The myth of ADHD

[calvnandhobbs68]

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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.

Oh yeah? I mean I do in about a 5 second search.

Childhood Bipolar Disorder: Erasing Myths

Recent blog posts on PT have attacked the concept of childhood bipolar disorder. I think it is important to give readers a different viewpoint from what seems to be the groupthink perspective of today.

www.psychologytoday.com

“It is completely illogical, for instance, to claim that a child had “major depressive disorder” (MDD)or ADHD when there are immediate family members with bipolar disorder.”

“There is a cultural zeitgeist among child psychiatrists against the diagnosis of bipolar disorder, and instead symptoms are given diagnostic labels, which is scientifically meaningless.”

“Rather, to diagnose ADHD, one should rule out bipolar disorder first.”

lol what? Oh hey let’s also totally ignore that in the COBY study he cites that a full 34% of those kids had Bipolar-NOS which is just as a dump of a diagnosis as if I had an ADHD study where 34% of the kids had an “unspecified ADHD” diagnosis.

Dude do you even actually know what he believes? Because every time I actually cite quotes and articles you just go “nah that’s not what he thinks”.

 

[Taddy Mason]

Dude do you even actually know what he believes? Because every time I actually cite quotes and articles you just go “nah that’s not what he thinks”.

Again I had him as a lecturer and attending for 3 years and have had numerous personal conversations with him. I don’t put him on a pedestal by any means and as I’ve repeatedly stated in this thread I don’t agree with everything he has to say. Sorry I can’t cite my personal correspondence with him. So far, in responding to my posts you’ve been incapable of engaging in a linear argument without repeated strawman arguments and other logical fallacies and repeatedly cherry pick and ignore context when citing his writings so it’s fruitless to engage (and why I haven’t been giving you the responses you seem to expect) and detracts from the thread. Like most CAPs you don’t like him, point made loud and clear. But here you go if it makes you feel better:

 

[calvnandhobbs68]

Again I had him as a lecturer and attending for 3 years and have had numerous personal conversations with him. I don’t put him on a pedestal by any means and as I’ve repeatedly stated in this thread I don’t agree with everything he has to say. Sorry I can’t cite my personal correspondence with him. So far, in responding to my posts you’ve been incapable of engaging in a linear argument without repeated strawman arguments and other logical fallacies and repeatedly cherry pick and ignore context when citing his writings so it’s fruitless to engage and detracts from the thread. Like most CAPs you don’t like him, point made loud and clear. But here you go if it makes you feel better:

Haha ah the old "I don't really have any evidence for what I'm saying so whatever guess you win NERD" argument. Oh followed by the "you're part of X group, so that's why you don't like this". Man again, deep thinking here.

I'm not exactly sure if you know what a strawman argument is. Let me know what specific ideas are strawman arguments and why that's the case.

Let me rephrase the last part for you. I have no idea if I "like him" or not, I've never met the guy. However, based on his writings and articles (which I've read and apparently...you haven't?) I think he's logically inconsistent and intentionally provocative. As noted previously, he fails to understand the shortcomings of or sometimes doesn't even seem to have read some sources he cites but puts them out there as firm evidence or doesn't understand the conclusions (or just cites his own articles half the time). I also think that he speaks from a position of authority to put forward ideas with fairly scant evidence that have the potential to be harmful to patients if we followed them at his word.

This isn't an internet argument about what build on Skyrim is better or something. These are ideas about real patients that influence actual clinical decision making. Although I'd hardly call it an argument based on you saying basically nothing besides "nuh uh I've talked to him and that's not what he really thinks".

 

[Mad Jack]

There is a adolescents that absolutely have bipolar disorder.

I never said there weren't, but again, this goes into making inferrences about what people are saying that aren't necessarily accurate, as I did with his statements

 

[Mad Jack]

Oh yeah? I mean I do in about a 5 second search.

Childhood Bipolar Disorder: Erasing Myths

Recent blog posts on PT have attacked the concept of childhood bipolar disorder. I think it is important to give readers a different viewpoint from what seems to be the groupthink perspective of today.

www.psychologytoday.com

“It is completely illogical, for instance, to claim that a child had “major depressive disorder” (MDD)or ADHD when there are immediate family members with bipolar disorder.”

“There is a cultural zeitgeist among child psychiatrists against the diagnosis of bipolar disorder, and instead symptoms are given diagnostic labels, which is scientifically meaningless.”

“Rather, to diagnose ADHD, one should rule out bipolar disorder first.”

lol what? Oh hey let’s also totally ignore that in the COBY study he cites that a full 34% of those kids had Bipolar-NOS which is just as a dump of a diagnosis as if I had an ADHD study where 34% of the kids had an “unspecified ADHD” diagnosis.

Dude do you even actually know what he believes? Because every time I actually cite quotes and articles you just go “nah that’s not what he thinks”.

Alright, good to know. I could have sworn I had read stuff like this by him before but was willing to concede I might have been mistaken because quite frankly I read a lot and could have mixed up authors in my head at some point. But this pretty much was what I remembered his opinions being, and thus why I took his "DMDD is just a way to not diagnose kids with bipolar disorder" as implying that DMDD was simply dodging what he believed the actual diagnosis to be. And his idea that a child cannot have major depressive disorder if the parents have bipolar disorder flies in the face of studies which have shown that offspring of those with bipolar disorder are more likely to have unipolar depression than bipolar disorder (though their risks of both are quite elevated compared to the population).

Mental disorders in offspring of parents with bipolar and major depressive disorders - PMC

There is limited information on the specificity of associations between parental bipolar disorder (BPD) and major depressive disorder (MDD) and the risk of psychopathology in offspring. The chief aim of the present study was to investigate the ...

pmc.ncbi.nlm.nih.gov

 

[Taddy Mason]

Alright, good to know. I could have sworn I had read stuff like this by him before but was willing to concede I might have been mistaken because quite frankly I read a lot and could have mixed up authors in my head at some point. But this pretty much was what I remembered his opinions being, and thus why I took his "DMDD is just a way to not diagnose kids with bipolar disorder" as implying that DMDD was simply dodging what he believed the actual diagnosis to be. And his idea that a child cannot have major depressive disorder if the parents have bipolar disorder flies in the face of studies which have shown that offspring of those with bipolar disorder are more likely to have unipolar depression than bipolar disorder (though their risks of both are quite elevated compared to the population).

Mental disorders in offspring of parents with bipolar and major depressive disorders - PMC

There is limited information on the specificity of associations between parental bipolar disorder (BPD) and major depressive disorder (MDD) and the risk of psychopathology in offspring. The chief aim of the present study was to investigate the ...

pmc.ncbi.nlm.nih.gov

From the Psychology Today article:
“For instance, bipolar disorder could cause all the above symptoms. I am not saying it always does, I am just saying it could.”

This is more or less still his stance. I distinctly remember discussing this in didactics with him and his stance is essentially that as a chronic and likely genetic disorder someone is effectively born with bipolar disorder and doesn’t “develop” it per se later in life. So they likely/possibly do show Sx in childhood but it’s diagnostically ambiguous and he acknowledges the consequences of an inappropriate diagnosis made at such a young age. Pragmatically he’s not for throwing out bipolar diagnosis in children willy nilly but he does believe that it likely manifests in childhood and not at the first major identified mood episode. As for DMDD his core argument around that is construct validity.

 

[Crayola227]

There is a adolescents that absolutely have bipolar disorder.

I don't think he's saying there's not, but there is also misdiagnosis in kids. Kids by definition can have intense emotions, wild mood swings, act impulsively, talk fast, psychomotor agitation, and they be so relative to peers and yet this could erroneously be considered bipolar, especially by folks with less training in kids and/or bipolar.

 

[Ceke2002]

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.

That sounds like the article, or something similar that I read. Interesting concept/idea and one I think I might sort of agree with to a certain degree - or at least one I wouldn't dismiss out of hand. From memory the stuff I read (it was a while ago) posited that hyperactivity alone (no issues with impulsivity or attention, like you mentions) was a different beast than hyperactivity coupled with attention and impulse control difficulties, which was more in line with ADHD. So if a child was diagnosed with Hyperkinetic Reaction of Childhood, but had no other symptoms apart from hyperactivity then the chances of them having a diagnosis of ADHD in later life should theoretically be close to zero (provided no other symptoms were missed). Is that about right?

I don't actually remember my diagnosis changing from HRoC to ADD when the DSM III came out, probably because I was diagnosed the first in 1975 and I was like 8 years old when they changed it to ADD in the DSM. I do remember prior to 1980 myself and a small number of other kids were referred to as 'Hyperactive' (we were the kids at Birthday parties that weren't allowed to have too much sugar or red food dye, seriously never understood the red food dye thing as a dietary treatment for hyperactivity), and post 1980 I started to hear it being referred to more in terms of Attention issues/deficits/etc. The idea that they may have been two separate disorders, albeit perhaps with some overlap of symptoms, is an interesting one to me. Especially in terms of care and treatment based on symptomology in both the short and long term.

 

[Crayola227]

Oh yeah? I mean I do in about a 5 second search.

Childhood Bipolar Disorder: Erasing Myths

Recent blog posts on PT have attacked the concept of childhood bipolar disorder. I think it is important to give readers a different viewpoint from what seems to be the groupthink perspective of today.

www.psychologytoday.com

“It is completely illogical, for instance, to claim that a child had “major depressive disorder” (MDD)or ADHD when there are immediate family members with bipolar disorder.”

“There is a cultural zeitgeist among child psychiatrists against the diagnosis of bipolar disorder, and instead symptoms are given diagnostic labels, which is scientifically meaningless.”

“Rather, to diagnose ADHD, one should rule out bipolar disorder first.”

lol what? Oh hey let’s also totally ignore that in the COBY study he cites that a full 34% of those kids had Bipolar-NOS which is just as a dump of a diagnosis as if I had an ADHD study where 34% of the kids had an “unspecified ADHD” diagnosis.

Dude do you even actually know what he believes? Because every time I actually cite quotes and articles you just go “nah that’s not what he thinks”.

Not your point, but to be fair, there is heritability with both bipolar and ADHD, and a family history of bipolar should probably at least make one think twice before calling symptoms ADHD?

And given the risk of suicide in bipolar that isn't in ADHD, plus the potential to worsen bipolar symptoms with stims, I think it does make sense to rule out bipolar first? Well, and vice versa right? Like it's just important to differentiate the two diagnoses because the potential for overlapping symptoms?

I'm sure I'm missing something in the conversation here.

 

[psycho-matic]

I don't think he's saying there's not, but there is also misdiagnosis in kids. Kids by definition can have intense emotions, wild mood swings, act impulsively, talk fast, psychomotor agitation, and they be so relative to peers and yet this could erroneously be considered bipolar, especially by folks with less training in kids and/or bipolar.

Well said. I agree. My anecdotal experience is that there's a sentiment among some MHPs that bipolar disorder shouldn't be diagnosed in minors.

 

[calvnandhobbs68]

Not your point, but to be fair, there is heritability with both bipolar and ADHD, and a family history of bipolar should probably at least make one think twice before calling symptoms ADHD?

And given the risk of suicide in bipolar that isn't in ADHD, plus the potential to worsen bipolar symptoms with stims, I think it does make sense to rule out bipolar first? Well, and vice versa right? Like it's just important to differentiate the two diagnoses because the potential for overlapping symptoms?

I'm sure I'm missing something in the conversation here.

So a couple points here. Probably at least 50% of family history of "bipolar disorder" is garbage, if you're at all aware of what the community standards for a "bipolar" diagnosis have typically been. We're starting to approach that with ADHD these days but I digress....

Putting that totally aside, yes you should be screening for bipolar disorder in the same way you should be screening for any other psychiatric comorbidity. Because if, of course, one was familiar with DSM criteria, they would be paying attention to the last part of ADHD criteria:

"The symptoms do not occur exclusively during the course of schizophrenia or anotherpsychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal)."

I'm just gonna be frank and say bipolar disorder (as it is classically defined) and ADHD are not difficult things to distinguish from each other for anyone who's putting in even the minimal amount of diagnostic effort. It's making a problem where really one shouldn't exist. They should, as currently defined, have completely different developmental trajectories and clinical presentations. At the most basic level, there should be no episodic nature to ADHD symptoms. In my experience, even when I'm semi-suspicious of mania and kids screen positive on the CMRS or ASRM parent or child rating screeners, when I go more in depth on the symptoms, they either seem to be normal range or not bipolar disorder (vast majority of the time they're screening positive for crappy sleep chronically, "talking more than usual" chronically or chronic hyperactivity).

The issue of course from Ghaemi's end is that in the expansionist camp of manic/depressive illness, many more symptoms COULD be bipolar disorder or COULD go on to be bipolar disorder in the future. I mean just read the article, read most of what he writes in general. He says that "none of the definitions" of any other diagnosis are meaningful and it's doesn't really matter if you don't diagnose them with bipolar disorder right away, as long as you don't diagnose any other of those lame not real diagnoses and don't give them any of those bad meds.

We can pull examples all day of odd or again, disingenuous statistics or interpretations of studies.
"About 90% of all children who meet mania criteria also meet ADHD criteria, because distractibility is one of the core criteria for mania."
What? By who? A criteria of ADHD is that symptoms must persist for at least 6 months. Is he saying all these kids were hypomanic or manic for 6 months straight?

From the Psychology Today article:
“For instance, bipolar disorder could cause all the above symptoms. I am not saying it always does, I am just saying it could.”

Who's making the strawman argument here? This quote comes right after an entire article where he literally craps on clinicians who diagnose kids with a family history of bipolar disorder with other conditions (I have the sneaking suspicion that maybe because he doesn't actually understand heritability vs recurrence risk). I quote again:

"It is completely illogical, for instance, to claim that a child had “major depressive disorder” (MDD) or ADHD when there are immediate family members with bipolar disorder."

 

[aim-agm]

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?

I use NRIs (atomoxetine, desipramine) and DRIs (bupropion primarily) quite frequently outside of ADHD, and one or the other are usually good options for most all of the psychiatric causes of impaired attention (e.g. anxiety, depression, PTSD) and a few non-psychiatric causes (e.g. TBI, pain).
Patients without ADHD may experience benefit for attention with these medications even if attention isn't impaired to begin (or impairment isn't related to their psychiatric conditions), and I have had a few cases where the effect on focus an adverse effect (i.e. would make them overfocus to problematic degree).
Response is not usually a reliable sign, although typically if they do respond the question of whether they have ADHD becomes moot - usually the medication they are already on is adequately addressing attention.

 

[Merovinge]

Not your point, but to be fair, there is heritability with both bipolar and ADHD, and a family history of bipolar should probably at least make one think twice before calling symptoms ADHD?

And given the risk of suicide in bipolar that isn't in ADHD, plus the potential to worsen bipolar symptoms with stims, I think it does make sense to rule out bipolar first? Well, and vice versa right? Like it's just important to differentiate the two diagnoses because the potential for overlapping symptoms?

I'm sure I'm missing something in the conversation here.

I mean every halfway decent CAP evaluation is going to be reviewing for mood symptoms. You can't rule out bipolar disorder in an 8 year old because very few of them will have had frank manic or depressive episodes. Once in awhile you can see some soft signs they might go on to develop frank mood episodes. I would not start a psychostimulant first line if there was a real-deal bipolar or schizophrenia diagnosis in a 1st degree relatively, frankly alpha-2-agonists and NRIs get the job done plenty of the time and have less risk. There does come a point that if you need to use a psychostimulant for clear ADHD in someone with a 1st degree relative with known bipolar/schizophrenia that you can have a reasonable conversation on risks/benefits and move on from there. That's clearly a different process that was is being suggesting by Ghaemi.

 

[Merovinge]

"It is completely illogical, for instance, to claim that a child had “major depressive disorder” (MDD) or ADHD when there are immediate family members with bipolar disorder."

Wow is he arguing that 80% of people with bipolar disorder's children have bipolar disorder!? They have data on this...

 

[Merovinge]

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.

I am not trying to argue that everyone needs to be an expert to comment on anything, but I do think people really get out of their lane on a regular basis, especially if they get famous and get a platform.

Again, I have thoughts on Chronic Lyme, but I have not scoured the data on this, so if someone is asking me as a medical doctor, I would give a cursory description of my understanding and then defer to ID folks who actually have reviewed all the literature.

I don't even feel comfortable in commenting on much of adult psychiatry these days as being 10+ years out of adult residency and spending 95% of my time taking care of kids-25 years olds has left me not keeping up with literature in a number of areas. The more I learn, the more I know what I don't know and am not an expert in. I went to APA for the first-time in ages as my job wanted me to for networking and even just doing that showed me how much literature if getting pumped out in areas that I am not up to date on.

 

[calvnandhobbs68]

Wow is he arguing that 80% of people with bipolar disorder's children have bipolar disorder!? They have data on this...

It's hard to tell but he just keeps saying "80% heritability" and then talking about how likely it is that these kids have or will develop bipolar disorder and how unlikely it is that there's anything else going on (of course this could also be because he thinks all other diagnoses don't exist, idk).

Of course, heritability (vs recurrence risk) would also be the wrong statistic to look at if you're looking at the probability that someone is diagnosed with bipolar disorder after having a first degree family member who was already diagnosed, so it's weird to be using that number at all.

 

[aim-agm]

Tangentially one pet peeve is that, at least in the context of ADHD treatment, people say "stimulant" but just mean methylphenidate or amphetamines. There are three basic mechanisms for treating ADHD: alpha-2 agonism, increasing dopamine, or increasing norepinephrine.* The latter two categories are certainly stimulating so save for two medications (guanfacine and clonidine) every ADHD treatment is a "stimulant."

*: MOA for viloxazine in not elucidated, possible it has a categorically different mechanism.

 

[futureapppsy2]

So a couple points here. Probably at least 50% of family history of "bipolar disorder" is garbage, if you're at all aware of what the community standards for a "bipolar" diagnosis have typically been. We're starting to approach that with ADHD these days but I digress....

Putting that totally aside, yes you should be screening for bipolar disorder in the same way you should be screening for any other psychiatric comorbidity. Because if, of course, one was familiar with DSM criteria, they would be paying attention to the last part of ADHD criteria:

"The symptoms do not occur exclusively during the course of schizophrenia or anotherpsychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal)."

I'm just gonna be frank and say bipolar disorder (as it is classically defined) and ADHD are not difficult things to distinguish from each other for anyone who's putting in even the minimal amount of diagnostic effort. It's making a problem where really one shouldn't exist. They should, as currently defined, have completely different developmental trajectories and clinical presentations. At the most basic level, there should be no episodic nature to ADHD symptoms. In my experience, even when I'm semi-suspicious of mania and kids screen positive on the CMRS or ASRM parent or child rating screeners, when I go more in depth on the symptoms, they either seem to be normal range or not bipolar disorder (vast majority of the time they're screening positive for crappy sleep chronically, "talking more than usual" chronically or chronic hyperactivity).

The issue of course from Ghaemi's end is that in the expansionist camp of manic/depressive illness, many more symptoms COULD be bipolar disorder or COULD go on to be bipolar disorder in the future. I mean just read the article, read most of what he writes in general. He says that "none of the definitions" of any other diagnosis are meaningful and it's doesn't really matter if you don't diagnose them with bipolar disorder right away, as long as you don't diagnose any other of those lame not real diagnoses and don't give them any of those bad meds.

We can pull examples all day of odd or again, disingenuous statistics or interpretations of studies.
"About 90% of all children who meet mania criteria also meet ADHD criteria, because distractibility is one of the core criteria for mania."
What? By who? A criteria of ADHD is that symptoms must persist for at least 6 months. Is he saying all these kids were hypomanic or manic for 6 months straight?



Who's making the strawman argument here? This quote comes right after an entire article where he literally craps on clinicians who diagnose kids with a family history of bipolar disorder with other conditions (I have the sneaking suspicion that maybe because he doesn't actually understand heritability vs recurrence risk). I quote again:

"It is completely illogical, for instance, to claim that a child had “major depressive disorder” (MDD) or ADHD when there are immediate family members with bipolar disorder."

Adding to the point on family history, a lot of people are unintentionally inaccurate in giving those. For example, my mom claimed for the longest time that her mom had bone and lung cancer, when her mom actually had lung cancer with metastasis to the bones. That’s why it can be important to ask what a family member’s bipolar disorder/ADHD/depression/etc looked like, rather than just taking the reported family history at their word.

 

[Stagg737]

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.

My point was just that the evidence for risperidone for (unipolar) depression is there. I'm not suggesting that means we should lump MDD with "manic depressive spectrum" as I think they're equally dubious diagnoses.

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.

Are you arguing ADHD isn't a thing? If so, what is a thing in psychiatry? Not saying it's a great diagnosis, and I look at it similarly to "schizophrenia": likely a cluster of "disorders" in which the core criteria does represent a unique pathophysiology but the diagnostic criteria are vague enough or misinterpreted so that multiple other unique pathophysiologies as well as some non-pathological symptoms get labeled as "ADHD". Again, it's arguably the most treatable state/condition/pathology/insert your label here we have. Again, I don't think the issue is the name or even whether a pathophysiological "ADHD" exists, it's our understanding and application that is the failure. That includes Ghaemi's arguments.

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.

Again, "I got meds for your symptoms". Just because we're now placing the tea leaves in nice packages doesn't mean many of us aren't still trying to read them in practice. We've just tried to create a manual for it. It's part of why I like C/L, I get to treat conditions that we can order labs and imaging for in addition to practicing our mysticism.