You don’t need to go to residency to prescribe Risperdal

[sloh]

I guess we are making slightly different points. As to the question of whether the DSM defined syndrome of ADHD has 'validity' - I find that to be a very unimportant question and its possible that it is or isn't. But ADHD amongst all of our diagnoses is the one that least needs a syndrome and can be understood in terms of basic brain functions. In clinical practice it is easy to detect attentional deficits, executive function deficits and increased impulsivity. It is also possible to assess the level of environmental stimulation that someone needs to feel calm and function well. These deficits are frequently responsive to biological treatments and environmental modifications. Adults can have these issues as well.

What do you make of his argument that neurologic development for boys is slower than in girls, and that the boys will mature out of ADHD?

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[clausewitz2]

What do you make of his argument that neurologic development for boys is slower than in girls, and that the boys will mature out of ADHD?

They themselves cite the more recent body of evidence suggesting these problems away completely for most kids. They seem to be arguing that the fact that there is a clear through line for a lot of people from childhood into adulthood means it is not a developmental disorder.

You will probably recognize this particular logic as insane.

 

[Attending1985]

Does anyone else get disheartened reading the critiques by Timimi and Moncreif? I agree with a lot of what they’re saying which makes me wonder what am I doing day to day? Is it harmful or helpful?

 

[FlowRate]

They themselves cite the more recent body of evidence suggesting these problems away completely for most kids. They seem to be arguing that the fact that there is a clear through line for a lot of people from childhood into adulthood means it is not a developmental disorder.

You will probably recognize this particular logic as insane.

I think a generous reading would be that they're more narrowly talking about the modern phenomenon of "adult (onset) ADHD" with that criticism. In other words, adults who come in with no noted deficit as kids (good grades, good behavior, no impairment). Although it is a weak point because of the "what if they just weren't detected as kids (who got a 3.8 in MS, HS, and college?)" argument.

I guess we are making slightly different points. As to the question of whether the DSM defined syndrome of ADHD has 'validity' - I find that to be a very unimportant question and its possible that it is or isn't. But ADHD amongst all of our diagnoses is the one that least needs a syndrome and can be understood in terms of basic brain functions. In clinical practice it is easy to detect attentional deficits, executive function deficits and increased impulsivity. It is also possible to assess the level of environmental stimulation that someone needs to feel calm and function well. These deficits are frequently responsive to biological treatments and environmental modifications. Adults can have these issues as well.

I'd be curious to hear what you think about the attached article. It remains a syndrome until there's actual objective testing that identifies underlying pathophysiology. The article also introduces literature regarding the medications not being particularly helpful long-term (and does encourage behavioral approaches.)

Honestly I meet very few (rigorous) psychiatrists who find adult ADHD to be an "easy" diagnosis. It seems to introduce a lot of existential dread in myself and my colleagues. I'm skeptical that the explosion of new adult ADHD diagnosis and prescription of stimulants reflects the field having "undertreated" ADHD historically.

Does anyone else get disheartened reading the critiques by Timimi and Moncreif? I agree with a lot of what they’re saying which makes me wonder what am I doing day to day? Is it harmful or helpful?

Agreed.

 

[WisNeuro]

I'd be curious to hear what you think about the attached article. It remains a syndrome until there's actual objective testing that identifies underlying pathophysiology. The article also introduces literature regarding the medications not being particularly helpful long-term (and does encourage behavioral approaches.)

I mean, this would throw many mental health diagnoses into the "syndrome" bucket if we adopt this framework.

 

[clausewitz2]

I mean, this would throw many mental health diagnoses into the "syndrome" bucket if we adopt this framework.

Another the thing the critical folks do consistently is dramatically overestimate the extent to which indisputably 'medical' problems are also like this. Hypertension is not a natural entity that has some underlying reality independent of medical practice and sociocultural factors. There is an arbitrary line and we have said 'above this is pathological' but it is a continuous distribution. I don't know how Moncrief et al aren't forced to admit high blood pressure is fabricated.

I am more interested in the ontology of diagnosis more than most but I have never seen a good explanation of why we should be any less concerned to treat or address a problem best characterized by being in the tails of a single distribution instead of being characterized as categorically different. ADHD being heritable, continuing into adulthood, causing impairment etc etc fits into either account just as well, so demonstrating the continuity is not a rhetorical triumph.

I continue to fail to understand this objection.

 

[FlowRate]

I mean, this would throw many mental health diagnoses into the "syndrome" bucket if we adopt this framework.

My point in that case is that they are all in the same boat and ADHD is no less syndrome than any other in my book. From me, that's not a criticism of the field--it's the best we have for now. I'm not taking Timimi's positions completely but I think it is helpful to remind oneself of some of the things he points out--namely that, lacking the same scientific rigor, we can fall prey to shifts in "diagnosis" in ways that are not in the best interests of our patients (--> and are in the interests of pharmaceutical companies.)

 

[WisNeuro]

My point in that case is that they are all in the same boat and ADHD is no less syndrome than any other in my book. From me, that's not a criticism of the field--it's the best we have for now. I'm not taking Timimi's positions completely but I think it is helpful to remind oneself of some of the things he points out--namely that, lacking the same scientific rigor, we can fall prey to shifts in "diagnosis" in ways that are not in the best interests of our patients (--> and are in the interests of pharmaceutical companies.)

I think the pharma benefiting thing is something of a red herring here. I mean, I'm fairly anti-pharma, but I wouldn't hold their benefit up as a reason to argue ADHD doesn't exist. I'm actually in agreement that "adult onset" likely does not exist, but from what I've seen of Timmimi, they do not do a good job of breaking out diagnosed with ADHD in childhood vs. possible missed diagnosis in childhood vs complete absence of symptoms in childhood. They just seem to cherry pick arguments here and there that would also damn most other diagnoses, and conveniently ignore some important things that don't fit their narrative. The writing I've seen so far makes it look as if they have an ax to grind and are only selectively looking at data to keep the wheel turning.

 

[FlowRate]

I think the pharma benefiting thing is something of a red herring here. I mean, I'm fairly anti-pharma, but I wouldn't hold their benefit up as a reason to argue ADHD doesn't exist. I'm actually in agreement that "adult onset" likely does not exist, but from what I've seen of Timmimi, they do not do a good job of breaking out diagnosed with ADHD in childhood vs. possible missed diagnosis in childhood vs complete absence of symptoms in childhood. They just seem to cherry pick arguments here and there that would also damn most other diagnoses, and conveniently ignore some important things that don't fit their narrative. The writing I've seen so far makes it look as if they have an ax to grind and are only selectively looking at data to keep the wheel turning.

Yeah the ax is that they think ADHD in all populations is overdiagnosed, including children, and that medications are overprescribed in children (and lead to harm, according to some of the studies they linked about long-term stimulant use.)

The pharma thing is somewhat relevant to adult ADHD because of the pharma push to market to adults, especially adult women and IMO clear evidence that their marketing is working.

 

[sloh]

I think the pharma benefiting thing is something of a red herring here. I mean, I'm fairly anti-pharma, but I wouldn't hold their benefit up as a reason to argue ADHD doesn't exist. I'm actually in agreement that "adult onset" likely does not exist, but from what I've seen of Timmimi, they do not do a good job of breaking out diagnosed with ADHD in childhood vs. possible missed diagnosis in childhood vs complete absence of symptoms in childhood. They just seem to cherry pick arguments here and there that would also damn most other diagnoses, and conveniently ignore some important things that don't fit their narrative. The writing I've seen so far makes it look as if they have an ax to grind and are only selectively looking at data to keep the wheel turning.

What's the axe to grind though? It doesn't really do him any favors to criticize his own specialty.

 

[WisNeuro]

Yeah the ax is that they think ADHD in all populations is overdiagnosed, including children, and that medications are overprescribed in children.

The pharma thing is somewhat relevant to adult ADHD because of the pharma push to market to women and IMO clear evidence that their marketing is working.

Their axe seems broader than that. I mean, I agree that it's overdiagnosed and overmedicated. But we don't need to invalidate the entire disorder to work on those problems.

 

[sloh]

Another the thing the critical folks do consistently is dramatically overestimate the extent to which indisputably 'medical' problems are also like this. Hypertension is not a natural entity that has some underlying reality independent of medical practice and sociocultural factors. There is an arbitrary line and we have said 'above this is pathological' but it is a continuous distribution. I don't know how Moncrief et al aren't forced to admit high blood pressure is fabricated.

Agree here. Perhaps, benefits of pharmacologic treatment of HTN have been oversold.

"These relative risk reductions correspond to the following absolute benefits: antihypertensive therapy for four to five years in patients whose blood pressure is 140 to 159 mmHg systolic or 90 to 99 mmHg diastolic prevents a coronary event in 0.7 percent of patients and a cerebrovascular event in 1.3 percent of patients for a total absolute benefit of approximately 2 percent. Thus, 100 patients must be treated for four to five years to prevent an adverse cardiovascular event in two patients."

 

[michaelrack]

Just because the cutoff between normal and mild disease is arbitrary, does not mean the disease is not real.. . For example, hypothyroidism, type 2 diabetes, and COPD

 

[clausewitz2]

Just because the cutoff between normal and mild disease is arbitrary, does not mean the disease is not real.. . For example, hypothyroidism, type 2 diabetes, and COPD

That is precisely my point.

 

[psychacad]

Just because the cutoff between normal and mild disease is arbitrary, does not mean the disease is not real.. . For example, hypothyroidism, type 2 diabetes, and COPD

Sure, but we have such a better understanding for the etiology of these things as opposed to any psychiatric diagnosis. So yeah, I agree, the comparison is neither here nor there.

Psychiatric "diagnoses" are not really diagnoses per se. Cause a diagnosis necessitate an understand of etiology at some level (the what is going on?). Psychiatric diagnoses per DSM are supposed to be based on statistical clustering of symptoms, and the idea is that clustering probably infers a common etiology.

However, even the supposed statistical clustering is not based on actual data. I'd love to be proven otherwise. Most of the "evidence" is the expert opinion of whoever wrote the DSM, sometimes going as far as based on the observations of Kraeplin, LOL!

The situation in psychiatry is quite pathetic to be frank, and I don't understand why we still don't have the large scale studies necessary to establish statistical clustering of symptoms if these are actually of any benefit. We can shut off all that criticism by actually being scientific in our approach. We're not there.

 

[psychacad]

I guess we are making slightly different points. As to the question of whether the DSM defined syndrome of ADHD has 'validity' - I find that to be a very unimportant question and its possible that it is or isn't. But ADHD amongst all of our diagnoses is the one that least needs a syndrome and can be understood in terms of basic brain functions. In clinical practice it is easy to detect attentional deficits, executive function deficits and increased impulsivity. It is also possible to assess the level of environmental stimulation that someone needs to feel calm and function well. These deficits are frequently responsive to biological treatments and environmental modifications. Adults can have these issues as well.

The thing is people can come up with these sort of post-hoc "brain mechanisms" explanations for all sort of symptom arrangements. It doesn't validate or explain the need for the diagnosis. And I disagree that the validity of the diagnosis is a "very unimportant question". Scientific rigor is important. It's how we end up with a great covid 19 vaccine. If we want to make progress in the field instead of merely adopting the latest fad, we need to have a strong empirical grounding (and probably more important a process) for why we're calling x a diagnosis. Otherwise we're leaving the flank of the field wide open for very valid attacks.

 

[clausewitz2]

The thing is people can come up with these sort of post-hoc "brain mechanisms" explanations for all sort of symptom arrangements. It doesn't validate or explain the need for the diagnosis. And I disagree that the validity of the diagnosis is a "very unimportant question". Scientific rigor is important. It's how we end up with a great covid 19 vaccine. If we want to make progress in the field instead of merely adopting the latest fad, we need to have a strong empirical grounding (and probably more important a process) for why we're calling x a diagnosis. Otherwise we're leaving the flank of the field wide open for very valid attacks.

I agree with you about most of this but it does not speak a whit to the question of whether attempts to ameliorate those symptoms are legitimate and worthy attempts to ease suffering/improve function or false consciousness/propaganda of greedy pharmaceutical companies.

Even if these impairments would not be considered pathological were society organized otherwise, the fact remains that at present it is not.

 

[psychacad]

I agree with you about most of this but it does not speak a whit to the question of whether attempts to ameliorate those symptoms are legitimate and worthy attempts to ease suffering/improve function or false consciousness/propaganda of greedy pharmaceutical companies.

Even if these impairments would not be considered pathological were society organized otherwise, the fact remains that at present it is not.

Of course it does, because if the diagnostic process is sketchy and unscientific, then people will rightly suggest a certain motive behind having it in the first place. I mean, let's face it, someone is making billions of dollars in psychopharm, and it would be pretty naive to think their interests are blind to how medicine is practiced. What is considered an ailment worthy of a cure is to a certain extent a dynamic process influenced by what the medical community says is an illness/ailment worthy of a cure. That is really the point; you're leaving the flank open to all sort of valid attacks if the foundations are shaky.

Having said all of that, I've read Tamimi and even though I think his DSM criticism and psychiatric diagnoses is valid, the style strikes me as unnecessarily hostile, even unprofessional to a point. And putting the stylistic stuff aside for a moment, he has a website that advertise behavioral interventions/nutrition/integrative psych for 'mental challenges'. I love how the standards of evidence suddenly disappear for their own fads.

 

[Attending1985]

Agree here. Perhaps, benefits of pharmacologic treatment of HTN have been oversold.

"These relative risk reductions correspond to the following absolute benefits: antihypertensive therapy for four to five years in patients whose blood pressure is 140 to 159 mmHg systolic or 90 to 99 mmHg diastolic prevents a coronary event in 0.7 percent of patients and a cerebrovascular event in 1.3 percent of patients for a total absolute benefit of approximately 2 percent. Thus, 100 patients must be treated for four to five years to prevent an adverse cardiovascular event in two patients."

I get more concerned about number needed to harm with psychotropics.

 

[Cath Up]

As it should! I think a student reading SDN would hear three loud messages, and be at risk for taking them as fact. 1) It doesn't matter where you train, its all the same; 2) Quality is entirely subjective and not really a thing, and 3) The job market is crazy and you need to push insane volumes to avoid being replaced. I think these things go together, as do the opposite. Everyone I trained with cared about getting good training, and tried to learn as much as possible. They believe quality is a thing, and they now have jobs that care about that too, and don't see 25 patients a day. I know that this isn't a fringe minority because we have data showing the average RVUs worked by a psychiatrist and it works out at around 10-11 inpatients a day. My boss (at the hospital, not my MD supervisor) is happy with the work I do and has no interest in replacing me with someone that will see 25 patients because thats just not what will support the mission of the hospital. I am sure that I don't work in the only humane environment left and its important that trainees don't despair.

Would you recommend psychiatry to medical students that suspect they would be happy in multiple specialties?
AKA me.

 

[SmallBird]

The thing is people can come up with these sort of post-hoc "brain mechanisms" explanations for all sort of symptom arrangements. It doesn't validate or explain the need for the diagnosis. And I disagree that the validity of the diagnosis is a "very unimportant question". Scientific rigor is important. It's how we end up with a great covid 19 vaccine. If we want to make progress in the field instead of merely adopting the latest fad, we need to have a strong empirical grounding (and probably more important a process) for why we're calling x a diagnosis. Otherwise we're leaving the flank of the field wide open for very valid attacks.

Post-hoc? The word attention is in the name. But I’m just missing your point somehow. If someone decided that are stroke classification system sucked we would still agree that people could have weakness. If the way ADHD has been studied, packaged and researched is problematic, that has not bearing on whether or not attention and executive function problems are real.

 

[psychacad]

Post-hoc? The word attention is in the name. But I’m just missing your point somehow. If someone decided that are stroke classification system sucked we would still agree that people could have weakness. If the way ADHD has been studied, packaged and researched is problematic, that has not bearing on whether or not attention and executive function problems are real.

I mean, another way to think about it is how many psychiatric illnesses are there where there are NO "attention and executive function problems"? Are we calling them ADHD? Those explanations are post-hoc in the sense that we came up with then after the fact we decided ADHD is a thing. Of course the attention problems are real but in itself this doesn't justify the existence of a separate diagnosis. This is actually an important question to answer because as Timimi said the onus is to prove that the null hypothesis is false. And if we're going to pretend that diagnosis is irrelevant, we might as well stop pretending that were practicing medicine, lol. The stroke example is great because in stroke we know a great deal about a specific etiology leading to weakness, and we developed targeted interventions that work. Here we have generalized explanations of deficits in attention and executive function which afaik are not specific to anything.

 

[Attending1985]

Would you recommend psychiatry to medical students that suspect they would be happy in multiple specialties?
AKA me.

I like my day to day practice. I love the relationships with patients. I love psychotherapy. I love seeing people improve their lives. I don’t like the pressure and habit to prescribe and over diagnose. I don’t like the lack of scientific validity. I wouldn’t not recommend it but I’d say go into it knowing these struggles and how they will impact you.

 

[clausewitz2]

I mean, another way to think about it is how many psychiatric illnesses are there where there are NO attention deficits? Are we calling them ADHD? Those explanations are post-hoc in the sense that we came up with then after the fact we decided ADHD is a thing. Of course the attention problems are real but in itself this doesn't justify the existence of a separate diagnosis. This is actually an important question to answer because as Timimi said the onus is to prove that the null hypothesis is false. And if we're going to pretend that diagnosis is irrelevant, we might as well stop pretending that were practicing medicine, lol. The stroke example is great because in stroke we know a great deal about a specific etiology leading to weakness, and we developed targeted interventions that work. Here we have generalized explanations of deficits in attention which afaik are not specific to anything.

If only we had a definition of ADHD that was actually more involved and specific than 'attention deficits.'

Oh wait.

 

[ridethecliche]

Did you tell her that you agree with her, which is why you're prescribing invega instead of risperdal?

I'm almost two years out of residency and I'm still learning new things. I love how I am able to blend psychopharmacology with psychotherapy with psychology with philosophy with religion with business. It's really a treat for me to treat deep thinkers and high performers. You cannot explore the finer aspects of practicing psychiatry (i.e. diving deep into the patient's mind) if it is just medication management.

This made me think of the time when as a PGY-1, I had a patient who had MDD with psychotic features or straight up schizophrenia. He was severely severely depressed and was stuck in an almost nihilistic rut of life being meaningless/worthless so whats the point I should just kill myself because there's no chance that I'll get better. Like very very stuck. You know... that super perseverative psychosis where everything comes back to the same thing and oh there are also voices that make things even more confusing.

So during an interview, with the inpatient attending present observing, I was like so (giant bong rip)... do you think that parallel universes exist?
"Yeah?"
-So in that scenario, it makes sense that there are infinite different possibilities for you right?
"Sure"
-So if there are infinite possibilities, you're saying that there could be a possibility where you get better and the medications help?
"I guess?"
-Okay, so how do you know that's not the possibility that you're living in right now?
"...."
-Just think about it.


Every day after that interaction, he told me that he was thinking about it. And I kid you not he started to get better.
Maybe I was able to meet him where he was...

But it was probably the risperidone.

(I probably butchered the heck out of this, but it was one of the most satisfying liberal arts major enhanced experiences I've had as a resident)

Edit: Page 2 of this thread jumps away from risperidone and into the RDOC like woah.

 

[Old&InTheWay]

This made me think of the time when as a PGY-1, I had a patient who had MDD with psychotic features or straight up schizophrenia. He was severely severely depressed and was stuck in an almost nihilistic rut of life being meaningless/worthless so whats the point I should just kill myself because there's no chance that I'll get better. Like very very stuck. You know... that super perseverative psychosis where everything comes back to the same thing and oh there are also voices that make things even more confusing.

So during an interview, with the inpatient attending present observing, I was like so (giant bong rip)... do you think that parallel universes exist?
"Yeah?"
-So in that scenario, it makes sense that there are infinite different possibilities for you right?
"Sure"
-So if there are infinite possibilities, you're saying that there could be a possibility where you get better and the medications help?
"I guess?"
-Okay, so how do you know that's not the possibility that you're living in right now?
"...."
-Just think about it.


Every day after that interaction, he told me that he was thinking about it. And I kid you not he started to get better.
Maybe I was able to meet him where he was...

Edit: Page 2 of this thread jumps away from risperidone and into the RDOC like woah.

But it was probably the risperidone.

(I probably butchered the heck out of this, but it was one of the most satisfying liberal arts major enhanced experiences I've had as a resident)

As much as I dislike you as a person because your avatar makes me feel like I'm going to have a seizure, that's a good story. . #kiddingnotkidding

 

[calvnandhobbs68]

This made me think of the time when as a PGY-1, I had a patient who had MDD with psychotic features or straight up schizophrenia. He was severely severely depressed and was stuck in an almost nihilistic rut of life being meaningless/worthless so whats the point I should just kill myself because there's no chance that I'll get better. Like very very stuck. You know... that super perseverative psychosis where everything comes back to the same thing and oh there are also voices that make things even more confusing.

So during an interview, with the inpatient attending present observing, I was like so (giant bong rip)... do you think that parallel universes exist?
"Yeah?"
-So in that scenario, it makes sense that there are infinite different possibilities for you right?
"Sure"
-So if there are infinite possibilities, you're saying that there could be a possibility where you get better and the medications help?
"I guess?"
-Okay, so how do you know that's not the possibility that you're living in right now?
"...."
-Just think about it.


Every day after that interaction, he told me that he was thinking about it. And I kid you not he started to get better.
Maybe I was able to meet him where he was...

But it was probably the risperidone.

(I probably butchered the heck out of this, but it was one of the most satisfying liberal arts major enhanced experiences I've had as a resident)

Edit: Page 2 of this thread jumps away from risperidone and into the RDOC like woah.

 

[thepoopologist]

Recently heard an attending psychiatrist telling med students that she believed nurses and PA’s provide equivalent care to physicians and snorted “You do don’t need to go to residency to be able to prescribe Risperdal!” She claimed that in her view the majority of our training was extraneous and that the ”literature” backed her claims of equivalency. She (the attending) is too high up in the food chain for me to critique face to face but I did feel pretty frustrated that she was trying to undermine her profession. In my mind since she’s close to retirement and holds some high positions in the hospital, I figure that her attitude is one of “I’m almost retired, to heck with the consequences of what I say!” and also heavily influenced by PC hospital politics.

If we follow her logic to its conclusion, wouldn’t a 3rd or 4th year medical student be superior to a PA in knowledge base? If she’s comfortable believing that a PA could replace us, would she be comfortable letting a med student run the service? I also find the reduction of what we do to simple brain dead prescribing a bit galling.

Thoughts?

 

[hallowmann]

This made me think of the time when as a PGY-1, I had a patient who had MDD with psychotic features or straight up schizophrenia. He was severely severely depressed and was stuck in an almost nihilistic rut of life being meaningless/worthless so whats the point I should just kill myself because there's no chance that I'll get better. Like very very stuck. You know... that super perseverative psychosis where everything comes back to the same thing and oh there are also voices that make things even more confusing.

So during an interview, with the inpatient attending present observing, I was like so (giant bong rip)... do you think that parallel universes exist?
"Yeah?"
-So in that scenario, it makes sense that there are infinite different possibilities for you right?
"Sure"
-So if there are infinite possibilities, you're saying that there could be a possibility where you get better and the medications help?
"I guess?"
-Okay, so how do you know that's not the possibility that you're living in right now?
"...."
-Just think about it.


Every day after that interaction, he told me that he was thinking about it. And I kid you not he started to get better.
Maybe I was able to meet him where he was...

But it was probably the risperidone.

(I probably butchered the heck out of this, but it was one of the most satisfying liberal arts major enhanced experiences I've had as a resident)

Edit: Page 2 of this thread jumps away from risperidone and into the RDOC like woah.

It's genuinely these patients and interactions that made me love inpatient and really question my previous plan for outpatient only life.

 

[Stagg737]

Sure, but we have such a better understanding for the etiology of these things as opposed to any psychiatric diagnosis. So yeah, I agree, the comparison is neither here nor there.

For some we do, but many we don't. What's the exact etiology of benign essential hypertension? Essential tremor? Pseudoseizures? I'd argue that we have a far better grasp of some psychiatric disorders's (ADHD, for example) than other medical conditions that we treat all the time.

The thing is people can come up with these sort of post-hoc "brain mechanisms" explanations for all sort of symptom arrangements. It doesn't validate or explain the need for the diagnosis.

Those explanations are post-hoc in the sense that we came up with then after the fact we decided ADHD is a thing.

I mean, how do you think most of large swaths of infectious disease were developed? We typically don't just go hunting for new pathogens (nor did we), a set of symptoms was identified and treatment was attempted for hundreds or thousands of years until we figured out what bacteria and viruses were. I'd argue that there was very much a need for diagnosis of ID even before the etiology was known in order to keep people alive...

The need for the diagnosis is just to create common language which we can all understand what is being referred to. There's literally dozens of causes of HTN (which is not just a diagnosis, but also a symptom), but when we say "hypertension" we all understand the basic concept of what this means. However, we don't understand the underlying etiology without far more descriptive measures and sometimes don't understand it at all. I think the argument of "why do we have a need for a diagnosis" is somewhat silly. I think the better argument/question is should we consider the definitions/criteria for those diagnoses adequate? You could successfully argue no to this fairly easily for most, maybe all, psych disorders. However, we could do the same thing for a plethora of medical disorders as well.

The other reason I find this a to be a silly discussion as to whether ADHD is valid as a diagnosis is the success rate of treatment with stimulants in those properly diagnosed. It's by far the most effective treatment we have for pretty much anything in our field and more effective than most medications are for treating, well, anything.

 

[psychacad]

For some we do, but many we don't. What's the exact etiology of benign essential hypertension? Essential tremor? Pseudoseizures? I'd argue that we have a far better grasp of some psychiatric disorders's (ADHD, for example) than other medical conditions that we treat all the time.





I mean, how do you think most of large swaths of infectious disease were developed? We typically don't just go hunting for new pathogens (nor did we), a set of symptoms was identified and treatment was attempted for hundreds or thousands of years until we figured out what bacteria and viruses were. I'd argue that there was very much a need for diagnosis of ID even before the etiology was known in order to keep people alive...

The need for the diagnosis is just to create common language which we can all understand what is being referred to. There's literally dozens of causes of HTN (which is not just a diagnosis, but also a symptom), but when we say "hypertension" we all understand the basic concept of what this means. However, we don't understand the underlying etiology without far more descriptive measures and sometimes don't understand it at all. I think the argument of "why do we have a need for a diagnosis" is somewhat silly. I think the better argument/question is should we consider the definitions/criteria for those diagnoses adequate? You could successfully argue no to this fairly easily for most, maybe all, psych disorders. However, we could do the same thing for a plethora of medical disorders as well.

The other reason I find this a to be a silly discussion as to whether ADHD is valid as a diagnosis is the success rate of treatment with stimulants in those properly diagnosed. It's by far the most effective treatment we have for pretty much anything in our field and more effective than most medications are for treating, well, anything.

I mean, you wrote all of that only to basically say exactly the point that "should we consider the definition/criteria for those diagnoses adequate? You could successfully argue no fairly easily for most, maybe all, psych disorders". Of course you see similar diagnostic issues in other medical fields particularly in dumping diagnoses, but not to this extent.

The point is that the critical issue here isn't the need for a binary category, but how much is our diagnostic procedure rooted in actual scientific knowledge and empirical evidence. When it is not, like the case in psych, we will rightly be attacked for being a mere vehicle for x and y. The counter point was that "oh we know brain mechanisms involved in executive function so ADHD is one of our most validated diagnoses" but these mechanisms are not specific to ADHD at all and these issues we see in all kind of psychiatric disorders and non-disorders.

As for the validity of the diagnosis because "x treatment works", I find that incredibly intellectually lazy. I mean, antipsychotics work for all kinds of things. The evidence base for stimulants is not as strong as you're suggesting anyway. Long term studies are lacking, even to the more favorable reviews. Quite a few reviews have concluded that the evidence quality is poor (see for ex: The Preschool Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS) 6-Year Follow-up).

 

[clausewitz2]

I mean, you wrote all of that only to basically say exactly the point that "should we consider the definition/criteria for those diagnoses adequate? You could successfully argue no fairly easily for most, maybe all, psych disorders". Of course you see similar diagnostic issues in other medical fields particularly in dumping diagnoses, but not to this extent.

The point is that the critical issue here isn't the need for a binary category, but how much is our diagnostic procedure rooted in actual scientific knowledge and empirical evidence. When it is not, like the case in psych, we will rightly be attacked for being a mere vehicle for x and y. The counter point was that "oh we know brain mechanisms involved in executive function so ADHD is one of our most validated diagnoses" but these mechanisms are not specific to ADHD at all and these issues we see in all kind of psychiatric disorders and non-disorders.

As for the validity of the diagnosis because "x treatment works", I find that incredibly intellectually lazy. I mean, antipsychotics work for all kinds of things.

You should probably tell our IM colleagues about how treatment response can't define conditions when they start talking about asthma.

 

[ridethecliche]

As much as I dislike you as a person because your avatar makes me feel like I'm going to have a seizure, that's a good story. . #kiddingnotkidding

Beaker is my internal monologue. Yes, it's quite loud in here.

MEEP MEEP MEEP.

Appreciate it thought. I think it may be time to find a new avatar though. This one served its purpose from MCAT through med school and onto step 1 and 2. With step 3 fast approaching, perhaps the change will signify a rite of passage.

Snoop

SMOKE WEED ERRYDAY.
I know this is Dre, but this article still gets me every.single.time.

An Interview with the Only Person Ever to Nail the “Smoke Weed Every Day” Line from That Dr. Dre Song – VICE

May his heroic tale of triumph inspire you for greatness.

www.vice.com

It's genuinely these patients and interactions that made me love inpatient and really question my previous plan for outpatient only life.

Science is the best remedy for existential angst. I'm not making light of my patient's course, because he was very very sick, but I definitely remember having a phase in high school where I was really into the existential authors and after a summer of reading Camus my brain was very much in the "What does anything mean? Do I only interact with people because I'm selfish? Does anything really matter?" phase. Looking back on it, it was a pretty interesting funk to have been in at 16...

I'm just glad I didn't discover Dostoyevsky, Kierkegaard, or Kafka. That would have been a major buzzkill.

Jokes aside, I think the COVID isolation is making a lot of very intelligent people fall into an existential depression of sorts. I've admitted a few college aged youth (up to maybe 30's) whose minds seemed to have taken that flavor of depression. It's pretty interesting, but it's hard to reason with because it's so circuitous. Surprising people seems to have been the only thing that throws them off to consider something above, like the patient metaphor above.

 

[psychacad]

I'll go back over it later when I have more time, but one example would be them criticizing what they describe as different symptom sets, noting that hyperactivity is not included in some adult symptom measures. There are a good number of longitudinal child studies that showed the hyperactivity component to be the symptoms most likely to decrease as the child grows into adolescence and early adulthood. This is fairly well known feature that they authors do not acknowledge, I assume because they would have to edit their criticism. There is no way that they could claim to have done a review of ADHD and not know this issue.

Having read the article fully, I feel that your line of argument here is kinda unfair.

When they referred to different symptom sets, their emphasis were on things like anger, risk taking, mood lability. Sure the particular line about hyperactivity probably doesn't support the point as the others, but it isn't key. When criteria become this broad, you really have to ask questions. The fact that adult ADHD is associated with so many comorbid psych 'disorders' (like everything in psychiatry) and inattention is prevalent in basically everything is more to the point.

The arguments about ADHD being a neurodevelopmental disorder are also valid. If it is, why would something like 'adult-onset' ADHD exist in the first place? It sounds like something entirely different, especially if the sex differences flip.

Key to understand their line of thinking is that the arguments above do not prove that adult-ADHD doesn't exist. Their key assumption is that the null hypothesis is that it doesn't exist, and so if you want to create a separate diagnostic category, you have to disprove the null hypothesis and show the evidence for diagnostic validity, and you have to answer these questions with evidence. That's the whole point of scientific rigor and the inherent causality underlying the medical diagnostic system. Of course I'm not sure there's a DSM diagnosis that meets these criteria anyway, so lol, we kinda know the answer there.

And I'm sure there will be someone that says, 'oh but stimulants work! so ADHD makes sense'. I don't think we needed a separate diagnostic category to know that stimulants can improve attention deficits on the short term. This is another key to their line of thinking: there's a whole lot more of implied assumptions when a new diagnostic category is created.

 

[WisNeuro]

Having read the article fully, I feel that your line of argument here is kinda unfair.

When they referred to different symptom sets, their emphasis were on things like anger, risk taking, mood lability. Sure the particular line about hyperactivity probably doesn't support the point as the others, but it isn't key. When criteria become this broad, you really have to ask questions. The fact that adult ADHD is associated with so many comorbid psych 'disorders' (like everything in psychiatry) and inattention is prevalent in basically everything is more to the point.

The arguments about ADHD being a neurodevelopmental disorder are also valid. If it is, why would something like 'adult-onset' ADHD exist in the first place? It sounds like something entirely different, especially if the sex differences flip.

Key to understand their line of thinking is that the arguments above do not prove that adult-ADHD doesn't exist. Their key assumption is that the null hypothesis is that it doesn't exist, and so if you want to create a separate diagnostic category, you have to disprove the null hypothesis and show the evidence for diagnostic validity, and you have to answer these questions with evidence. That's the whole point of scientific rigor and the inherent causality underlying the medical diagnostic system. Of course I'm not sure there's a DSM diagnosis that meets these criteria anyway, so lol, we kinda know the answer there.

And I'm sure there will be someone that says, 'oh but stimulants work! so ADHD makes sense'. I don't think we needed a separate diagnostic category to know that stimulants can improve attention deficits on the short term. This is another key to their line of thinking: there's a whole lot more of implied assumptions when a new diagnostic category is created.

My read is equal emphasis on those parts, still doesn't excuse ignoring the well-known literature on some of this, as well as well known literature on gender differences in presentation. I do think they have some points, but to say that this is a "critical analysis" is simply untrue. It's a persuasion piece.

Again, I also do not think there is justification for adult-onset ADHD, but do think there is plenty of evidence for children with ADHD who happen to age into adulthood with continuing symptoms.

Last, anyone who uses a patient reporting improvement on stimulants as a diagnostic indicator is simply a *****. Unfortunately, many of these people exist.

 

[Attending1985]

What if we discussed ADHD not is terms of a disorder but a neurologic atypica? So medications aren’t correcting what’s “wrong” but altering your brain function so you perform in a more average manner.

 

[psychacad]

My read is equal emphasis on those parts, still doesn't excuse ignoring the well-known literature on some of this, as well as well known literature on gender differences in presentation. I do think they have some points, but to say that this is a "critical analysis" is simply untrue. It's a persuasion piece.

Again, I also do not think there is justification for adult-onset ADHD, but do think there is plenty of evidence for children with ADHD who happen to age into adulthood with continuing symptoms.

Last, anyone who uses a patient reporting improvement on stimulants as a diagnostic indicator is simply a *****. Unfortunately, many of these people exist.

From the context the article was referring to 'adult onset'. Their arguments in general are correct. The 'diagnosis' is poorly validated. This is a mere descriptor and not an actual diagnosis. It's shocking to me how uncritical the psychiatric 'community' is, so we do need to hear these strongly critical voices.

Of course they think the same applies to child ADHD. I think there are valid arguments there as well. As long as our diagnostic procedure is this nebulous and the actual evidence for diagnostic validity is scarce, we do need to face the fact that we are merely describing behavior and putting a bandaid. But then this wouldn't work out when you're trying to brand stimulants for the population.

 

[Stagg737]

The point is that the critical issue here isn't the need for a binary category, but how much is our diagnostic procedure rooted in actual scientific knowledge and empirical evidence. When it is not, like the case in psych, we will rightly be attacked for being a mere vehicle for x and y. The counter point was that "oh we know brain mechanisms involved in executive function so ADHD is one of our most validated diagnoses" but these mechanisms are not specific to ADHD at all and these issues we see in all kind of psychiatric disorders and non-disorders

I think you're grossly overestimating the strength and validity of evidence in many areas of medicine, both in terms of diagnoses and treatment. And the mechanisms may not be unique to ADHD, but neither are symptoms or etiology of many diagnoses in medicine. The basis of all of western medicine is that we identify symptoms and treat them. The idea of identifying an actual root etiology and directly treating that to ameliorate an illness or trauma is a much more eastern philosophy and is a fairly young concept in western medicine and something which nearly every field does a poor job of achieving consistently.

 

[psychacad]

I think you're grossly overestimating the strength and validity of evidence in many areas of medicine, both in terms of diagnoses and treatment. And the mechanisms may not be unique to ADHD, but neither are symptoms or etiology of many diagnoses in medicine. The basis of all of western medicine is that we identify symptoms and treat them. The idea of identifying an actual root etiology and directly treating that to ameliorate an illness or trauma is a much more eastern philosophy and is a fairly young concept in western medicine and something which nearly every field does a poor job of achieving consistently.

lol. "The basis of all western medicine is that we identify symptoms and treat them"? I feel this is why we should get more exposure to philosophy of medicine in medical school. Almost all of modern medicine hinges on finding naturalistic causes of symptoms and treating the underlying cause. It's funny that you mention ID, perhaps the field where it's easiest to show a contrast with psychiatry. When someone comes with a fever and cough, you don't diagnose them with "fever and cough disorder" and prescribe them a cough suppressant and tylenol and tell them to go home. You run a bunch of tests, figure out the bug and treat it. And yes of course there are situations where the science isn't there yet, but that misses the point entirely. When you apply this model to psychiatry (which has been hugely successful in most areas of medicine), it fails spectacularly.

 

[brosa]

lol. "The basis of all western medicine is that we identify symptoms and treat them"? I feel this is why we should get more exposure to philosophy of medicine in medical school. Almost all of modern medicine hinges on finding naturalistic causes of symptoms and treating the underlying cause. It's funny that you mention ID, perhaps the field where it's easiest to show a contrast with psychiatry. When someone comes with a fever and cough, you don't diagnose them with "fever and cough disorder" and prescribe them a cough suppressant and tylenol and tell them to go home. You run a bunch of tests, figure out the bug and treat it. And yes of course there are situations where the science isn't there yet, but that misses the point entirely. When you apply this model to psychiatry (which has been hugely successful in most areas of medicine), it fails spectacularly.

I am not sure if psychiatry fails that bad.

Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses | The British Journal of Psychiatry | Cambridge Core

Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses - Volume 200 Issue 2

www.cambridge.org

All effect sizes in online Tables DS3 and DS4 are presented except for duplicates (e.g. effect size on dichotomous response and continuous reduction of severity in schizophrenia). Online Fig. DS25 identifies which dot corresponds to which result, and Figs DS26–29 present the results of dichotomous outcomes as relative and absolute risk/responder differences. Data on older meta-analyses from Table DS1 are not included. Effect sizes of dichotomous outcomes were converted to standardised mean differences expressed as Hedges’ g. Effect sizes of general medicine medication are presented on the left-hand side (median 0.37, mean 0.45, 95% CI 0.37–0.53) and psychiatric drugs on the right-hand side (median 0.41, mean 0.49, 95% CI 0.41–0.57).



Bottom point: psych medications are pretty much as effective as general medicine ones. Yes, some are not that great, but so are they in general medicine.

 

[psychacad]

I am not sure if psychiatry fails that bad.

Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses | The British Journal of Psychiatry | Cambridge Core

Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses - Volume 200 Issue 2

www.cambridge.org

View attachment 334768

All effect sizes in online Tables DS3 and DS4 are presented except for duplicates (e.g. effect size on dichotomous response and continuous reduction of severity in schizophrenia). Online Fig. DS25 identifies which dot corresponds to which result, and Figs DS26–29 present the results of dichotomous outcomes as relative and absolute risk/responder differences. Data on older meta-analyses from Table DS1 are not included. Effect sizes of dichotomous outcomes were converted to standardised mean differences expressed as Hedges’ g. Effect sizes of general medicine medication are presented on the left-hand side (median 0.37, mean 0.45, 95% CI 0.37–0.53) and psychiatric drugs on the right-hand side (median 0.41, mean 0.49, 95% CI 0.41–0.57).



Bottom point: psych medications are pretty much as effective as general medicine ones. Yes, some are not that great, but so are they in general medicine.

Most of these medications were being used before the DSM or their discovery had literally nothing to do with our diagnostic system. How we use them is also almost completely independent of diagnosis. That point is extraneous. Having said that, yes, our medications work pretty well for short term symptomatic relief. However I'd caution about 'primary outputs'. There's also a ton of data that the burden of mental illness hasn't improved.

 

[Attending1985]

This is off topic but all this talk of adhd made me wonder if anyone uses tik tok and has seen the insane amount of women on there proclaiming they have or think they have adhd then listing off symptoms convincing others they have it too. It’s quite disturbing IMO.

 

[sloh]

The evidence base for stimulants is not as strong as you're suggesting anyway. Long term studies are lacking, even to the more favorable reviews. Quite a few reviews have concluded that the evidence quality is poor (see for ex: The Preschool Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS) 6-Year Follow-up).

I found this worth addressing as well.

 

[Sushirolls]

ADD is my latest Chief Complaint cluster for the past few months. So far most are receptive to working on the other more pressing issues before jumping straight to ADD=Stimulant=Expectation now

 

[clausewitz2]

Key to understand their line of thinking is that the arguments above do not prove that adult-ADHD doesn't exist. Their key assumption is that the null hypothesis is that it doesn't exist, and so if you want to create a separate diagnostic category, you have to disprove the null hypothesis and show the evidence for diagnostic validity, and you have to answer these questions with evidence. That's the whole point of scientific rigor and the inherent causality underlying the medical diagnostic system. Of course I'm not sure there's a DSM diagnosis that meets these criteria anyway, so lol, we kinda know the answer there.

I don't think that the null hypothesis is especially sensible if are talking about adults who continue to have symptoms of ADHD that they also had as children. The scientific response to a large group of people who have a certain set of experiences and difficulties as children that cause significant problems in their lives who then continue to have similar problems as an adult is not "doesn't exist." I think it's totally reasonable to have disagreements about causes, treatments, whether it should count as pathology/something medicalized, and how vested commercial and hegemonic interests might shape patterns of diagnosis. If you instead assert that it is simply illegitimate to regard the difficulties in question as something that might be deserving of voluntary treatment or amelioration, I don't understand how you explain them. Are these people all just confused about what is difficult for them or what tasks they routinely fail at? Are they all lying? Is there in fact a grand time-traveling conspiracy to insert references to "diseases of attention" that sound a heck of a lot like ADHD into medical texts in the 18th century?

I am deeply skeptical of the role of pharma and power structures in shaping medical practice but doing that the authors do and casting aspersions on things by vaguely gesturing towards Neoliberal Capitalism is not radical critique. It's just lazy.

Also, tell me again about how all of modern medicine is about identifying underlying natural causes and treating them specifically and how this applies to the HTN/HLD/T2DM trifecta that is like half of most PCP clinics. I am especially keen on elaboration on how co-morbidity makes the diagnosis invalid and how it applies in this context.

If you read deeply into philosophy of medicine you will note that the very issue of what constitutes a disease a priori is far away from being a settled question. You are asserting a certainty and consensus when it comes to medical practice that does not exist, and then chiding psychiatry for not living up to that standard. ID is absolutely the area of medicine where your statement is most true because Koch's disease concept was articulated to describe infectious diseases. It would be kind of shocking if it didn't fit their field the best.

 

[Stagg737]

lol. "The basis of all western medicine is that we identify symptoms and treat them"? I feel this is why we should get more exposure to philosophy of medicine in medical school. Almost all of modern medicine hinges on finding naturalistic causes of symptoms and treating the underlying cause. It's funny that you mention ID, perhaps the field where it's easiest to show a contrast with psychiatry. When someone comes with a fever and cough, you don't diagnose them with "fever and cough disorder" and prescribe them a cough suppressant and tylenol and tell them to go home. You run a bunch of tests, figure out the bug and treat it. And yes of course there are situations where the science isn't there yet, but that misses the point entirely. When you apply this model to psychiatry (which has been hugely successful in most areas of medicine), it fails spectacularly.

I've actually taken more than a few classes which addressed h/o medicine and philosophy, including classes specifically about differences in medical philosophy in different cultures. Historically, the basis of western medicine IS the treatment of symptoms while Eastern cultures focus more on treating "roots" through systems like Ayurveda, Chakras, and Qi. We can argue the problems and validities of each system, but this is the 10,000 foot view. This has evolved greatly in our society to the point that western medicine does try to identify root causes, but if you're going to argue that we don't focus heavily on "symptom reduction" as opposed to bringing pathological processes into non-pathological states, I don't know what to tell you. Symptom reduction and not resolution of pathology is the treatment goal for countless conditions in nearly all fields. I'm more than happy to discuss philosophy of medicine through various cultures and modalities, as this was part of a capstone project I did in undergrad. Bottom line is that

For ID, I do agree that currently there is a huge contrast. My example with ID was more of a historical perspective regarding how we treated pathogen-induced conditions hundreds and thousands of years before the advent of techniques allowing us to identify and genetically classify organisms. If I didn't convey this clearly, I apologize. I do think it's a bit unfair to compare the massive leaps in advancement of certain fields in the last 25-50 years

To the bolded: you serious? Go to your PCP with a cough and mild to moderate fever that's been there less than 5 days and that's exactly what they'll do, they'll just call it a URI or sinus infection and add some Tessalon pearls for the cough. If you read AAFP guidelines that's actually part of the standard of care. unless the fever is either very high, there are other concerning symptoms (CURB-65, for example), or symptoms have been present 10+ days. They don't "run a bunch of tests" unless there's some other indication. I think your point is a fair one if you're comparing more severe conditions in FM compared to psych, but for mild and some moderate conditions there's little to no difference.

 

[ridethecliche]

If American Medicine was about root causes, we'd actually give a rats ass about properly addressing poverty and income/health inequality...

 

[psychacad]

To the bolded: you serious? Go to your PCP with a cough and mild to moderate fever that's been there less than 5 days and that's exactly what they'll do, they'll just call it a URI or sinus infection and add some Tessalon pearls for the cough. If you read AAFP guidelines that's actually part of the standard of care. unless the fever is either very high, there are other concerning symptoms (CURB-65, for example), or symptoms have been present 10+ days. They don't "run a bunch of tests" unless there's some other indication. I think your point is a fair one if you're comparing more severe conditions in FM compared to psych, but for mild and some moderate conditions there's little to no difference.

Not sure how you think this example makes your point. You're describing a fairly technical and elaborate diagnostic procedure that actually makes a big difference on treatment and prognosis. Is it viral, bacterial, pneumonia, viral URI, the flu tonsillitis..etc. Sure if it's viral then we treat symptomatically because we don't have treatment options right now to address the root cause, but at least we know something about the etiology and pathophysiology of the symptoms, have a good idea about prognosis...etc I feel like there are some important conceptual misunderstandings here, so we'll agree to disagree.

 

[Stagg737]

Not sure how you think this example makes your point. You're describing a fairly technical and elaborate diagnostic procedure that actually makes a big difference on treatment and prognosis. Is it viral, bacterial, pneumonia, viral URI, the flu tonsillitis..etc. Sure if it's viral then we treat symptomatically because we don't have treatment options right now to address the root cause, but at least we know something about the etiology and pathophysiology of the symptoms, have a good idea about prognosis...etc I feel like there are some important conceptual misunderstandings here, so we'll agree to disagree.

We may have to agree to disagree, but I'll try and briefly clarify my previous statements. To the first bolded, it doesn't really matter what the etiology of fever + cough is unless there are other significant symptoms on presentation or they've been present for 10+ days. The treatment will be supportive regardless of the above etiology. It's not until new symptoms become subacute or chronic, or until they become severe where hospitalization may become necessary that further diagnostic tests are taken. Not sure how any of what I mentioned above is "fairly technical and elaborate". We have the same things in psych with various psychological scales an instruments. How much more accurate do you think something like CURB-65 is? Unless you were referring to something else.

To the second bolded, this is also true in psych? We may not know all the details, but we still know which neurotransmitters, pathways, brain structures, etc are involved with various disorders even if we aren't able to narrow things down as specifically as other fields.

 

[Marasmus1]

He is right.

BUT What these folks don't understand is you go to residency to learn when not to prescribe risperdal.