The myth of ADHD

[Taddy Mason]

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I'm curious, does Ghaemi (I believe that's who you're referring to?) practice and treat patients with ADHD or whatever he labels it as?

He refuses. His practice is extremely small though due to research and consulting. He used to do inpatient as well as outpatient and take call until ~10 years ago.

 

[FatherPsychiatry]

I'm curious, does Ghaemi (I believe that's who you're referring to?) practice and treat patients with ADHD or whatever he labels it as?

I like Ghaemi but the sense I get from reading his work and watching his videos (which I like a lot and agree with him like 90% of the time), is he would find some way to shoehorn the person's symptoms into some kind of Bipolar.

 

[Taddy Mason]

I like Ghaemi but the sense I get from reading his work and watching his videos (which I like a lot and agree with him like 90% of the time), is he would find some way to shoehorn the person's symptoms into some kind of Bipolar.

The way his practice is set up anyone with ADHD is pretty well filtered out. But you’re probably correct on the shoehorning into a mood disorder of some sort if that were to happen. FWIW, the one time I referred a patient to him to r/o bipolar (it was a complicated case) he actually agreed with my schizophrenia Dx and didn’t try to fit it to bipolar even though there were suspicious Sx and a family Hx.

 

[Ceke2002]

Curious regarding the inclusion of ADD (with or without hyperactivity) in the DSM III, replacing the previous name of 'Hyperkinetic Reaction of Childhood'. I have seen some arguments saying that HROC was potentially a completely different disorder, and by renaming it ADD the DSM inadvertently created a new disorder where one hadn't previously existed. Thoughts?

 

[R. Matey]

Curious regarding the inclusion of ADD (with or without hyperactivity) in the DSM III, replacing the previous name of 'Hyperkinetic Reaction of Childhood'. I have seen some arguments saying that HROC was potentially a completely different disorder, and by renaming it ADD the DSM inadvertently created a new disorder where one hadn't previously existed. Thoughts?

A Canadian psychologist named Virginia Douglas was really instrumental in arguing against the hyperkinetic or hyperactivity paradigm back in the 1970s and 1980s. She argued (as some have upthread) that hyperkinetic symptoms can be accounted for by other disorders and instead argued that problems with attention and impulsivity were hallmarks of the disorder. Ironically, the same can be said of what we now call executive functioning.

 

[TexasPhysician]

He refuses. His practice is extremely small though due to research and consulting. He used to do inpatient as well as outpatient and take call until ~10 years ago.

Why would he comment on something that he has purposely excluded for so long? Just inviting drama for drama sake?

I see very little schizophrenia and don’t have a single patient on an injectable. You won’t find me commenting on how injectables are worthless.

 

[Taddy Mason]

Why would he comment on something that he has purposely excluded for so long? Just inviting drama for drama sake?

I see very little schizophrenia and don’t have a single patient on an injectable. You won’t find me commenting on how injectables are worthless.

It’s about the bigger picture and goes back to his arguments about construct validity with the diagnostic system since DSM-III onward. He’s not arguing to go back to the pre-DSM-III system but that we as a field can and should strive to do better. And like I’ve said before he’s equally critical of his beloved bipolar disorder if you actually bother to read/listen to what he has to say and check his references.

Also, like I’ve previously stated, I agree with a lot of what he has to say but not everything. I think he has some very valid points concerning ADHD but I don’t agree with all of it. Don’t throw the baby out with the bath water.

Edit - He’s also not afraid to admit some of the stances he’s taken in the past he’s been incorrect about, which is something many people struggle with.

 

[Chimed]

It’s about the bigger picture and goes back to his arguments about construct validity with the diagnostic system since DSM-III onward. He’s not arguing to go back to the pre-DSM-III system but that we as a field can and should strive to do better. And like I’ve said before he’s equally critical of his beloved bipolar disorder if you actually bother to read/listen to what he has to say and check his references.

Also, like I’ve previously stated, I agree with a lot of what he has to say but not everything. I think he has some very valid points concerning ADHD but I don’t agree with all of it. Don’t throw the baby out with the bath water.

Edit - He’s also not afraid to admit some of the stances he’s taken in the past he’s been incorrect about, which is something many people struggle with.

I don't believe someone has to treat a disorder in order to have a valid critique of it. But, I do believe that being "in the trenches" so to speak, can give a different perspective, especially in regards to the nuances of diagnosis, therapy, and prescribing. It's interesting that a lot of people that I've communicated with either in conversation or online regarding the validity of psychiatric disorders rarely have clinical experience with it. Unfortunately, ADHD is often misdiagnosed, in my opinion, by pediatricians or providers that don't have the will or time to see the bigger picture.

 

[MedMan80]

Every other patient is on a stimulant, what's going on?

 

[Crayola227]

This is just like fauxtism. The extreme prevalence of fauxtism does not in any way make real autism a myth.

What's going on? Well, for some of it, like the parts that involve treatments only prescribers can offer, is a failure of gate-keeping under patient pressure.

From what I can tell, after this very week having 2 lifelong best friends tell me, one that they have autism, and the other ADHD, (oh, right, the first one has AuDHD too [Autism & ADHD]), that is seems like it's coming from ancillary providers like therapists and NP/PAs. No doubt some physicians are playing a role but this is just my inkling.

I have a relative born when I was a teenager with severe nonfunctional nonverbal autism living in a facility, and have been surrounded by actual ADHD for 30 years. I'm pretty sure these folks I literally watched grow up, I would have been able to catch on at least after med school if they had these diagnoses.

But the excitement I'm observing seems to come from conversations with therapists. Not to hate on therapists but from what I can tell some are very bad.

 

[Stagg737]

Every other patient is on a stimulant, what's going on?

Gotta use something to balance out those bennies....

 

[Crayola227]

What do you guys think about the use of non-stimulant meds for "ADHD"? How does it affect patients differently? Does it avoid some of the negatives that you might see in patients without the disorder on stims? Does it affect patients with and without actual ADHD differently? Does response offer any clues (ie it works for patients who really have ADHD, but not really for those without it, whereas stims arguably might "help" either type of patient)? Or does the fact it works only weakly or not at all for however many real ADHD patients limit the utility of response as a sign?

 

[Crayola227]

Gotta use something to balance out those bennies....

My friend always makes the joke "Elvis liked his uppers and downers too, and look at him, he died on a toilet!"

Somehow this seems to explain this to many people better than anything else I've found.

 

[MedMan80]

Gotta use something to balance out those bennies....

I once had a patient at the VA who was on so many downers, we swore his Adderall was keeping him alive...it was amazing.

 

[Merovinge]

I once had a patient at the VA who was on so many downers, we swore his Adderall was keeping him alive...it was amazing.

If you get the perfect mixture of KetaXannyButal with MethAdderall (I'm told it's roughly a 1:1:1:1:2 ratio, because math), there's nothing quite like it!

 

[Merovinge]

I don't believe someone has to treat a disorder in order to have a valid critique of it. But, I do believe that being "in the trenches" so to speak, can give a different perspective, especially in regards to the nuances of diagnosis, therapy, and prescribing. It's interesting that a lot of people that I've communicated with either in conversation or online regarding the validity of psychiatric disorders rarely have clinical experience with it. Unfortunately, ADHD is often misdiagnosed, in my opinion, by pediatricians or providers that don't have the will or time to see the bigger picture.

I've got to be honest, I'm pretty uninterested in what an academic or "famous" clinician opines about if they don't treat the disorder. I don't see a lot of Ob/gyn bemoan the lack of efficiency of lysis of endometrial adhesions as it relates to fertility if they don't do the procedure itself.

 

[Taddy Mason]

I've got to be honest, I'm pretty uninterested in what an academic or "famous" clinician opines about if they don't treat the disorder. I don't see a lot of Ob/gyn bemoan the lack of efficiency of lysis of endometrial adhesions as it relates to fertility if they don't do the procedure itself.

What about “fibromyalgia” or “chronic” Lyme disease?

 

[romanticscience]

I've got to be honest, I'm pretty uninterested in what an academic or "famous" clinician opines about if they don't treat the disorder. I don't see a lot of Ob/gyn bemoan the lack of efficiency of lysis of endometrial adhesions as it relates to fertility if they don't do the procedure itself.

In some of Ghaemi's books, there are some case histories. I remember reading them and wondering, how in my private practice, it would go with someone with mood disorder and ADHD without collateral (Am I going to interview these patients' mothers and 1st grade teachers?), responding to my recommendation to try "low-dose Depakote." He does advise this, ironically, without evidence for those who score (maybe he's changed it) high on his bipolar spectrum narrative assessment. Yea, great writer but not very successful in private practice.

 

[Taddy Mason]

Yea, great writer but not very successful in private practice.

See posts above. His practice is fine.

 

[randomdoc1]

Every other patient is on a stimulant, what's going on?

this is one factor that led to me moving away from general psychiatry. Too burned out from the same unproductive convo over and over again and patients refusing to acknowledge it's "just" depression or "just" anxiety. The appointments were sucking my soul away. Shifted more towards a smaller panel, psychotherapy, TMS, building the practice and making it psychotherapy focused (so many of the new psychiatry patient calls are "I want someone who will rx me adderall no questions asked"), practicum providers and teaching evidence based therapy. Had to get away without abandoning behavioral medicine altogether.

 

[Merovinge]

What about “fibromyalgia” or “chronic” Lyme disease?

I do occasionally joke about those, but honestly I am only really interested in what rheumatologists say about it if they treat the condition (and sure ID for the later as well). I don't think simply receiving an MD or even completing a residency makes a person king of all medical understanding.

If you get a PhD in algebra, no one asks you your thoughts about topology or logic (for those that know the main subdomains of mathematics). The whole thing about an increasingly complex world due to the higher depth of knowledge is why we have experts. If you want to be an expert in something, I think you need to do that thing.

 

[calvnandhobbs68]

It’s about the bigger picture and goes back to his arguments about construct validity with the diagnostic system since DSM-III onward. He’s not arguing to go back to the pre-DSM-III system but that we as a field can and should strive to do better. And like I’ve said before he’s equally critical of his beloved bipolar disorder if you actually bother to read/listen to what he has to say and check his references.

Also, like I’ve previously stated, I agree with a lot of what he has to say but not everything. I think he has some very valid points concerning ADHD but I don’t agree with all of it. Don’t throw the baby out with the bath water.

Edit - He’s also not afraid to admit some of the stances he’s taken in the past he’s been incorrect about, which is something many people struggle with.

I know you're a big fan of his apparently but no he's literally said things like "DSM III is 95.2% false" and that DSM IV/V basically suck because they don't expand bipolar and prodromal schizophrenia concepts and annoyed that they created DMDD to "discourage bipolar diagnosis" (which I agree isn't a great diagnosis but is better than throwing all these kids with "unspecified bipolar disorder" on antipsychotics....he doesn't seem to care too much about that). Don't see much equal criticism of his beloved bipolar disorder.

Why DSM is mostly false

95.2% false, to be exact

ghaemi.substack.com

Idk man titles like "why dsm is mostly false"....maybe academic edgelord makes more sense huh?

 

[Taddy Mason]

I know you're a big fan of his apparently but no he's literally said things like "DSM III is 95.2% false"

Yeah. I know. That’s in line with the post I made…

… Don't see much equal criticism of his beloved bipolar disorder.

What is manic-depressive illness?

Also, I had him as a lecturer and attending so have perspectives of his view points beyond random blog articles.

As for the ADHD thing, yeah he doesn’t treat it or believe it be a valid diagnostic construct but he backs that up with literature and an arguably sound rationale v. just saying he doesn’t believe it so f-off.

 

[calvnandhobbs68]

Yeah. I know. That’s in line with the post I made…

What is manic-depressive illness?

Also, I had him as a lecturer and attending so have perspectives of his view points beyond random blog articles.

Ahhh there it is:

"If we accept a spectrum concept, we would be more flexible about using dopamine blockers or mood stabilizers for treating depressive conditions, and indeed those agents are effective for many depressive conditions that are not part of the narrow DSM defined bipolar disorder definition."

🤣 how is this literally any different from the "ADHD spectrum" stuff? Lets call everyone who's depressed as being on the "manic depressive spectrum" shall we? Oh and don't worry if you don't fit into any of these categories you can always be having a "mixed" episode! All seemingly primarily based on self reporting from the patient...I mean damn at least in ADHD I'm getting standardized collateral from multiple other reporters.

How on brand.

 

[Merovinge]

Ahhh there it is:

"If we accept a spectrum concept, we would be more flexible about using dopamine blockers or mood stabilizers for treating depressive conditions, and indeed those agents are effective for many depressive conditions that are not part of the narrow DSM defined bipolar disorder definition."

🤣 how is this literally any different from the "ADHD spectrum" stuff? Lets call everyone who's depressed as being on the "manic depressive spectrum" shall we? Oh and don't worry if you don't fit into any of these categories you can always be having a "mixed" episode! All seemingly primarily based on self reporting from the patient...I mean damn at least in ADHD I'm getting standardized collateral from multiple other reporters.

How on brand.

Also with the robust evidence of Depakote in the treatment of depression, or risperidone in the treatment of depression...

 

[Orgone]

Yeah. I know. That’s in line with the post I made…

What is manic-depressive illness?

Also, I had him as a lecturer and attending so have perspectives of his view points beyond random blog articles.

As for the ADHD thing, yeah he doesn’t treat it or believe it be a valid diagnostic construct but he backs that up with literature and an arguably sound rationale v. just saying he doesn’t believe it so f-off.

Ahhh there it is:

"If we accept a spectrum concept, we would be more flexible about using dopamine blockers or mood stabilizers for treating depressive conditions, and indeed those agents are effective for many depressive conditions that are not part of the narrow DSM defined bipolar disorder definition."

🤣 how is this literally any different from the "ADHD spectrum" stuff? Lets call everyone who's depressed as being on the "manic depressive spectrum" shall we? Oh and don't worry if you don't fit into any of these categories you can always be having a "mixed" episode! All seemingly primarily based on self reporting from the patient...I mean damn at least in ADHD I'm getting standardized collateral from multiple other reporters.

How on brand.

As best as I can tell this is a faithful summary of Ghaemi's reasoning in the linked post:

1. Historically, what we now call separately major depression and bipolar were under the same umbrella of "manic-depressive illness".

2. Later, differences in symptoms along with genetics (family history) and course of illness (age of onset) were used to separate out major depression and bipolar disorder.

3. However, in some people the "genetics and course" are mismatched, e.g. a "bipolar genetics and course" person only exhibits symptoms of what we now call major depression.

4. Therefore, there is a paradox, and the only two possible solutions are that "manic depressive illness is one disease" or "there is a mood spectrum between classic bipolar disorder and classic unipolar depression" but either way "'Major depressive disorder' is still scientifically meaningless".


Maybe I'm just not smart enough to follow along, but this reasoning sounds totally nuts. The fact that some people with bipolar "genetics" only exhibit unipolar depression means ... unipolar depression isn't "real"? And since we don't know the underlying "mechanism" and diagnose solely based on symptoms, that means that somehow the only solution is that ... everyone's manic-depressive? Whether they've ever had mania or not? That is a more logical or scientific conclusion?

 

[Taddy Mason]

As best as I can tell this is a faithful summary of Ghaemi's reasoning in the linked post:

1. Historically, what we now call separately major depression and bipolar were under the same umbrella of "manic-depressive illness".

2. Later, differences in symptoms along with genetics (family history) and course of illness (age of onset) were used to separate out major depression and bipolar disorder.

3. However, in some people the "genetics and course" are mismatched, e.g. a "bipolar genetics and course" person only exhibits symptoms of what we now call major depression.

4. Therefore, there is a paradox, and the only two possible solutions are that "manic depressive illness is one disease" or "there is a mood spectrum between classic bipolar disorder and classic unipolar depression" but either way "'Major depressive disorder' is still scientifically meaningless".


Maybe I'm just not smart enough to follow along, but this reasoning sounds totally nuts. The fact that some people with bipolar "genetics" only exhibit unipolar depression means ... unipolar depression isn't "real"? And since we don't know the underlying "mechanism" and diagnose solely based on symptoms, that means that somehow the only solution is that ... everyone's manic-depressive? Whether they've ever had mania or not? That is a more logical or scientific conclusion?

His point is that it’s a false dichotomy. At least with the information we currently have.

 

[calvnandhobbs68]

As best as I can tell this is a faithful summary of Ghaemi's reasoning in the linked post:

1. Historically, what we now call separately major depression and bipolar were under the same umbrella of "manic-depressive illness".

2. Later, differences in symptoms along with genetics (family history) and course of illness (age of onset) were used to separate out major depression and bipolar disorder.

3. However, in some people the "genetics and course" are mismatched, e.g. a "bipolar genetics and course" person only exhibits symptoms of what we now call major depression.

4. Therefore, there is a paradox, and the only two possible solutions are that "manic depressive illness is one disease" or "there is a mood spectrum between classic bipolar disorder and classic unipolar depression" but either way "'Major depressive disorder' is still scientifically meaningless".


Maybe I'm just not smart enough to follow along, but this reasoning sounds totally nuts. The fact that some people with bipolar "genetics" only exhibit unipolar depression means ... unipolar depression isn't "real"? And since we don't know the underlying "mechanism" and diagnose solely based on symptoms, that means that somehow the only solution is that ... everyone's manic-depressive? Whether they've ever had mania or not? That is a more logical or scientific conclusion?

There's also quite a bit of either not actually knowing what the categories were in DSM II (which I'd find weird for someone so critical of DSM) or intentional obfuscation here.

The ACTUAL categories in DSM II were that all these syndromes were put under "Psychoses not attributed to physical conditions listed previously", which included schizophrenia under that subheading along with manic/depressive psychoses...which was to be differentiated from the other major subcategory, neuroses. That is, the affective disorders categorized under this were so severe that they "interfere with patient's ability to meet the ordinary demands of life and recognize reality". He also completely ignores the depressive neuroses category.

So to somehow use DSM II as your justification that manic-depressive psychoses used to be a single thing so what we should actually do is put all these people under one subheading and then actually think of this as a SPECTRUM which should include "a lot of people in the middle with mixtures of unipolar and bipolar features"....is kind of funny. Its pretty much the opposite of DSM II which is intentionally NOT including less severe cases.

 

[Taddy Mason]

There's also quite a bit of either not actually knowing what the categories were in DSM II (which I'd find weird for someone so critical of DSM) or intentional obfuscation here.

The ACTUAL categories in DSM II were that all these syndromes were put under "Psychoses not attributed to physical conditions listed previously", which included schizophrenia under that subheading along with manic/depressive psychoses...which was to be differentiated from the other major subcategory, neuroses. That is, the affective disorders categorized under this were so severe that they "interfere with patient's ability to meet the ordinary demands of life and recognize reality". He also completely ignores the depressive neuroses category.

So to somehow use DSM II as your justification that manic-depressive psychoses used to be a single thing so what we should actually do is put all these people under one subheading and then actually think of this as a SPECTRUM which should include "a lot of people in the middle with mixtures of unipolar and bipolar features"....is kind of funny. Its pretty much the opposite of DSM II which is intentionally NOT including less severe cases.

He does talk about neurotic depression just not in that blog post. Part of the reason MDD was created and split off from MDI was to have a category for neurotic depression beings psychoanalytic thought still dominated at that time and there was concern that if neurotic depression were left as its own entity or relabeled minor depression it wouldn’t reimburse that well. That’s part of the reason we have MDD today and is hardly scientific at all.

 

[calvnandhobbs68]

He does talk about neurotic depression just not in that blog post. Part of the reason MDD was created and split off from MDI was to have a category for neurotic depression beings psychoanalytic thought still dominated at that time and there was concern that if neurotic depression were left as its own entity or relabeled minor depression it wouldn’t reimburse that well. That’s part of the reason we have MDD today and is hardly scientific at all.

Yeah way to not actually address anything else there, my point was that he's using this as justification for envisioning MDD and bipolar disorders as one overall concept and completely ignoring the severity aspect of the manic/depressive psychoses subject.

Are you saying his "criticism" of bipolar disoder is this concept that like basically all affective mood states are some flavor of mania or depression? Cause you realize that's what he's saying right? Why even if you have a "hyperthymic" or "dysthymic" or "cyclothymic" temperment you could benefit from a little depakote or lithium or abilify based on....personal experience. How scientific!

ADHD isn't real, no, no, what's going on with that condition is that it could actually be...manic depressive spectrum a lot of the time.

"Thus the claim that ADHD runs in families is misleading if one ignores the fact that those same patients may have bipolar illness and severe unipolar depression, which actually are the diseases running in those families. "
"Since mania causes inattention and executive dysfunction, it makes sense to conclude that such patients simply have mania with those cognitive effects, rather than unluckily having two diseases at the same time."

To refer back to the original post, he also completely butchers the actual conclusions from the MTA 3 year followup. Again, not sure if he's being intentionally disingenuous or what. Since they actually address this in their discussion:

We hypothesized that this unexpected pattern may be due to a tendency of those who aredoing well either to stay off medication or to discontinue it and those doing poorly either to start taking it or to continue it. This may hold for any modality of treatment because we found a similar pattern of disadvantage (p = .007) for educational services: those receiving a higher level of such services were doing worse at 36 months than those receiving a lower level (or none), especially for CC, in which improvement was only about half as great (p = .0006)for those receiving 91 hour/week of special educational services. Selection effects may be operative here, that is,that those children with worse problems receive more treatment, either with medication or with educationals ervices. This hypothesis is further tested and discussed

 

[Taddy Mason]

Yeah way to not actually address anything else there, my point was that he's using this as justification for envisioning MDD and bipolar disorders as one overall concept and completely ignoring the severity aspect of the manic/depressive psychoses subject.

Are you saying his "criticism" of bipolar disoder is this concept that like basically all affective mood states are some flavor of mania or depression? Cause you realize that's what he's saying right? Why even if you have a "hyperthymic" or "dysthymic" or "cyclothymic" temperment you could benefit from a little depakote or lithium or abilify based on....personal experience. How scientific!

ADHD isn't real, no, no, what's going on with that condition is that it could actually be...manic depressive spectrum a lot of the time.

"Thus the claim that ADHD runs in families is misleading if one ignores the fact that those same patients may have bipolar illness and severe unipolar depression, which actually are the diseases running in those families. "
"Since mania causes inattention and executive dysfunction, it makes sense to conclude that such patients simply have mania with those cognitive effects, rather than unluckily having two diseases at the same time."

To refer back to the original post, he also completely butchers the actual conclusions from the MTA 3 year followup. Again, not sure if he's being intentionally disingenuous or what. Since they actually address this in their discussion:

JFC 🙄…

 

[calvnandhobbs68]

JFC 🙄…

lol deep thoughts

 

[Stagg737]

I do occasionally joke about those, but honestly I am only really interested in what rheumatologists say about it if they treat the condition (and sure ID for the later as well). I don't think simply receiving an MD or even completing a residency makes a person king of all medical understanding.

If you get a PhD in algebra, no one asks you your thoughts about topology or logic (for those that know the main subdomains of mathematics). The whole thing about an increasingly complex world due to the higher depth of knowledge is why we have experts. If you want to be an expert in something, I think you need to do that thing.

Sorry, but I'll disagree here. You shouldn't need to be an ID doc to know the concept of chronic lyme is garbage or that there's a difference between "chronic lyme" and chronic sequelae from previous lyme infections. The idea that we have to be an "expert" to understand or comment on a subject is kind of ridiculous.

Also with the robust evidence of Depakote in the treatment of depression, or risperidone in the treatment of depression...

Fair point for depakote, but there's plenty of evidence for risperidone for depression...

I know you're a big fan of his apparently but no he's literally said things like "DSM III is 95.2% false" and that DSM IV/V basically suck because they don't expand bipolar and prodromal schizophrenia concepts and annoyed that they created DMDD to "discourage bipolar diagnosis" (which I agree isn't a great diagnosis but is better than throwing all these kids with "unspecified bipolar disorder" on antipsychotics....he doesn't seem to care too much about that). Don't see much equal criticism of his beloved bipolar disorder.

Why DSM is mostly false

95.2% false, to be exact

ghaemi.substack.com

Idk man titles like "why dsm is mostly false"....maybe academic edgelord makes more sense huh?

The DSM IS largely garbage though. Talk to any psychologists that study nosology and diagnostic validity at higher levels and they'll tell you exactly that. It's the whole reason academic psychology has been so high on the HiTOP model and identifying superspectra and the common P factor which connects all the supposed diagnoses we put in the DSM other than some of the somatoform disorders. It's also why psychologists have been harping on the dimensional model of personality disorders for a few decades now. Our construct validity sucks. Just because there is clinical utility in their existence doesn't make them valid.

I think it was Clause that once very succinctly stated, "I've got meds for your symptoms", which pretty much sums up the vast majority of our field.

 

[calvnandhobbs68]

Fair point for depakote, but there's plenty of evidence for risperidone for depression...

The effect size for antipsychotic monotherapy is not significantly or consistently higher than SSRI monotherapy. If all this MDD was really “manic depressive spectrum” or whatever in disguise, it’s not clear what his explanation is for that. Remember this is coming from a guy who proposes exactly that.

The DSM IS largely garbage though. Talk to any psychologists that study nosology and diagnostic validity at higher levels and they'll tell you exactly that. It's the whole reason academic psychology has been so high on the HiTOP model and identifying superspectra and the common P factor which connects all the supposed diagnoses we put in the DSM other than some of the somatoform disorders. It's also why psychologists have been harping on the dimensional model of personality disorders for a few decades now. Our construct validity sucks. Just because there is clinical utility in their existence doesn't make them valid.

I think it was Clause that once very succinctly stated, "I've got meds for your symptoms", which pretty much sums up the vast majority of our field.

It’s not that all these disorders in DSM are correct or valid….its that he feigns being “scientific” to say look this is why all these disorders don’t really exist but what’s REALLY going on is that most of these people are manic-depressive spectrum and we should be hitting them with mood stabilizers and antipsychotics. With unclear evidence for why this would be the case. If one is putting themselves out there as such a scientist who thinks so deeply about nosology and evidence, I’d think you’d have more evidence for suggesting to put people chronically on teratogenic and metabolically deranging medication. It’s just as wild of a concept as saying ADHD is a thing.

It’s like saying organized religion sucks and God isn’t real….so come join my church. Which is kind of what half of psychiatry has been anyway lol not exactly novel.

He also completely ignores the harm in this approach. Like the whole DMDD thing…is it a great diagnosis? No. Do I diagnose it a lot? No. But it serves a reasonable purpose which was to try to stop people from doing exactly what he proposes… give an excuse to throw a bunch of kids with chronic/fluctuating irritability or behavioral dysregulation under the “unspecified bipolar” category and put therm on those medications.

 

[Crayola227]

teratogenic and metabolically deranging medication.

Thank you for this. Depakote might be more benign compared to many other agents for bipolar like antipsychotics, but that doesn't make it benign.

 

[Taddy Mason]

The effect size for antipsychotic monotherapy is not significantly or consistently higher than SSRI monotherapy. If all this MDD was really “manic depressive spectrum” or whatever in disguise, it’s not clear what his explanation is for that. Remember this is coming from a guy who proposes exactly that.



It’s not that all these disorders in DSM are correct or valid….its that he feigns being “scientific” to say look this is why all these disorders don’t really exist but what’s REALLY going on is that most of these people are manic-depressive spectrum and we should be hitting them with mood stabilizers and antipsychotics. With unclear evidence for why this would be the case. If one is putting themselves out there as such a scientist who thinks so deeply about nosology and evidence, I’d think you’d have more evidence for suggesting to put people chronically on teratogenic and metabolically deranging medication. It’s just as wild of a concept as saying ADHD is a thing.

It’s like saying organized religion sucks and God isn’t real….so come join my church. Which is kind of what half of psychiatry has been anyway lol not exactly novel.

He also completely ignores the harm in this approach. Like the whole DMDD thing…is it a great diagnosis? No. Do I diagnose it a lot? No. But it serves a reasonable purpose which was to try to stop people from doing exactly what he proposes… give an excuse to throw a bunch of kids with chronic/fluctuating irritability or behavioral dysregulation under the “unspecified bipolar” category and put therm on those medications.

Idk if it’s intentional or not, but you’re repeatedly missing the forest for the trees and cherry picking things just to throw out anything he has to say without checking his resources/citations.

 

[calvnandhobbs68]

Idk if it’s intentional or not, but you’re repeatedly missing the forest for the trees and cherry picking things just to throw out anything he has to say without checking his resources/citations.

Care to provide anything of actual substance? All you’ve repeatedly provided are vague statements and links to his substack….which I’ve also pulled direct quotes from. You do realize these are actual ideas he posits right? Like he literally says people who have a “hyperthymic” or “dysthymic” temperament should be put on “low dose” antipsychotics and anticonvulsants.
Or doesn’t realize the logical inconsistency of arguing that ADHD isn’t an actual diagnosis because stimulants improve multiple other psychiatric symptoms/conditions while using that same argument for the manic-depressive spectrum stuff (“look classes of medications we use for bipolar disorder work for a set of people with just depressive or “mixed” symptoms, it must mean they have manic-depressive spectrum illness”).

I’m aware of the citations for those substack posts, do you have anything in particular you’re referring to?

 

[Taddy Mason]

Care to provide anything of actual substance? All you’ve repeatedly provided are vague statements and links to his substack….which I’ve also pulled direct quotes from. You do realize these are actual ideas he posits right? Like he literally says people who have a “hyperthymic” or “dysthymic” temperament should be put on “low dose” antipsychotics and anticonvulsants.

I’m aware of the citations for those substack posts, do you have anything in particular you’re referring to?

This is pointless with your repetitive strawmans. Hence my curt response above.

 

[calvnandhobbs68]

This is pointless with your repetitive strawmans. Hence my curt response above.

Yeah about what I figured.

 

[lobstar]

Sometimes it seems like we go in these circles to justify medications. Whether it's a "disease" or just people in the bottom half of attention/organization/conscientiousness clearly the meds help.

And at this point, barring some actual development with imaging or labs, ADHD and stimulants are so entangled with performance enhancement it all seems pretty meaningless. It's the psych version of TRT. Like look what the German army did in the 40s by giving stimulants to everyone. Pretty more everyone would be better at their jobs/life with an appropriately dosed stimulant.

 

[Crayola227]

Sometimes it seems like we go in these circles to justify medications. Whether it's a "disease" or just people in the bottom half of attention/organization/conscientiousness clearly the meds help.

And at this point, barring some actual development with imaging or labs, ADHD and stimulants are so entangled with performance enhancement it all seems pretty meaningless. It's the psych version of TRT. Like look what the German army did in the 40s by giving stimulants to everyone. Pretty more everyone would be better at their jobs/life with an appropriately dosed stimulant.

You haven't discussed kids at all. Do normal kids become less wiggly on stims? Just curious.

 

[psycho-matic]

[

It's the same problem I see regularly on consults of everyone calling patients who aren't of sound mind "psychotic" or "schizophrenic" when there are identifiable medical problems driving the condition which just get overlooked or thrown aside because the psychiatric label is easier to assign.

I couldn't have said it better. If I had $100 for every time I see someone diagnosed with bipolar disorder because they had "explosive anger," "labile mood," "mood swings" that change over the course of hours to 2 days, teenagers "acting out" etc. etc. that have been misdiagnosed as having mania or bipolar disorder... I encounter this on a daily basis. It's hard to believe that people in our field really don't understand what mania looks like, or maybe they're just lazy.

Having to re-educate these patients on what mania means and telling them they don't have bipolar disorder is time-consuming. This cohort had often had multiple SSRIs and sometimes stimulants without activation. That by itself should lower suspicion. They often lack a family history of bipolar. Less often, but not infrequently, a patient's "mania" was induced by illicit drugs and again, they are misdiagnosed. Bipolar is one of the disorders where diagnostic accuracy actually matters because the diagnosis strongly informs treatment decisions.

 

[Mad Jack]

I wanted to get other Psychiatrists opinion on a controversial matter: that the ADHD diagnosis simply doesn't exist! I recently stumbled on a substack post from Ghaemi:
(Link: The Diagnostic Invalidity of ADHD), and I'll try to summarize his arguments for why ADHD isn't real:

​

1. Ghaemi asserts that adult ADHD fails accepted criteria for valid psychiatric diagnoses—namely course of illness, genetics, biological markers, and symptom specificity—with adult ADHD lacking rigorous empirical support:


2.Relying on prospective longitudinal studies, he argues ~80% of childhood ADHD does not persist into adulthood—contradicting retrospective estimates (~50–60%) and challenging claims of continuity.

3. The diagnosis of adult ADHD, Ghaemi maintains, surged post-1996—when atomoxetine (Strattera) gained FDA approval. He frames this as a case of disease‑mongering tied to profit motives, rather than discovery of a genuine nosological entity. Also, most ADHD medications are NA reuptake blockers, which can work a variety of other conditions, such as depression.

4. He emphasizes the neglect of diagnostic hierarchy: inattention and executive dysfunction are often symptoms of mood or anxiety disorders, not indicators of a separate ADHD. He points out high comorbidity rates—e.g., epidemiological studies showing ~84% of adult ADHD cases also meet criteria for mood disorders .

​

5. Cyclothymia and other mood temperaments may be chronically misdiagnosed as ADHD. Ghaemi cites internal research indicating 60–62% of supposed adult ADHD cases actually have undiagnosed temperamental mood disorders.

6.He challenges the logic that stimulants validate adult ADHD, since such medications enhance cognition even in non‑ADHD individuals. Moreover, stimulants may exacerbate anxiety—creating a feedback loop worsening inattention symptoms.

So what you guys think? He has some really controversial ideas about diagnostic nosology, but I found this discussion fascinating.

We have actual proof that treatment of ADHD improves outcomes in several domains, including reduced rates of incarceration, accidents, and substance use. The rates of these outcomes deviate in those diagnosed with ADHD from the general population quite substantially. ADHD is also highly heritable, amongst the most so of any psychiatric condition. So it is a condition that both has a relatively reliable genetic predisposition which puts one at very high risk for substantial negative outcomes, and this is a condition we have medications by which we can improve those outcomes. In my opinion, that tells me that we would be negligent in our duties as physicians to not offer such treatment.

Course of illness is another issue altogether, and I theorize that ADHD, much like schizophrenia, is a common presentation of multiple illnesses that are beyond our current ability to fully delineate. Perhaps in a subset of patients, it is the result of delayed myelination, while in others it relates to alterations in connection density between regions of the brain involved in focus and attention, or any number of other possible issues. Some of these issues improve as the brain completes development in the third decade of life, while others do not. But at its heart, ADHD is a set of neurodevelopmental abnormalities or delays that can impair focus, attention, behavioral control, emotional regulation, and executive function.

However, is it *really* an illness, or does it serve adaptive purposes? I think that ADHD is an adaptation for a world that no longer exists, in which exploration, hunting, foraging, and making impulsive mating decisions were beneficial traits for one to possess. The very traits that are problematic when one is being forced to sit in an office or school for 8 hours at a clip would have been wonderful for someone to have as a hunter, sailor, or explorer. Impulsivity can also tend toward creativity and experimentation that can keep culture and society moving forward. There's a reason something so strongly determined by genetics has stuck around for so long.

Is it overdiagnosed? I think it is in some populations, but that it is underdiagnosed in others. There was a great paper out of Sweden recently that showed a decrease in the effectiveness of ADHD treatment over time which correlated in an increase in prescriptions, which pretty clearly shows these meds are going to a less impaired population (and in the case of white middle-aged women, one that exceeded the prevalence of ADHD and thus was likely not impaired at all). However, there are some populations in which behaviors often get passed off as any number of other disorders (conduct disorder, intermittent explosive disorder, etc) or where treatment just isn't available, resulting in poor and avoidable long-term outcomes.

 

[Mad Jack]

I know you're a big fan of his apparently but no he's literally said things like "DSM III is 95.2% false" and that DSM IV/V basically suck because they don't expand bipolar and prodromal schizophrenia concepts and annoyed that they created DMDD to "discourage bipolar diagnosis" (which I agree isn't a great diagnosis but is better than throwing all these kids with "unspecified bipolar disorder" on antipsychotics....he doesn't seem to care too much about that). Don't see much equal criticism of his beloved bipolar disorder.

Why DSM is mostly false

95.2% false, to be exact

ghaemi.substack.com

Idk man titles like "why dsm is mostly false"....maybe academic edgelord makes more sense huh?

As someone that treats DMDD with some regularity, he's highly misinformed to say it was created to "discourage bipolar diagnosis." The natural course of DMDD tends to be one that leads to depression and anxiety as a teenager and adult, and they are extremely unlikely to develop bipolar disorder. They also tend to benefit or completely resolve in symptoms with SSRIs and/or therapy, which a bipolar patient would not. I basically just view it as depression, but in a child that has a limited means by which to understand and express those feelings. As their brain further develops, they get more of the SIG E CAPS that crop up.

But this is why doing a very careful assessment is important. ADHD, DMDD, childhood depression, and early onset bipolar disorder have a lot of shared and overlapping features. If you throw a stimulant at a kid with DMDD they generally get a lot worse very quickly, while an SSRI tends to do nothing for a kid with only ADHD. Therapy can help with depression and to some extent DMDD but doesn't do a thing for ADHD or bipolar disorder (not saying it's worthless but it doesn't move the needle on core symptoms). But carefully diagnosing, you end up with better outcomes while using far fewer medications overall. It always seems the kids I freshly start in treatment end up on 0-2 meds while referrals always seem to come in on 3-4+, which I can usually trim down by reassessing the original diagnoses.

 

[hamstergang]

As someone that treats DMDD with some regularity, he's highly misinformed to say it was created to "discourage bipolar diagnosis." The natural course of DMDD tends to be one that leads to depression and anxiety as a teenager and adult, and they are extremely unlikely to develop bipolar disorder. They also tend to benefit or completely resolve in symptoms with SSRIs and/or therapy, which a bipolar patient would not. I basically just view it as depression, but in a child that has a limited means by which to understand and express those feelings. As their brain further develops, they get more of the SIG E CAPS that crop up.

DMDD was in fact created to reduce over-diagnosis of bipolar disorder in kids. These kids were getting diagnosed inappropriately with bipolar disorder, and this led to inappropriate treatments and labeling that followed them later in life. Now, we can diagnosis DMDD instead, which as you point out more commonly leads to unipolar than bipolar depression. So it seems that the goal of the DMDD label has been achieved.

 

[Mad Jack]

DMDD was in fact created to reduce over-diagnosis of bipolar disorder in kids. These kids were getting diagnosed inappropriately with bipolar disorder, and this led to inappropriate treatments and labeling that followed them later in life. Now, we can diagnosis DMDD instead, which as you point out more commonly leads to unipolar than bipolar depression. So it seems that the goal of the DMDD label has been achieved.

I think my point and yours are the same, it was created to accurately describe an illness based upon its natural course so that it can be treated properly. It was not created specifically to avoid another diagnosis.

Edit: I'll read through the history of diagnosis proposals for the DSM and educate myself on the matter before making assumptions. Perhaps by renaming the condition and further studying it we did some good on accident. He would know the inner workings of how the DSM 5 was crafted far better than I

 

[Taddy Mason]

His sentiment, if I recall correctly, was that these kids actually have bipolar disorder and that this diagnosis was created to avoid giving kids a diagnosis he felt was appropriate.

That’s incorrect. He’s critical of childhood bipolar diagnoses. I don’t have any writings off the top of my head to cite just personal discussion with him having had him as a lecturer and attending.

 

[Mad Jack]

That’s incorrect. He’s critical of childhood bipolar diagnoses. I don’t have any writings off the top of my head to cite just personal discussion with him having had him as a lecturer and attending.

Good to know. I retract my statement, looking at his writing it seems I may have simply inferred incorrectly based upon upon it being a relatively nonspecific statement in the greater context of the what he had written. He says he thinks it is not good because it was made to avoid diagnosing children with bipolar disorder, but the greater context was related to construct validity rather than the relation of one diagnosis to the next, and the travesty was not the switch of one diagnosis to another, but that he felt the latter diagnosis should not exist at all, which is a fair argument in the context of how it may have been conceived but I think is incorrect in light of evolving research

 

[Taddy Mason]

Edit: I'll read through the history of diagnosis proposals for the DSM and educate myself on the matter before making assumptions. Perhaps by renaming the condition and further studying it we did some good on accident. He would know the inner workings of how the DSM 5 was crafted far better than I

I highly recommend “The Making of DSM-III” as was posted previously in this thread.

 

[psycho-matic]

Good to know. I retract my statement, looking at his writing it seems I may have simply inferred incorrectly based upon upon it being a relatively nonspecific statement in the greater context of the what he had written. He says he thinks it is not good because it was made to avoid diagnosing children with bipolar disorder, but the greater context was related to construct validity rather than the relation of one diagnosis to the next, and the travesty was not the switch of one diagnosis to another, but that he felt the latter diagnosis should not exist at all, which is a fair argument in the context of how it may have been conceived but I think is incorrect in light of evolving research

There is a adolescents that absolutely have bipolar disorder.