THE MEANING OF ADHD

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This post is dedicated to my Twitter friend Jeff Emmerson @ADHD_Hope and his followers.  I ask your pardon if I am telling you what you already know.  It is my strong belief that what follows still needs to be repeated.

DSM5 diagnostic criteria for ADHD are as follows:

Inattention: fails to give close attention to details resulting in careless mistakes, often has difficulty paying attention, does not seem to listen when spoken to directly, does not follow through on instructions and fails to finish tasks, has difficulty organizing tasks and activities, avoids tasks that require sustained mental effort, loses things necessary for tasks and activities, is easily distracted by extraneous stimuli, is often forgetful in daily activities.

Hyperactivity and impulsivity: fidgets, leaves seat in situations when remaining seated is expected, runs about when inappropriate, unable to engage in leisure activities quietly, acting as if “driven by a motor”, talks excessively, blurts out an answer before the question is asked, has difficulty waiting his/her turn, often interrupts or intrudes on others.

It is important to note that this list of well-established symptoms is followed in the DSM by a section on Differential Diagnosis that, to the lay person, is best understood as other diagnoses that might cause similar symptoms.  It is here that I will dig in my heels because it is here that psychiatric diagnoses and the DSM specifically are so often misused.

I will start off by saying that a trained clinician is supposed to be the one best able to understand the symptoms of any diagnosis.  I consider it unfortunate that the majority of clinicians of every stripe, especially those with limited time to devote to patients, will not review symptoms fully with a patient, but for brevity sake just give a diagnosis without discussing the symptoms that support it and which would explain the reasons that the practitioner believes the diagnosis is appropriate.  This may be driven by the notion that a patient would not be able to understand the symptoms, but it also serves to assert the clinician’s authority and control over treatment.

It is worth reminding clinicians and patients alike that, since the DSM-IV, the patient should be thought of as having a mental disorder, just like a physical illness.  The patient should not be described as being the illness.  We are to think of sufferers as having a cold or ADHD or cancer even schizophrenia, not that you are a schizophrenic, a cold, ADHD or cancer because that would imply that it was an integral part of your being, which we are hoping is not so because then the possibility of cure or how we think of you as a person will be interfered with.  We want to give people with illnesses their dignity or should want to anyway.

Having said all this, I will explain the drama of diagnosing in practical terms.  When I took Abnormal Psychology or Psychopathology (same thing) for the first time, I was in a room full of master’s level students, my peers.  The most frequent comment to be heard among us was that, when reviewing diagnostic symptoms, people could relate with them all.  Many students thought that they had all those illnesses.  Don’t freak out, ladies and gentlemen!  This should be considered a sign of empathy on the part of budding clinicians, not an indication that they were all mentally ill, although a few probably were.  As I write this, I also reflect on how a similar class would be understood by psychiatrists in training, that is, people who have already received instruction on treating the body and are about to learn how to treat brain chemistry to affect the mind.  It seems likely that, for MDs, empathy would be less of a factor than learning how to treat your chemistry to make you feel and behave better.  It would be the difference between doing to and doing with the patient and is a convenient and accurate way to understand the difference between the disciplines.  And, as I am sure you can imagine, that difference is often vast.

Practically speaking, this means for the patient that, if you believe as a human being we are mostly physical and not psychic or mental, then you go for the med.  But, if you think we are mostly mental, you go for counseling.  If you believe that our consciousness is made up of both, then you go for both.  In my professional experience, I have found that meds help symptoms, but, where there are root causes, issues that would lead to another Differential Diagnosis for example (see above), the sufferer needs to consider psychotherapy instead.  It is also my experience that many people prefer taking a pill if they don’t want to think about the traumas they lived through prior to seeking treatment.

I have often said that, to accurately diagnose, you can only do it on “a level playing field”.  What I mean by this is that you, both clinician and patient, should not begin treatment with a preconceived notion of what the right answer is diagnostically or treatment wise.  At the time of this writing, I read clinical histories of real people multiple times a day and I am fascinated by how many patients are prepared to diagnose themselves or end up being diagnosed by clinicians based on a diagnosis that was made of a close relative.  On a percentage basis, this most often leads to incorrect conclusions, diagnoses, and treatment.  Unfortunately, it is all too often that the diagnosis and treatment is never revisited even after the patient has taken the medication for years, even without experiencing desired effects.  This leads to the patient going through life saying that their diagnosis is X and they continue to take ineffective meds and continue ineffective psychotherapy even twenty years later without the hope that anything might change.  And they have to be thinking all the while, “This is what’s supposed to happen, right?  Nobody ever really gets better.  We just have to hope that, over time, the clinicians are right and eventually I will feel better.”  That’s also the reason people play the lottery.  But, that is a philosophical issue.

I recall reading an article decades ago of a research on the genetic basis of schizophrenia.  The results were that, for people whose parents were both schizophrenic, the likelihood of having schizophrenia themselves was 25%.  I don’t know if the research was ever repeated, but this taught me that one should never jump to conclusions, that one must always have an open mind, and that the genetic imprint isn’t the only influence on a person’s life.  If it were, there would be no sense in living.

For all that, the biggest concern, in my opinion, is that psychiatric diagnosis is too often guided by fads.  Today the preferred diagnosis is Bipolar. Yesterday, it was ADHD.  It becomes a bit of a generational thing that is guided by research, patients’ most frequent complaints, and the most recent refinements in medication, the majority of which occur in isolation and without considering alternatives.

To bring ADHD out of its isolation and onto the level playing field, I will invite the reader to review the symptoms listed above and consider other explanations for their cause in your particular case.  For example, many people might have trouble paying close attention if they were raised in an anxious environment or may have trouble controlling impulses because they may be in an unsafe situation.  Besides anxiety, one of the listed Differential Diagnoses, symptoms may be caused by a history of severe trauma (PTSD, another anxiety disorder), by a head injury, depression, personality characteristics, or for a host of other possible reasons, some of which may just have to do with circumstance.

It should not be revolutionary to consider alternative explanations for symptoms.  That indicates both flexible thinking and a curious mind.  What could be a problem is when, in considering explanations, it leads someone to find him/herself in such a quandary as to not be able to take necessary action.

Where it concerns our internal investigation and discovery, I will quote Dylan Thomas, “Do not go gentle into that good night. Rage, rage against the dying of the light.”  Never accept anything passively, especially when there is the possibility of shedding new light on who you are.  Even death might offer unexpected alternatives when we finally get there.