e., did not have statistically significant outcomes vs. placebo). But Bero and co-authors note that “changes in effect sizes may be more meaningful to clinicians and patients.” Indeed, given competing drug choices, knowing how well a medication achieves a particular outcome can be especially important.

 

[VellenThoss]

I am a 29 year old male with a fairly long history of ADHD.

I had the typical issues, the inability to pay attention to pretty much anything that didnt totally captivate me (Grades 8 through 12 were not very fun for me, and I came very close to failing 11th grade because I could not force myself to pay attention and apply myself for some of the classes I had). I had issues with money; yes, I am aware that a lot is said about parents who spoil their children and do not teach them the value of saving. Mine did, in fact teach me what it means to save and work for what you want, I have not taken a penny of my parent's money for anything since I was 15 when I got my first job.

I also had impulsive behavioral issues too, I would get frustrated to the point of vocal outbursts and yelling over some of the most petty things. I can honestly say I rarely ever get genuinely angry, but my frustration level tolerance when I am not medicated is incredibly low.

My parents only ever felt I was just a typical rebellious teenager who got fresh sometimes. My father refused to accept that there could be any other underlying issue. My mother however, wondered.

I was first clinically diagnosed when I was 18. I saw a therapist, and together we attempted to formulate a plan on how to cope with my behavior and best deal with my issues - without medicating. I was not a fan of the stigma associated with the typical ADHD ritalin popping teenager and I was hoping I could work through my issues without it. I grew frustrated at my lack of progress, nothing got better, I constantly felt like my mind was going at 10,000 miles per hour, that I could never apply myself to finish anything (even video games!) I could literally forget being told something 5 seconds after I heard it. From age 15 to 19 I went through 8 or 9 jobs. I would get so bored working somewhere that I would have to force myself some days to get up and get dressed for work. I could not even count a stack of twenty dollar bills without losing my count 2 or three times.

I finally gave in and asked my therapist about other options, and she told me I could talk to my primary care doctor about Concerta, or methylphenidate. I started on Concerta, and took it for about 7 months. Things improved marginally, but the side effects were not something I could deal with. There were many sleepless nights, as well as erectile dysfunction. There is nothing more infuriatating than being 21 and not being able to get it up. So I stopped taking my medication and threw out the pills.

Fast forward 7 and a half years.

I met the love of my life, and I knew immediately that she was the woman I was meant to be with, and meant to grow old and play bingo with when we were 70. Having been single for several years, and living on my own, I never had to bother anyone with my behavioral issues, and my job at the time was so mindless, that my lack of attention did not interfere, plus it paid well, so I kept it. Needless to say, being in a relationship again allowed my now fiance to see every single issue I have. The inability to follow through on even chores, the feeling I gave her that things she would tell me went in one ear and out the other, the forgetfulness, and most saddening, our arguments escalated quickly because of my inability to not react and blow up.

It almost destroyed our relationship and it drove me deep into depression.

Unless you genuinely have ADHD, you will *NEVER* *EVER*understand what it feels like.

I finally stopped myself and told my fiance that I would get help. I began seeing a therapist, and also a psychiatrist. I was put on 40mg doses of Vyvanse, lysdexamfetamine.

The Vyvanse, combined with the tools my therapist has given me, I am able to better control my behavior, I am better able to concentrate and think before responding. I am able to *genuinely* listen to what is being told to me, I am able to remember to do tasks and I am able to function at the same level as my family and my coworkers, in fact I am now a supervisor at a bank and plan on sticking with this career path.

I feel normal. I have no issues sleeping, no issues with intimacy and my brain no longer feels like it's going 10,000mph.

This is my experience.

Do I feel ADHD is overdiagnosed in children? Yes, I do. I think what many, including myself consider typical childish attention spans is often diagnosed for parents seeing to make sure little Johnny has a 5.0 GPA in 2nd grade so he doesnt blow his chance at being a Harvard lawyer.

Do I feel that ADHD drugs and treatment should be restricted to teenagers over 16? Probably. I think the middle teenage years are when the childish behaviors start to disappear and the genuine ADHD indicators manifest.

I also feel that unless you KNOW what it is like to have ADHD, you have no right to tell me that my disorder is subjective at best and outright fraudulent at worst.

 

[Dmytry]

Regarding unpublished studies, this article looks interesting.
http://pharmacy.ucsf.edu/news/2012/01/20/1/

In more than 90% of the 42 outcomes, the inclusion of the FDA’s unpublished trial data in revised meta-analyses changed the estimates of a given drug’s efficacy.
But, contrary to the researchers’ hypothesis, those changes were decidedly mixed: Estimates of drug efficacy increased as often as they decreased (for 46% of outcomes each). Another 7% of the outcomes in the revised meta-analyses showed the same drug effectiveness.

The revised meta-analyses did not find that any of the drugs were ineffective (i.e., did not have statistically significant outcomes vs. placebo). But Bero and co-authors note that “changes in effect sizes may be more meaningful to clinicians and patients.” Indeed, given competing drug choices, knowing how well a medication achieves a particular outcome can be especially important.

Interesting. In the Ben Goldacre's new book, he asserts that some of the medications have been found ineffective in the unpublished trials of substantially larger size than the published trials: http://readersupportednews.org/opinion2 ... al-scandal .

Other rather troubling bit is that depression in particular is often measured with Hamilton Depression Scale that adds points for weight loss and insomnia (but not excessive weight gain and sleepiness), so the drugs that make you sleepy and gain weight are slightly more effective than placebo in treating "depression" as measured. This could be how antidepressants seem to improve the "depression" as measured, but not suicide rate which is an objective metric.

 

[Dmytry]

also with regards to ADHD, I have mild hyper-thyroidism, this results in slight hand tremor, some anxiety (that I learnt to ignore long before checking the thyroid), trouble sleeping, and so on. Thyroid issues seem to sometimes be diagnosable as ADHD if not identified by endocrinologist first: http://www.ncbi.nlm.nih.gov/pubmed/8410504 . Also, http://psychcentral.com/lib/2010/it-may-not-be-adhd/ . Wouldn't it be more constructive to demote "ADHD" to a symptom, and openly declare that psychiatry is symptom management? Then someone could e.g. get "ADHD" medications to relieve their thyroid related symptoms while waiting for proper cure. Or people with "ADHD" label would be re-screened as the other medical fields advance and more and more physical disorder shaped holes are cut out from the psychiatric circle in the Venn diagram of disorders.

 

[VellenThoss]

also with regards to ADHD, I have mild hyper-thyroidism, this results in slight hand tremor, some anxiety (that I learnt to ignore long before checking the thyroid), trouble sleeping, and so on. Thyroid issues seem to sometimes be diagnosable as ADHD if not identified by endocrinologist first: http://www.ncbi.nlm.nih.gov/pubmed/8410504 . Also, http://psychcentral.com/lib/2010/it-may-not-be-adhd/ . Wouldn't it be more constructive to demote "ADHD" to a symptom, and openly declare that psychiatry is symptom management? Then someone could e.g. get "ADHD" medications to relieve their thyroid related symptoms while waiting for proper cure. Or people with "ADHD" label would be re-screened as the other medical fields advance and more and more physical disorder shaped holes are cut out from the psychiatric circle in the Venn diagram of disorders.

With ADHD diagnoses that do not possess comorbidity with other conditions, it is believed to be an issue related to dopamine and its effects, or lack thereof. I have been tested for conditions that produce ADHD like symptoms, especially given that my mother has a history of thyroid issues.

It is believed that my ADHD was inherited from my father, who has no history of any conditions that are comorbid with ADHD symptoms.

That being said, I agree with you that ADHD is a *symptom* for most people. In its pure form however, it seems to be linked to the genes related to dopamine transport. This is something that cannot be fixed with our current understanding of genetics and neurological disorders. As are countless other mental conditions related to genetics and brain chemistry. At the moment, all that can be done is to treat the symptoms with medication and give patients the tools to manage their behaviors that are affected by ADHD through therapy.

Judging from your posts, your belief is that any mental condition that does not have a quantified, physiological link that you can point at and say "thats exactly what is causing it", then it is not a true ailment. This is where I disagree with you, as would countless other psychiatrists.

 

[Dmytry]

also with regards to ADHD, I have mild hyper-thyroidism, this results in slight hand tremor, some anxiety (that I learnt to ignore long before checking the thyroid), trouble sleeping, and so on. Thyroid issues seem to sometimes be diagnosable as ADHD if not identified by endocrinologist first: http://www.ncbi.nlm.nih.gov/pubmed/8410504 . Also, http://psychcentral.com/lib/2010/it-may-not-be-adhd/ . Wouldn't it be more constructive to demote "ADHD" to a symptom, and openly declare that psychiatry is symptom management? Then someone could e.g. get "ADHD" medications to relieve their thyroid related symptoms while waiting for proper cure. Or people with "ADHD" label would be re-screened as the other medical fields advance and more and more physical disorder shaped holes are cut out from the psychiatric circle in the Venn diagram of disorders.

With ADHD diagnoses that do not possess comorbidity with other conditions, it is believed to be an issue related to dopamine and its effects, or lack thereof. I have been tested for conditions that produce ADHD like symptoms, especially given that my mother has a history of thyroid issues.

It is believed that my ADHD was inherited from my father, who has no history of any conditions that are comorbid with ADHD symptoms.

That being said, I agree with you that ADHD is a *symptom* for most people. In its pure form however, it seems to be linked to the genes related to dopamine transport. This is something that cannot be fixed with our current understanding of genetics and neurological disorders. As are countless other mental conditions related to genetics and brain chemistry. At the moment, all that can be done is to treat the symptoms with medication and give patients the tools to manage their behaviors that are affected by ADHD through therapy.

Judging from your posts, your belief is that any mental condition that does not have a quantified, physiological link that you can point at and say "thats exactly what is causing it", then it is not a true ailment. This is where I disagree with you, as would countless other psychiatrists.

I do not agree with what is implied in this "it is a true aliment". It can be a bunch of aliments we can't discriminate. The statement that patient A has same cause as patient B is a statement that needs empirical support, but it is being made without empirical support via clever semantic trick: we give a label to what patient A has, and to what patient B has, which is OK, and then we argue emotionally whenever the label is a true aliment, entirely obscuring the fact that we don't know enough to claim that patient A's aliment is the same thing as patient B's (which we'll see it as same if we take it to be "a true aliment"). WRT the dopamine, while it is certain that dopamine is involved in the symptoms, it is unclear if the dopamine related anything is the cause. It's like inferring that cough is caused by some dopamine problems, from the efficacy of dopamine affecting medications in cough. Everything that you do which has anything to do with motivation has the signal pass through dopamine signalling somewhere along the way.

There is a lot of complexity here, not to mention the much more subtle issues that may have to do with patterns of activity rather than any bulk chemical concentrations or receptor densities. I'm not a neurologist but I am working in neurology related field right now (making software for viewing and processing 3D electron microscopy scan data, when they shave nanometre by nanometre some brain tissue and scan it with electron microscope). There's ridiculous number of things that can go wrong. To start with, the connectivity may be wrong, the wiring in your head is not truly random. I fully expect that all of psychiatric disorders will be dissolved into many specific neurological problems, with little correspondence between neurological problems and the psychiatric disorders (e.g. neurological issue A, that could well have nothing to do with dopamine but instead with embryonic development and patterns of connectivity (too many connections between neuron type 1 and neuron type 2 relatively to connections between neuron type 1 and neuron type 3, for example, possibly with the types that we don't even recognize as distinct today), would cause obsessive compulsive disorder in 30% patients, ADHD in 40% patients, be asymptomatic in 28% of patients, and cause schizophrenia in 2% of patients when co-morbid with neurological issues B and C in absence of D) . This sort of stuff. There is enough complexity that the disorder-symptom correspondence would be hopelessly too complicated for inferring from epidemiological statistics, as in, there would never be enough data to infer anything at statistical significance level even if you had trillions trillions humans. Note that I am just giving an example of what the cause may look like, to illustrate the complexity.

That being said, symptom management is definitely important, even if we don't understand anything we may be able to improve people's lives, simply by classifying symptoms by the available classes of drugs that alleviate said symptoms. What's wrong is misrepresentation to the patients, symptom classification for the purpose of symptom management trying to claim equivalence to rest of medicine, mostly by the way of emotionally charged arguments like whenever it is a "real aliment" or not.

 

[Shavano]

From what I understand, the dividing line between a mental disorder and a personality quirk is whether or not it interferes with the person's ability to function on a daily basis. School is arguably the most important thing in a child's day, so if you're looking at a kid who meets a certain number of items on the list of diagnostic criteria and can't function in school because of them, you have your diagnosis. It's an official observation that the child is in fact having trouble functioning in daily life.

Note that there's no best course of treatment, or "real source of the problem" baked in. If there are issues with these parts of the situation, it's not right to point to the rate of diagnosis as an evil.

But if the real cause of the problem is your kid is not mature enough to be asked to sit in a desk and do tedious work six hours a day, the solution isn't medication. It's hold-the-kid-back or find-a-better-school.

 

[robots]

But if the real cause of the problem is your kid is not mature enough to be asked to sit in a desk and do tedious work six hours a day, the solution isn't medication. It's hold-the-kid-back or find-a-better-school.

You skipped the part where we identify the real cause of the problem. How do we do that?