The enhancement branch is already running at scale. Undergraduates on many campuses have learned the ADHD self-report script well enough to walk out with Ritalin specifically for exam season. It's not a boundary case. It's how the diagnostic infrastructure actually functions when the incentive gradient points one way and self-report is the only door in.
The second one I'm less sure about, and it's the one I've been circling in my own writing on layered honesty about diagnosis. The obesity substrate you use as the stable anchor is itself institutionally indexed. In a food-scarce environment, efficient fat storage was adaptive, not pathological. What changed wasn't the substrate. It was the world the substrate landed in.
If that's right, the same move might apply to ADHD. Traits that read as attentional pathology in an environment demanding sustained focus on sedentary abstract tasks weren't necessarily pathological in the environments those traits evolved in. The industrial revolution didn't just make our epistemic access indirect. It made "attentional pathology" a category the substrate is being read through.
I’ve modified the thought experiment by swapping in depression for obesity. Not many disagree that there is something usefully called depression. The debates are about what kind, is it many kinds, what should we do about it etc. ADHD seems to insist it is just like obesity or other physical conditions and certainly different in kind to other psychiatric syndromes. It tends to limit the conversation with my adolescent patients, particularly when they arrive with everything already settled in their minds. I’ve bailed out of doing “ADHD assessments “ because I haven’t found a way to have both ADHD and a developing human being in my consulting room.
I always love your thought experiments, and I found this one both thoughtful and thought-provoking. But I think it may understate something important about how clinicians actually evaluate a disorder like ADHD.
Psychiatrists understandably spend a lot of time with symptoms, perhaps because symptoms are what patients bring into the room. But from a neuropsychological perspective, the absence of a biomarker does *not* mean that ADHD is inferred primarily from self-report. We are trying to triangulate toward a latent construct from *multiple* imperfect indicators.
That includes credible subjective symptoms, but also credible reports of observable signs; evidence that those signs occur across settings; actual functional impairment; developmental course; family loading; known correlates; differences between clinical and nonclinical groups at the group level; and careful exclusion of other explanations for the same complaints. None of those things is sufficient alone, but together they form the syndrome.
So if adiposity were literally invisible, I don’t think we would simply ask people whether they felt overweight and then confront all the epistemic problems that follow from that. We would build a syndrome from converging evidence. We might look for subjective distress around hunger, eating, body heaviness, or exertion, sure. But we would *also* look for observable patterns: consuming substantially more energy than activity demands, difficulty stopping eating despite satiety (e.g. spouse says they often say “I’m full but this just tastes so good I can’t stop”), avoidance of exertion, difficulty climbing stairs, difficulty finding clothing that fits, physiological correlates such as inflammatory markers, family history, course over time, and so forth. We would also rule out alternative causes of the same symptom, for example, hunger caused by severe caloric restriction, medication effects, depression-related hyperphagia, etc.
What worries me about ADHD right now is not simply that more people are reporting symptoms. It is that many people appear to be presenting with a *different pattern altogether*.
In adult assessment, for example, we increasingly see extraordinarily elevated self-reported executive dysfunction — sometimes at levels more extreme than we would expect even in advanced neurological disease —alongside relatively little corroborating evidence of the traditional observable signs of ADHD. Some newer complaints are also highly nonspecific or transdiagnostic, such as rejection sensitivity, and are being folded into the ADHD phenotype despite not functioning very well as discriminating indicators.
We also increasingly hear versions of what used to be observable signs converted into subjective symptoms: not “I routinely fail to complete tasks” but “it feels much harder for me to complete tasks than it seems to be for other people”; not “I repeatedly lose things” but “I feel as though I would lose things if I didn’t compensate so intensely.” Those experiences may be completely genuine, but they are epistemically *different* from the signs that historically helped define the syndrome. The symptom picture is also extraordinarily broad, with clinical elevations on almost all self-report measures, even for low incidence symptoms (and it’s not uncommon to see a dozen low incidence conditions being heavily endorsed by the individual).
If this newer presentation is also associated with less observable impairment, weaker cross-setting corroboration, different developmental histories, weaker familial patterns, and different outcome correlates, then I think the scientific question becomes: are we still talking about the *same syndrome*?
That is not the same as asking whether these people are suffering! I have no interest in dismissing their distress. The question is whether the distress is best understood as ADHD, whether it arises from the same mechanisms, and whether it should therefore be treated in the same way.
This matters especially once treatment enters the picture. A patient’s report that a medication is life-changing is important, but it is not *by itself* proof that we have correctly identified the underlying problem. There are interventions that can feel profoundly helpful while reinforcing a dysfunctional process. Giving a GLP-1 medication to someone with an eating disorder could plausibly produce enormous subjective relief around appetite and control while still moving the person in the wrong direction medically. Subjective benefit and construct validity are related questions, but they are not identical.
So I think your obesity analogy works beautifully, but perhaps in a slightly different direction than you intend. If adiposity were invisible, we would not solve the problem by relying more heavily on self-report. We would become *even more dependent* on careful triangulation across behavior, impairment, course, collateral information, physiology, family history, and differential diagnosis.
And if a new population began presenting with a very different configuration of symptoms, signs, impairment, correlates, and treatment response, I think we would be scientifically *obligated* to ask whether the category itself had changed underneath us.
Part of this obligation would be driven by empathy and a desire for quality care for the people in our offices, but I feel I also have a duty of care for the people not in my office at this moment. That is, I worry that the rapid expansion of a category may leave behind the people with the fewest resources — in this case, those with more classic ADHD, whose impairments may be less articulate, less socially legible, or less easily translated into the language now being used to access assessment and treatment. If clinical attention and limited treatment resources are increasingly directed toward a newer, more privileged presentation, we may inadvertently make it harder for those with longstanding, observable, and often more disabling ADHD to be recognized and helped. I’ve also elaborated in other comments on my concerns on how too much empathy for self reported symptoms may have implications for the people in our patients’ lives (e.g. what it means for parents, spouses, teachers, etc when we lend medical weight to a person’s self reported distress), for our culture as a whole (are we creating a kind of “skinny culture”), and what it could mean to lose valuable signal from the environment, but you allude to all these in your post so I’ll only mention these concerns in passing here.
In any case, I wish we could ask these hard but important questions without having them interpreted as evidence that we lack empathy, are not listening to lived experience, or are trying to gatekeep care. Taking patients’ experiences seriously does not require treating every interpretation of those experiences as equally well supported. In fact, careful diagnostic questioning is part of taking both patients and the science seriously. That’s what I’m hopeful of an abundance of: serious, thoughtful, pluralistic conversations.
(With thanks as always for creating this space for these conversations.)
It is a wonderful thought experiment, Awais. As with many other diagnoses and non diagnoses, we have to consider the evaluator as well. Evaluators who themselves are diagnosed with ADHD or obesity may bring judgments and perspectives different from those who don't have one of those; not better or worse, but there's a countertransference component here ( as always, but maybe more so here than with most other conditions). Also, ADHD - different from obesity - has a functional piece part of the definition, so depending on what a person is doing ( or trying to do), ADHD is impairing or not. That also leads to the matter of who is entitled to accommodations. I doubt obese people ask for special treatment, though maybe some want to avoid, say, paying for 2 seats on an airplane.
You're overthinking it. Nothing more than ordinary reasoning is required. There is something worth saying here about judgement calls and consensus.
We might just as well ask, "Can humans levitate?" People believe all sorts of strange things, and we cannot control what others believe, but we all use judgement and can arrive at a consensus. The more objective evidence there is, the more likely we are to judge something sound and reach a consensus. Ideally, this is how every idea becomes either widely accepted or widely rejected.
In the case of obesity, we have many objective signs, so a broad consensus naturally follows. In the case of humans levitating, we do not seem to have any evidence at all, so most people reject the idea, although there are always a few strange people out there.
ADHD sits somewhere between those two extremes. The question is whether certain biases or other factors put their thumb on the scales and allow a rather bad idea to gain widespread acceptance. Clearly, the answer is yes. Strange ideas catch on all the time.
Is ADHD itself a wholly bad or strange idea? No. Is the overextended form of ADHD a bad or strange idea? In my judgement, yes, and hopefully we eventually reach a consensus.
The only thing thats changed in the last few decades is we seem to be having lots of bad ideas and not many good ones. Maybe we should spend more time thinking up good ideas and less time polishing up bad ones.
Really interesting Awais. Makes me think of one of the first patients I saw in my psychiatric training. From across the waiting room, he was fidgeting so profoundly I wondered if he had a physical problem (this was pre-smartphone era). He wound up clearly meeting ADHD criteria.
Also, not quite "visible," but I think it's interesting how some clinicians try to base the diagnosis in longitudinal evidence of decreased function / underperformance despite adequate intelligence and social supports. Also using multiple informants. And of course some require neuropsych testing, though that's imperfect and a funny proxy for time/effort, not really a diagnostic test per se.
Point being, the diagnosis is not purely invisible in the sense that is always solely self-report, though it may degrade to that in some clinical and research contexts.
Ironically, of all the medical conditions I've ever been diagnosed with, ADHD requires the most paperwork for the patient to fill out and the most-frequent return visits despite difficulty managing things like that being part of the condition. I wonder if part of the perception that "adult ADHD" is "cognitive doping" (taking terms from another comment here) comes from survivorship bias—if you don't actually know lots of the impoverished ADHDers living in squalor who struggle to access treatment at all, maybe it looks like all ADHD adults are the non-impaired perfectionist types?
Powerful analogy. The absence of a public biomarker does not make ADHD unreal; it makes diagnosis unusually vulnerable to projection, gatekeeping, and demand created by environments built around sustained productivity. The next question is not only who has ADHD, but what kinds of lives make stimulants feel necessary.
I like Awais' sense of humor. This is a frustrating topic. I place adult ADHD at the top of the list of "things I have an informed opinion about but no one asked me". Apparently my region, perhaps the whole country, has decided that cognitive doping is a good idea, though we seem to mostly agree sports doping, isn't.
I don't know what the downsides are from everyone's taking stimulants to enhance their performance. I haven't seen any cases of cardiovascular compromize, addiction (!) or even manic decompensation in twenty five years of prescribing them. There have been exceptions none of which fit the paradigm of de novo prescriptions' leading to some negative outcome. And yet I find it absurd. Plus, this new practice is doing nothing to enhance psychiatry's reputation, on the contrary.
A real mid-career disappointment I have to say. But maybe my resenting being forced to do something I don't approve of, is my own psychological problem? I guess, like Fauci, when I am interrogated about this, I will take the Fifth.
A thought experiment I use with children who have ADHD is to imagine what the world would look like if, instead of 5 percent of people having ADHD, it were 95 percent. How would schools look? How would society be different?
It is partly a story about difference. There is nothing morally better or worse about how your brain works. That does not mean ADHD cannot be genuinely impairing. It means its impact is also shaped by the world a person has to navigate.
So many children with ADHD are constantly punished and told they are bad, careless, disruptive, or doing things wrong.
That is not simply a problem inside the child. It is also a social and political question about which minds our institutions are built to accommodate.
Two textures worth adding.
The enhancement branch is already running at scale. Undergraduates on many campuses have learned the ADHD self-report script well enough to walk out with Ritalin specifically for exam season. It's not a boundary case. It's how the diagnostic infrastructure actually functions when the incentive gradient points one way and self-report is the only door in.
The second one I'm less sure about, and it's the one I've been circling in my own writing on layered honesty about diagnosis. The obesity substrate you use as the stable anchor is itself institutionally indexed. In a food-scarce environment, efficient fat storage was adaptive, not pathological. What changed wasn't the substrate. It was the world the substrate landed in.
If that's right, the same move might apply to ADHD. Traits that read as attentional pathology in an environment demanding sustained focus on sedentary abstract tasks weren't necessarily pathological in the environments those traits evolved in. The industrial revolution didn't just make our epistemic access indirect. It made "attentional pathology" a category the substrate is being read through.
I’ve modified the thought experiment by swapping in depression for obesity. Not many disagree that there is something usefully called depression. The debates are about what kind, is it many kinds, what should we do about it etc. ADHD seems to insist it is just like obesity or other physical conditions and certainly different in kind to other psychiatric syndromes. It tends to limit the conversation with my adolescent patients, particularly when they arrive with everything already settled in their minds. I’ve bailed out of doing “ADHD assessments “ because I haven’t found a way to have both ADHD and a developing human being in my consulting room.
I always love your thought experiments, and I found this one both thoughtful and thought-provoking. But I think it may understate something important about how clinicians actually evaluate a disorder like ADHD.
Psychiatrists understandably spend a lot of time with symptoms, perhaps because symptoms are what patients bring into the room. But from a neuropsychological perspective, the absence of a biomarker does *not* mean that ADHD is inferred primarily from self-report. We are trying to triangulate toward a latent construct from *multiple* imperfect indicators.
That includes credible subjective symptoms, but also credible reports of observable signs; evidence that those signs occur across settings; actual functional impairment; developmental course; family loading; known correlates; differences between clinical and nonclinical groups at the group level; and careful exclusion of other explanations for the same complaints. None of those things is sufficient alone, but together they form the syndrome.
So if adiposity were literally invisible, I don’t think we would simply ask people whether they felt overweight and then confront all the epistemic problems that follow from that. We would build a syndrome from converging evidence. We might look for subjective distress around hunger, eating, body heaviness, or exertion, sure. But we would *also* look for observable patterns: consuming substantially more energy than activity demands, difficulty stopping eating despite satiety (e.g. spouse says they often say “I’m full but this just tastes so good I can’t stop”), avoidance of exertion, difficulty climbing stairs, difficulty finding clothing that fits, physiological correlates such as inflammatory markers, family history, course over time, and so forth. We would also rule out alternative causes of the same symptom, for example, hunger caused by severe caloric restriction, medication effects, depression-related hyperphagia, etc.
What worries me about ADHD right now is not simply that more people are reporting symptoms. It is that many people appear to be presenting with a *different pattern altogether*.
In adult assessment, for example, we increasingly see extraordinarily elevated self-reported executive dysfunction — sometimes at levels more extreme than we would expect even in advanced neurological disease —alongside relatively little corroborating evidence of the traditional observable signs of ADHD. Some newer complaints are also highly nonspecific or transdiagnostic, such as rejection sensitivity, and are being folded into the ADHD phenotype despite not functioning very well as discriminating indicators.
We also increasingly hear versions of what used to be observable signs converted into subjective symptoms: not “I routinely fail to complete tasks” but “it feels much harder for me to complete tasks than it seems to be for other people”; not “I repeatedly lose things” but “I feel as though I would lose things if I didn’t compensate so intensely.” Those experiences may be completely genuine, but they are epistemically *different* from the signs that historically helped define the syndrome. The symptom picture is also extraordinarily broad, with clinical elevations on almost all self-report measures, even for low incidence symptoms (and it’s not uncommon to see a dozen low incidence conditions being heavily endorsed by the individual).
If this newer presentation is also associated with less observable impairment, weaker cross-setting corroboration, different developmental histories, weaker familial patterns, and different outcome correlates, then I think the scientific question becomes: are we still talking about the *same syndrome*?
That is not the same as asking whether these people are suffering! I have no interest in dismissing their distress. The question is whether the distress is best understood as ADHD, whether it arises from the same mechanisms, and whether it should therefore be treated in the same way.
This matters especially once treatment enters the picture. A patient’s report that a medication is life-changing is important, but it is not *by itself* proof that we have correctly identified the underlying problem. There are interventions that can feel profoundly helpful while reinforcing a dysfunctional process. Giving a GLP-1 medication to someone with an eating disorder could plausibly produce enormous subjective relief around appetite and control while still moving the person in the wrong direction medically. Subjective benefit and construct validity are related questions, but they are not identical.
So I think your obesity analogy works beautifully, but perhaps in a slightly different direction than you intend. If adiposity were invisible, we would not solve the problem by relying more heavily on self-report. We would become *even more dependent* on careful triangulation across behavior, impairment, course, collateral information, physiology, family history, and differential diagnosis.
And if a new population began presenting with a very different configuration of symptoms, signs, impairment, correlates, and treatment response, I think we would be scientifically *obligated* to ask whether the category itself had changed underneath us.
Part of this obligation would be driven by empathy and a desire for quality care for the people in our offices, but I feel I also have a duty of care for the people not in my office at this moment. That is, I worry that the rapid expansion of a category may leave behind the people with the fewest resources — in this case, those with more classic ADHD, whose impairments may be less articulate, less socially legible, or less easily translated into the language now being used to access assessment and treatment. If clinical attention and limited treatment resources are increasingly directed toward a newer, more privileged presentation, we may inadvertently make it harder for those with longstanding, observable, and often more disabling ADHD to be recognized and helped. I’ve also elaborated in other comments on my concerns on how too much empathy for self reported symptoms may have implications for the people in our patients’ lives (e.g. what it means for parents, spouses, teachers, etc when we lend medical weight to a person’s self reported distress), for our culture as a whole (are we creating a kind of “skinny culture”), and what it could mean to lose valuable signal from the environment, but you allude to all these in your post so I’ll only mention these concerns in passing here.
In any case, I wish we could ask these hard but important questions without having them interpreted as evidence that we lack empathy, are not listening to lived experience, or are trying to gatekeep care. Taking patients’ experiences seriously does not require treating every interpretation of those experiences as equally well supported. In fact, careful diagnostic questioning is part of taking both patients and the science seriously. That’s what I’m hopeful of an abundance of: serious, thoughtful, pluralistic conversations.
(With thanks as always for creating this space for these conversations.)
It is a wonderful thought experiment, Awais. As with many other diagnoses and non diagnoses, we have to consider the evaluator as well. Evaluators who themselves are diagnosed with ADHD or obesity may bring judgments and perspectives different from those who don't have one of those; not better or worse, but there's a countertransference component here ( as always, but maybe more so here than with most other conditions). Also, ADHD - different from obesity - has a functional piece part of the definition, so depending on what a person is doing ( or trying to do), ADHD is impairing or not. That also leads to the matter of who is entitled to accommodations. I doubt obese people ask for special treatment, though maybe some want to avoid, say, paying for 2 seats on an airplane.
You're overthinking it. Nothing more than ordinary reasoning is required. There is something worth saying here about judgement calls and consensus.
We might just as well ask, "Can humans levitate?" People believe all sorts of strange things, and we cannot control what others believe, but we all use judgement and can arrive at a consensus. The more objective evidence there is, the more likely we are to judge something sound and reach a consensus. Ideally, this is how every idea becomes either widely accepted or widely rejected.
In the case of obesity, we have many objective signs, so a broad consensus naturally follows. In the case of humans levitating, we do not seem to have any evidence at all, so most people reject the idea, although there are always a few strange people out there.
ADHD sits somewhere between those two extremes. The question is whether certain biases or other factors put their thumb on the scales and allow a rather bad idea to gain widespread acceptance. Clearly, the answer is yes. Strange ideas catch on all the time.
Is ADHD itself a wholly bad or strange idea? No. Is the overextended form of ADHD a bad or strange idea? In my judgement, yes, and hopefully we eventually reach a consensus.
The only thing thats changed in the last few decades is we seem to be having lots of bad ideas and not many good ones. Maybe we should spend more time thinking up good ideas and less time polishing up bad ones.
Really interesting Awais. Makes me think of one of the first patients I saw in my psychiatric training. From across the waiting room, he was fidgeting so profoundly I wondered if he had a physical problem (this was pre-smartphone era). He wound up clearly meeting ADHD criteria.
Also, not quite "visible," but I think it's interesting how some clinicians try to base the diagnosis in longitudinal evidence of decreased function / underperformance despite adequate intelligence and social supports. Also using multiple informants. And of course some require neuropsych testing, though that's imperfect and a funny proxy for time/effort, not really a diagnostic test per se.
Point being, the diagnosis is not purely invisible in the sense that is always solely self-report, though it may degrade to that in some clinical and research contexts.
Ironically, of all the medical conditions I've ever been diagnosed with, ADHD requires the most paperwork for the patient to fill out and the most-frequent return visits despite difficulty managing things like that being part of the condition. I wonder if part of the perception that "adult ADHD" is "cognitive doping" (taking terms from another comment here) comes from survivorship bias—if you don't actually know lots of the impoverished ADHDers living in squalor who struggle to access treatment at all, maybe it looks like all ADHD adults are the non-impaired perfectionist types?
Powerful analogy. The absence of a public biomarker does not make ADHD unreal; it makes diagnosis unusually vulnerable to projection, gatekeeping, and demand created by environments built around sustained productivity. The next question is not only who has ADHD, but what kinds of lives make stimulants feel necessary.
I like Awais' sense of humor. This is a frustrating topic. I place adult ADHD at the top of the list of "things I have an informed opinion about but no one asked me". Apparently my region, perhaps the whole country, has decided that cognitive doping is a good idea, though we seem to mostly agree sports doping, isn't.
I don't know what the downsides are from everyone's taking stimulants to enhance their performance. I haven't seen any cases of cardiovascular compromize, addiction (!) or even manic decompensation in twenty five years of prescribing them. There have been exceptions none of which fit the paradigm of de novo prescriptions' leading to some negative outcome. And yet I find it absurd. Plus, this new practice is doing nothing to enhance psychiatry's reputation, on the contrary.
A real mid-career disappointment I have to say. But maybe my resenting being forced to do something I don't approve of, is my own psychological problem? I guess, like Fauci, when I am interrogated about this, I will take the Fifth.
If you cannot rely on self-report, behavioral observation, or objective measurement, then how do you make a diagnosis?
A thought experiment I use with children who have ADHD is to imagine what the world would look like if, instead of 5 percent of people having ADHD, it were 95 percent. How would schools look? How would society be different?
It is partly a story about difference. There is nothing morally better or worse about how your brain works. That does not mean ADHD cannot be genuinely impairing. It means its impact is also shaped by the world a person has to navigate.
So many children with ADHD are constantly punished and told they are bad, careless, disruptive, or doing things wrong.
That is not simply a problem inside the child. It is also a social and political question about which minds our institutions are built to accommodate.