I scanned this thoughtful post. I would like to add two points that weren't mentioned.
1) "Adult ADHD" is not in the DSM. I don't mean to stand on principle or play games with words. Check the DSM, the ADHD diagnosis exclusively describes children, if you apply it to adults you have to use your own imagination to translate it to adult problems. Furthermore, ,I only have the DSM on my phone (in a an app). I don't have time to hunt around for "proposed" adult symptoms or the consensus of some advocacy organization I don't know. Translating the ADHD criteria to adult experience is as, or more challenging than differentiating mood disorders from psychotic disorders in the DSM famework, for example.
2) The author made no mention that ADHD is a specific type of cognitive impairment that appears in childhood. I don't mean to fight the battle of "if it wasn't there before...". I mean to point out that there are numerous etiologies of this sort of impairment besides the disorder we have called "ADHD". Sleep deprivation for example; a promotion to a job for which you are unprepared; young children; multiple jobs that exceed a manageable amount of waking time. Adults with reported ADHD haven't really been systematically studied to explore these etiologies. Patients in menopause report this; patients after chemotherapy; patients with multiple schlerosis. We have to acknowledge this then decide what to do about it. We all know the question: who gets stimulants? We can't discuss ADHD diagnosiss without mentioning stimulants.
Absolutely, absolutely. But the criteria are clearly geared to children. So now this involves some active thinking, what are these criteria "translated to" in adulthood? I am reading directly from the criteria, which do propose some "adult translations". The DSM suggests adult symptoms to be:
avoids, dislikes, or is reluctant to engage in...preparing reports, completing forms, (or) reviewing lengthy papers
is often easily distracted by...unrelated thoughts
is often forgetful in...returning calls, paying bills, (or) keeping appointments
feeling restless
intrudes into or takes over what others are doing
That's it. Even by DSM standards (vague, descriptive, dependent on operationalization), this is pretty slender pickings. I experience them every single day. I can't say this about many DSM diagnoses, all of us experience parts of syndromes like borderline personality (after a divorce for example), OCPD (when dealing with a boundary-pushing patient), perhaps even paranoid personality (when competing against classmates in medical school). Many of us have simple phobias, supposedly the most common diagnosis identified in the ECS. But even in comparison to these examples, the ADHD "adult" criteria are pretty poorly differentiated from normal experience. Plus, of course, I doubt anyone has measured the inter-rater reliability of the ADHD diagnosis in adults. Feel free to prove me wrong.
There is an enormous literature on alien abductions as well. What I mean to say is, most or all psychiatrists are like me, they are time limited and utilize unstructured assessment coupled with the DSM, I would estimate this describes 99% of all psychiatric encounters. So if we want to identify the problem we need to focus on the DSM.
The list of indicators stops one indicator short of the clinic. Signs, continuity, course, impairment, history, alternatives: all six are gathered before anyone prescribes. The one gathered after is what happens when the drug is taken away, and her own appetite-suppressant example is where that shows. In the STEP 1 extension, adults with obesity who stopped semaglutide had regained about two-thirds of the lost weight within a year, which says the drug managed a mechanism it never changed. Stimulants behave the same way in the randomized withdrawal trials collected in the 2021 Frontiers in Psychiatry review: most stable responders relapse within two weeks of switching to placebo, and roughly 30 percent do not. Nobody, as far as I can tell, has asked which presentation that 30 percent came from. If the newer profile she describes, high self-reported dysfunction with few corroborated signs, clusters among the people who stop and stay well, that is a different syndrome by a test the clinic already runs. If it clusters among the relapsers, the phenotype widened and the construct held. The withdrawal trials on file were run on the older presentation, so they cannot settle this by themselves, and the non-relapsers may just be people whose demands dropped or who built the compensations she mentions. I don't know. What strikes me is that NICE already requires an annual review and permits a trial of discontinuation, so the data point is being generated and then filed as a dosing decision. The record that would move me is a withdrawal trial run on the new presentation.
I scanned this thoughtful post. I would like to add two points that weren't mentioned.
1) "Adult ADHD" is not in the DSM. I don't mean to stand on principle or play games with words. Check the DSM, the ADHD diagnosis exclusively describes children, if you apply it to adults you have to use your own imagination to translate it to adult problems. Furthermore, ,I only have the DSM on my phone (in a an app). I don't have time to hunt around for "proposed" adult symptoms or the consensus of some advocacy organization I don't know. Translating the ADHD criteria to adult experience is as, or more challenging than differentiating mood disorders from psychotic disorders in the DSM famework, for example.
2) The author made no mention that ADHD is a specific type of cognitive impairment that appears in childhood. I don't mean to fight the battle of "if it wasn't there before...". I mean to point out that there are numerous etiologies of this sort of impairment besides the disorder we have called "ADHD". Sleep deprivation for example; a promotion to a job for which you are unprepared; young children; multiple jobs that exceed a manageable amount of waking time. Adults with reported ADHD haven't really been systematically studied to explore these etiologies. Patients in menopause report this; patients after chemotherapy; patients with multiple schlerosis. We have to acknowledge this then decide what to do about it. We all know the question: who gets stimulants? We can't discuss ADHD diagnosiss without mentioning stimulants.
*Adult-onset* ADHD is not in the DSM but there is no restriction in the DSM that childhood-onset ADHD cannot continue into adulthood.
Absolutely, absolutely. But the criteria are clearly geared to children. So now this involves some active thinking, what are these criteria "translated to" in adulthood? I am reading directly from the criteria, which do propose some "adult translations". The DSM suggests adult symptoms to be:
avoids, dislikes, or is reluctant to engage in...preparing reports, completing forms, (or) reviewing lengthy papers
is often easily distracted by...unrelated thoughts
is often forgetful in...returning calls, paying bills, (or) keeping appointments
feeling restless
intrudes into or takes over what others are doing
That's it. Even by DSM standards (vague, descriptive, dependent on operationalization), this is pretty slender pickings. I experience them every single day. I can't say this about many DSM diagnoses, all of us experience parts of syndromes like borderline personality (after a divorce for example), OCPD (when dealing with a boundary-pushing patient), perhaps even paranoid personality (when competing against classmates in medical school). Many of us have simple phobias, supposedly the most common diagnosis identified in the ECS. But even in comparison to these examples, the ADHD "adult" criteria are pretty poorly differentiated from normal experience. Plus, of course, I doubt anyone has measured the inter-rater reliability of the ADHD diagnosis in adults. Feel free to prove me wrong.
That’s a problem with the DSM, yeah, but there is of course a lot more literature on the topic. This was just published in NEJM for example: https://www.nejm.org/doi/full/10.1056/NEJMcp2516040
There is an enormous literature on alien abductions as well. What I mean to say is, most or all psychiatrists are like me, they are time limited and utilize unstructured assessment coupled with the DSM, I would estimate this describes 99% of all psychiatric encounters. So if we want to identify the problem we need to focus on the DSM.
The list of indicators stops one indicator short of the clinic. Signs, continuity, course, impairment, history, alternatives: all six are gathered before anyone prescribes. The one gathered after is what happens when the drug is taken away, and her own appetite-suppressant example is where that shows. In the STEP 1 extension, adults with obesity who stopped semaglutide had regained about two-thirds of the lost weight within a year, which says the drug managed a mechanism it never changed. Stimulants behave the same way in the randomized withdrawal trials collected in the 2021 Frontiers in Psychiatry review: most stable responders relapse within two weeks of switching to placebo, and roughly 30 percent do not. Nobody, as far as I can tell, has asked which presentation that 30 percent came from. If the newer profile she describes, high self-reported dysfunction with few corroborated signs, clusters among the people who stop and stay well, that is a different syndrome by a test the clinic already runs. If it clusters among the relapsers, the phenotype widened and the construct held. The withdrawal trials on file were run on the older presentation, so they cannot settle this by themselves, and the non-relapsers may just be people whose demands dropped or who built the compensations she mentions. I don't know. What strikes me is that NICE already requires an annual review and permits a trial of discontinuation, so the data point is being generated and then filed as a dosing decision. The record that would move me is a withdrawal trial run on the new presentation.