The myth of ADHD

[thelastpsych]

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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:

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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 .

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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.

 

[splik]

Ghaemi is one of very few scholarly thinkers in psychiatry. As a bipolar specialist, he preaches the gospel of bipolar disorder and doesn't seem to know very much about non-mood disorders. He has written a load of nonsense about borderline PD too. He doesn't even seem to have read papers he cites in his screed. For example, he reports that the MTA study showed amphetamines were not helpful even though no one got any amphetamines in that study which was looking at methylphenidate and behavioral interventions.

There is no doubt that the validity and reliability of the ADHD diagnosis are poor. Yet he also claims he is not rejecting psychiatric diagnosis even though the reliability and validity of the vast majority of DSM diagnoses are very poor. Which is to say, there is nothing special about ADHD in the regard. Mania is unusual in its high inter rater reliability. He claims it is "postmodern antipsychiatry" to be against psychiatric diagnosis when he himself has done so and there is nothing wrong with challenging out current diagnostic system.

As for the marketing of ADHD by drug companies- this is nothing unique to ADHD. Even his beloved bipolar disorder was heavily marketed beginning in 1994 with the advent of Depakote for bipolar and continued in the 2000s with the repackaging of atypical antipsychotics for this indication.

My biggest issue with his critique is holding up the Kraepelinian approach as some model of psychiatric wisdom. Kraepelin earns his place in psychiatric history for taking an "amorphous mass of madness" and delineating it into dementia praecox and manic-depressive insanity. But he was a dolt. He also thought masturbation was a cause of mental illness, that homosexuality was a mental disorder caused by "seduction", and promulgated racist, eugenecist ideas based on Neo-Larmackism. No, diagnosis is NOT prognosis and prognosis is NOT diagnosis (as Ghaemi, chanelling Kraepelin, claims). This kind of circular reasoning is exactly what has held back advances in our understanding of psychiatric disorders.

Is ADHD a valid and reliable diagnosis? No and No. Is it a fixed natural kind rooted in biology? No. Is it a useful construct that holds enormous sway in psychiatry and society at large? Apparently so. We needed a way of communicating the significance of difficulties with attention and executive functioning to navigating contemporary society and the ADHD construct achieves this. I am sure there are better ways of doing so and this will evolve over time.

 

[Taddy Mason]

Say what you will about Ghaemi and bipolar disorder, but he’s equally critical of that too, especially as defined by the DSM-III onward.

 

[Sushirolls]

Let's just pretend for a second that this is truth. ADHD is not a valid diagnosis, child nor adult.

Trying to then stuff that cat, back into the bag, is going to be like telling a Democrat that Trump is a great president and deserves Mount Rushmore placement - gonna get yer eyes clawed out.

I hypothesize the volume of stimulants prescribed in the country are at volume to be detectable in water bodies, and at least one fish somewhere is likely to cross threshold on a routine UDS.

 

[comp1]

I strongly agree that taking this on from a practical perspective of what to do, if anything, as opposed to a philosophical discussion of defining the concept of illness is a lot more interesting.

 

[lobstar]

Psychiatry is essentially the land up made-up-ness, and I don't think it's restricted to ADHD. As soon as there's an actual lab value, pathology slide, or imaging finding it just gets shuffled over to Neurology a la NMDA encephalitis.

We're still in the dark ages of diagnosis. Imagine IM or surgery calling something abdominal pain disorder, fever type...well, that abdominal pain doesn't cause psychosocial dysfunction, since she's still able to work and raise the kids, so it's not a pathology. Wow, that other guy has been here 5 times this week, better give him opioids for the psychosocial dysfunction. Oh, and you know, I bet the pathophysiology of abdominal pain disorder, fever type, is related to a lack of endogenous opioids since giving an opioid agonist makes the pain better...and this donepezil med causes abdominal pain, so certainly acetylcholine plays a role in abdominal pain disorder, fever type as well!

 

[clausewitz2]

I strongly agree that taking this on a from a practical perspective of what to do, if anything, as opposed to a philosophical discussion of defining the concept of illness is a lot more interesting.

The trouble is if you ignore the philosophical implications of what you are doing and the conceptual grounding of the entities you invoke, it is very easy to end up operating according to Politician's Logic, to whit:

1. Something must be done
2. This is something
3. Therefore it must be done.

Without clarity about what you are actually doing (and I mean the clarity of phronesis, not techne) you can do rather a lot of harm and not very much good in the big picture.

 

[Crayola227]

Besides side effects and missing more serious pathology that needs different treatment, ain't nothing wrong with treating symptoms. My response to lobstar. So yeah find the balance of it, subjective matters so subjective improvement matters.

I get why we've become obsessed with functional scores, but let's say I'm trapped on my couch in some kind of pain. You give me pills, now I feel better. Still in pain. Still not working, not socializing more/better, still not getting up to do my housework. Maybe all I do is watch Netflix and I still do that, but it feels better. Let's say for sake of argument this isn't placebo (I could describe how we might know this but bear with me). So do most functional measures go up here? Not really. Subjective score? Yes.

Lastly, I disagree vehemently that ADHD does not represent a real biologically based neurodevelopmental entity, whether or not that's pathology or only is in our society and this is just a normal variation, but these people's brains are different/function different, and respond to these drugs so differently that I don't think it's basically just "give anyone stims and these measures improve."

That's my 2 cents. I'm working on not belaboring so I'll spare how I came to the last conclusion. My N is not a study, but I've spent my entire life without ADHD yet surrounded by individuals who clearly have it. When you live it so intimately, and it's not just a checklist, I think it's hard to be convinced it's made up. Hysteria maybe wasn't as it was formulated, but let's not forget, most of those women had something bugging them!

Most issues I think we see has to do with differentiating patients, not "realness" of this difference, setting aside where it may have evolved, is adaptive, etc considerations.

Not a psychiatrist. Is someone drowing in ADHD. Try watching TV or Netflix with these individuals. If you like to enjoy a story start to finish, you will rip out your hair.

 

[TexasPhysician]

You could make very similar arguments for every psych diagnosis. These are the same repetitive critiques of the field that is young in knowledge.

 

[calvnandhobbs68]

I’ve brought this up before but if we’re talking about “reliability” in terms of inter-rater reliability, I would disagree with some of the above responses.

Childhood diagnosed ADHD has a higher inter-rater reliability than many other psychiatric diagnoses, including bread and butter MDD and GAD.

As others have said, if you toss ADHD out as a construct, for better or worse, you might as well toss out many other psychiatric diagnoses.

 

[FlowRate]

We needed a way of communicating the significance of difficulties with attention and executive functioning to navigating contemporary society and the ADHD construct achieves this. I am sure there are better ways of doing so and this will evolve over time.

I feel like the ADHD "concept" has been continually pushed to include an ever-broadening set of personal problems, especially in the popular conscience, to the point that it's lost its utility as a differentiator (in adults.) To the layperson, all potential difficulties with sustaining attention, procrastination/achieving activation energy, and any other work performance problem is now "ADHD" until proven otherwise.

I think Ghaemi's point about persistence rates in prospective vs retrospective studies and other research on the fallibility of retrospective recall are important. Clinically, I see many many patients who probably don't have whatever "ADHD" was supposed to mean "originally" but they all suddenly recall "disproportionate" difficulty being a high achiever in school than their peers.

I think there's also something to the attention-destroying forms of phone/social media engagement (shorts/tiktok/algorithm only engagement/etc.) that's under-studied/contributing.

I strongly agree that taking this on a from a practical perspective of what to do, if anything, as opposed to a philosophical discussion of defining the concept of illness is a lot more interesting.

The trouble is if you ignore the philosophical implications of what you are doing and the conceptual grounding of the entities you invoke, it is very easy to end up operating according to Politician's Logic, to whit:

1. Something must be done
2. This is something
3. Therefore it must be done.

Without clarity about what you are actually doing (and I mean the clarity of phronesis, not techne) you can do rather a lot of harm and not very much good in the big picture.

This is why I feel like academic psychiatry has failed us especially in this area. Our supposed thought leaders have done little to address this issue that's been developing since the early 90's--and the DSM 5 contributed to worsening it. Even when I was in residency, our faculty barely had much opinion on the newest wave of adults seeking ADHD assessment.

 

[randomdoc1]

it's really muddied the waters of psychiatric care. patients are so enamored with ADHD. It's the flavor of the month. I do find a degree of validity. But it is so dwarfed in comparison to how much harm the trend has done. People like to blame "my ADHD" for everything. It's so appealing to think a pill can fix things. Especially when something feels as good as an amphetamine, which is a slippery medication to work with in the first place. There's mood disorders, anxiety, poor psychological defenses, downright bad habits --- all this other stuff gets ignored and people bark up the ADHD tree. Until they have exhausted every stim, maxed out doses, dangerous doses, black market doses, maybe lost a few jobs, some burned relationships later down the line. Whether the patient has ADHD or no ADHD, the way people go about it, most of the time I find to be quite unhealthy (this can apply to every psych dx but I've seen this soooo much more with ADHD in my career). Healthy and effective choices are not always easy and usually they are challenging and uncomfortable. I don't like eating vegetables or exercising either. But it is what it is. You wanna have wealth? Save money and invest, be patient and don't buy to much house or car. That's how I got there. etc etc. But such a culture of now, now, now. Gimme, gimme, gimme. I think people often tend to lean on blaming something else too much. This applies to other examples I've seen in patient care.
"it's this lousy job"
"it's the bad people around me"
"it's the bad economy"
"it's the bad weather"
"it's my medical issues"

Sure, sure. But what can YOU mitigate. What does blaming something else and insisting something else fix itself for you achieve though? I guess this is going down a philosophical rabbit hole... lol

 

[aim-agm]

Psychiatry is essentially the land up made-up-ness, and I don't think it's restricted to ADHD. As soon as there's an actual lab value, pathology slide, or imaging finding it just gets shuffled over to Neurology a la NMDA encephalitis.

We're still in the dark ages of diagnosis. Imagine IM or surgery calling something abdominal pain disorder, fever type...well, that abdominal pain doesn't cause psychosocial dysfunction, since she's still able to work and raise the kids, so it's not a pathology. Wow, that other guy has been here 5 times this week, better give him opioids for the psychosocial dysfunction. Oh, and you know, I bet the pathophysiology of abdominal pain disorder, fever type, is related to a lack of endogenous opioids since giving an opioid agonist makes the pain better...and this donepezil med causes abdominal pain, so certainly acetylcholine plays a role in abdominal pain disorder, fever type as well!

I disagree. The function of the brain (insofar as we deal with it from a psychiatric standpoint) is to adaptively control behavior to successfully navigate life. Whatever is the brain is doing, no matter how strange, is not diseased if the person is functioning well because the brain is accomplishing its purpose. So clinically significant distress or dysfunction is pretty much the only differentiation between pathologic and not (although obviously there are more nuances than that). Or, more pithily, "it's a problem if it is a problem."

For example, anxiety is an integral part of successfully navigating life; if we lacked anxiety, we wouldn't have studied well enough for the tests we've had to take to get this far in our career. There can be too much anxiety or too little anxiety, with a broad range of reasonable degrees of anxiety in between - e.g. how certain of passing STEP 3 did you want to be before you took it? We'd say 5% is far to low (i.e. too little anxiety), and 99.999999% is far to high (i.e. too much anxiety) but we could see 90%,95%, 99% and other degrees of confidence as reasonable (i.e. appropriate range of anxiety).
How do you know if the anxiety is pathologic? If it is causing a problem but the brain isn't adapting/correcting so that it doesn't, and dysfunction/distress persists. To continue the above example, if the brain requires an inordinate degree of certainty that the test will be passed, to the point that the person is excessively studying and having problems in other areas of life (e.g. neglecting relationships), the brain ought to weigh competing needs to find a workable compromise; if it fails to adapt leading to failure to accomplish its function (i.e. successfully navigate life), that indicates pathology.

 

[clausewitz2]

I disagree. The function of the brain (insofar as we deal with it from a psychiatric standpoint) is to adaptively control behavior to successfully navigate life. Whatever is the brain is doing, no matter how strange, is not diseased if the person is functioning well because the brain is accomplishing its purpose. So clinically significant distress or dysfunction is pretty much the only differentiation between pathologic and not (although obviously there are more nuances than that). Or, more pithily, "it's a problem if it is a problem."

These phrases are doing some very heavy lifting but they are also impossible to define in a way that does not smuggle in the values and worldview of the evaluating clinician. They are also generally sensitive to sociological facts about societal trends and norms. This is not a way around the problem of subjectivity in diagnosis.

 

[FlowRate]

These phrases are doing some very heavy lifting but they are also impossible to define in a way that does not smuggle in the values and worldview of the evaluating clinician. They are also generally sensitive to sociological facts about societal trends and norms. This is not a way around the problem of subjectivity in diagnosis.

Right, part of the problem is the lack of a consensus bar for functional impairment.

 

[Dr. Pookie]

Thinking about the issue of diagnostic ambiguity as a broader topic, I wonder what psychiatry will look like at the end of my career (just starting out). What about in 100 years? 500? Will it even exist as a field as we know it, or will it be absorbed into another medical specialty - presumably neurology (as if they wanted it lol)? Will it cease to exist as a medical specialty altogether (ie. LCSW do the therapy and primary care and NPs prescribe meds). My pharma reps always tell me that I'm "the only psychiatrist in a sea of NPs" as it is.

People talk about the future of the field being neuromodulation and psychedelics, but I'm pretty skeptical.

I do agree that once a mental health diagnosis gets a "medical etiology," that it then gets adopted by neurology - and psychiatry is left perpetually holding the "maladies yet to be understood" ball.

 

[Sushirolls]

*We didn't get the ball for Fibromyalgia or POTS or Lyme Disease or Long Covid.

 

[FatherPsychiatry]

Schizophrenia
Mania
Melancholy (not “MDD”)
OCD
= real (whatever that means)

All else = fake (whatever that means)
But the $ is real 🙂

 

[Ceke2002]

Curious how much of the current overdiagnosis/attachment to diagnosis is due, not necessarily to the usual suspects (social media et al), but to certain groups influencing changes to diagnostic criteria in the DSM and/or poor diagnosticians using the 'check box' method of diagnosing anything?

 

[lobstar]

*We didn't get the ball for Fibromyalgia or POTS or Lyme Disease or Long Covid.

I, for one, can't wait for the year 2225 psychiatry when neurology, rheumatology, and ID have taken over the "real" psych things that have a targetable biological basis and psychiatry is left with personality disorders, conversion disorder, and somatic symptoms disorder. I can even see prestigious fellowships in intermittent explosive disorder.

Although, on the other hand, if our leaders are right about biological psychiatry being right around the corner, maybe we'll be sending suicidal patients by helicopter to academic centers as class A to the OR for the newest ablation of the suicide nucleus.