Thank you, Awais, for a very clear-eyed and pragmatic take on ADHD, and on the "medical model" in general--a concept widely misunderstood, as you point out. In that regard, I think the core of your article is this:
"Medical conditions do not always have a single, identifiable “cause.” Medical disorders can still be legitimate even if they lack clear physical lesions or biomarkers...Many medical conditions are heterogeneous syndromes, not unitary diseases with essences. Many medical diagnoses exist because of their usefulness in guiding treatment and communication, even if their etiological status is uncertain. Medical disorders need not be categorical in nature; many medical disorders are dimensional. Environment can play a vital role in the vulnerability, causation, and progression of medical disorders. The rationale for medical treatments lies in their practical benefits, such as symptom improvement and relapse."
When critics of psychiatry complain about applying "the medical model", they often proffer a subsidiary claim about "medicalizing normality." In both claims, their arguments are deeply problematic and, in my view, largely misguided. I cover these topics in a paper that appeared in 2013, just as DSM-5 was coming out. Interested readers may find it here:
Thank you, Awais, for this lovely and heartfelt analysis. At the risk of being overly simplistic and maybe a bit pessimistic, I'd venture to add that these issues of multiple and competing perspectives on both mental illness and human mental life in general are eternal and unresolvable. I recently learned a great deal from Alva Noe's wonderful book, The Entanglement, where he argues that these issues of multiple perspectives are "aesthetic" dilemmas. They are eternally entangled. Trying to intellectually resolve the perspectives of bio-, psycho-, social- environmental-, familial-, and spiritual- . . . Is difficult, or impossible, because human mental life is never reducible to one, or even two, perspectives. And it is very difficult for most people too hold multiple perspectives without falling into some sort of reductionism. Psychological anthropologist Tanya Luhrmann described it as a human tendency to cling to a life-raft in a stormy sea. The residents I teach can attest to this. The only thing essential is to keep the conversation going and resist the life-raft clinging however we can.
I always appreciate your thoughtful framing of these things!
I have a question: ADHD is still presented by many clinicians, as well as by the larger community of diagnosed activists, as always having a neurodevelopmental etiology, which seems to imply the symptoms can be managed, but the overall basis of the problem cannot be cured. This is why (I think) people who are diagnosed with ADhD are opting to use first person language “ADHDers” — to signify these attention issues are immutable traits that can’t be reversed.
When you say that ADHD is heterogeneous, is it your opinion that not all manifestations of it are neurodevelopmental? Is what is being captured by the ADHD diagnosis something broader with a more varied etiology?
Thank you for your timely post. And, thank you so much for mentioning me and my 2013 book. If I may toot my horn a bit -- my 2013 book is available as a free, fully-searchable pdf at my substack adhdexplainer
I do think you have done well with your coverage of the issues found in that NYTimes piece. I will be writing an intense critique of that article using a redlined rewording of it. Maybe we can do a dueling shrink thing (smile).
If I could only keep up with the continuing misinformation about relevant aspects of what we currently call ADHD, I would be thrilled. But I can't. So, I am thankful that there are docs like you who are continuing to think deeper and write more accurately about what we currently call ADHD.
I should add that I am introducing a term ADHD* for the current definition found in the literature. For my purposes, I am using the term "working memory vulnerability" ("WMV"). I am attempting to limit the use of dopamine enhancers to current ADHD diagnosis WITH poor working memory at baseline. The most reliable predictor of who will be helped the most, with the least side effects, is poor working memory, in addition to ADHD*. WM is best tested, in my opinion, by correct reverse digit span testing.
Sensory sensitive ADHD*ers, in my world, require some additional considerations for assessment and assistance (much longer discussion). Sensory sensitivities are not part of poor WM or ADHD*, but can be coexisting as a separate entity in all of our populations, not just in ASD or ADHD*
Thank you for mentioning Barkley's youtube. Barkley has been an ever-present, enduring expert teacher and presenter. In my opinion, he is the closest to my thinking and understanding of ADHD* but was a little "slow" on bringing the powerful variable of working memory into the equation. Although, he has been part of around 85 research publications, I am not sure if he has a track record of actually providing clinical services to individuals, families, etc. I don't want to go into a detailed critique of his message or his work, but I will say this.
He and practically all of the gurus of ADHD do not correctly identify the upside of ADHD (low working memory) and, in my opinion, do a disservice by not delving deeper into the literature in an attempt to discover or dispute my conclusion that the huge upside of ADHD (except when there is coexisting sensory sensitivities) is threat response capabilities. In other words, threat treats WMV by reliably increasing tonic dopamine (short acting, unfortunately). For those with optimal WM (a proxy for tonic dopamine), threat pushes dopamine to above-optimal and that is not such a great thing (longer discussion).
Poor threat response in nonADHDers is the downside of nonADHD. I have been doing an intense dive into ADHD for the last 20 years, both clinically and review of the literature and I am still doing intense reading of the literature to fact-check my conclusions in my 2013 book and update it this year with the title "The Dopamine Dilemma of ADHD*" So far, it has stood the test of time and of aggressive peer review.
I have written about stimulants here at substack in response to other posts. However, since I am new to substack, I think I replied in ways that did not appear where I thought they should. I hope you will excuse me for adding one of those responses here.
*************************
From earlier reply re "stimulants."
As you may have noticed in my earlier notes, the term "stimulant" is tantamount to calling ibuprofen "kidney damage pills." Stim is a side effect of above optimal or incorrect dopamine enhancement, not a desired effect. Calling it stim is bad science and should be ditched for "dopamine enhancers," or "Da/Ne enhancers" (dopamine norepinephrine) or NE enhancers.
Not only is it bad science but it is great advertising. Who wouldn't like a stim for stim? Using it for stim, a side effect of too much dopamine or no real need for enhancement seems so much more "attractive" than what it is really is. Kinda of dull to call it what it is -- dopamine enhancer. Also, stim was a class of drugs that was named that way because the scientists had no idea of what it was actually doing. Now the legacy keeps staying alive, somehow, to the disadvantage of those who are actually using a dopamine enhancer for anything but stim.
In my book I write a lot about using stims if you are in threat related activities, like flying jets, and how that can really mess you up. See the case of the jet pilot who killed a bunch of Canadian soldiers with a 500 pound guided bomb against orders because he could not task switch due to above optimal dopamine generated by his "go-pills." 2002 Tanak Farm Incident, Afganistan. Wikipedia has a pretty good report on it.
Excellent piece. The emotional component of ADHD and stimulants, which you mention, is extremely important and so often overlooked. People often have the idea that problems labeled ADHD exist solely in some purely cognitive domain. It's both illuminating and practical to explore with people how, eg, their focus challenges are related to their feelings (and not just as a downstream consequence).
Thank you for the clarity here, Awais. ADHD is one of the harder conditions to treat because it comes with so much baggage socially and culturally.
Thank you, Awais, for a very clear-eyed and pragmatic take on ADHD, and on the "medical model" in general--a concept widely misunderstood, as you point out. In that regard, I think the core of your article is this:
"Medical conditions do not always have a single, identifiable “cause.” Medical disorders can still be legitimate even if they lack clear physical lesions or biomarkers...Many medical conditions are heterogeneous syndromes, not unitary diseases with essences. Many medical diagnoses exist because of their usefulness in guiding treatment and communication, even if their etiological status is uncertain. Medical disorders need not be categorical in nature; many medical disorders are dimensional. Environment can play a vital role in the vulnerability, causation, and progression of medical disorders. The rationale for medical treatments lies in their practical benefits, such as symptom improvement and relapse."
When critics of psychiatry complain about applying "the medical model", they often proffer a subsidiary claim about "medicalizing normality." In both claims, their arguments are deeply problematic and, in my view, largely misguided. I cover these topics in a paper that appeared in 2013, just as DSM-5 was coming out. Interested readers may find it here:
https://philosophynow.org/issues/99/Does_Psychiatry_Medicalize_Normality
Best regards,
Ron
Ronald W. Pies, MD
My life is way, way simpler and less dangerous when I take methylphenidate
It's as simple as that - people can call it whatever they want, ADHD, mental disorder, lazyness - I couldn't care less
Thank you, Awais, for this lovely and heartfelt analysis. At the risk of being overly simplistic and maybe a bit pessimistic, I'd venture to add that these issues of multiple and competing perspectives on both mental illness and human mental life in general are eternal and unresolvable. I recently learned a great deal from Alva Noe's wonderful book, The Entanglement, where he argues that these issues of multiple perspectives are "aesthetic" dilemmas. They are eternally entangled. Trying to intellectually resolve the perspectives of bio-, psycho-, social- environmental-, familial-, and spiritual- . . . Is difficult, or impossible, because human mental life is never reducible to one, or even two, perspectives. And it is very difficult for most people too hold multiple perspectives without falling into some sort of reductionism. Psychological anthropologist Tanya Luhrmann described it as a human tendency to cling to a life-raft in a stormy sea. The residents I teach can attest to this. The only thing essential is to keep the conversation going and resist the life-raft clinging however we can.
Wise words, Steve!
I always appreciate your thoughtful framing of these things!
I have a question: ADHD is still presented by many clinicians, as well as by the larger community of diagnosed activists, as always having a neurodevelopmental etiology, which seems to imply the symptoms can be managed, but the overall basis of the problem cannot be cured. This is why (I think) people who are diagnosed with ADhD are opting to use first person language “ADHDers” — to signify these attention issues are immutable traits that can’t be reversed.
When you say that ADHD is heterogeneous, is it your opinion that not all manifestations of it are neurodevelopmental? Is what is being captured by the ADHD diagnosis something broader with a more varied etiology?
Hi Awais:
Thank you for your timely post. And, thank you so much for mentioning me and my 2013 book. If I may toot my horn a bit -- my 2013 book is available as a free, fully-searchable pdf at my substack adhdexplainer
I do think you have done well with your coverage of the issues found in that NYTimes piece. I will be writing an intense critique of that article using a redlined rewording of it. Maybe we can do a dueling shrink thing (smile).
If I could only keep up with the continuing misinformation about relevant aspects of what we currently call ADHD, I would be thrilled. But I can't. So, I am thankful that there are docs like you who are continuing to think deeper and write more accurately about what we currently call ADHD.
I should add that I am introducing a term ADHD* for the current definition found in the literature. For my purposes, I am using the term "working memory vulnerability" ("WMV"). I am attempting to limit the use of dopamine enhancers to current ADHD diagnosis WITH poor working memory at baseline. The most reliable predictor of who will be helped the most, with the least side effects, is poor working memory, in addition to ADHD*. WM is best tested, in my opinion, by correct reverse digit span testing.
Sensory sensitive ADHD*ers, in my world, require some additional considerations for assessment and assistance (much longer discussion). Sensory sensitivities are not part of poor WM or ADHD*, but can be coexisting as a separate entity in all of our populations, not just in ASD or ADHD*
Thank you for mentioning Barkley's youtube. Barkley has been an ever-present, enduring expert teacher and presenter. In my opinion, he is the closest to my thinking and understanding of ADHD* but was a little "slow" on bringing the powerful variable of working memory into the equation. Although, he has been part of around 85 research publications, I am not sure if he has a track record of actually providing clinical services to individuals, families, etc. I don't want to go into a detailed critique of his message or his work, but I will say this.
He and practically all of the gurus of ADHD do not correctly identify the upside of ADHD (low working memory) and, in my opinion, do a disservice by not delving deeper into the literature in an attempt to discover or dispute my conclusion that the huge upside of ADHD (except when there is coexisting sensory sensitivities) is threat response capabilities. In other words, threat treats WMV by reliably increasing tonic dopamine (short acting, unfortunately). For those with optimal WM (a proxy for tonic dopamine), threat pushes dopamine to above-optimal and that is not such a great thing (longer discussion).
Poor threat response in nonADHDers is the downside of nonADHD. I have been doing an intense dive into ADHD for the last 20 years, both clinically and review of the literature and I am still doing intense reading of the literature to fact-check my conclusions in my 2013 book and update it this year with the title "The Dopamine Dilemma of ADHD*" So far, it has stood the test of time and of aggressive peer review.
I have written about stimulants here at substack in response to other posts. However, since I am new to substack, I think I replied in ways that did not appear where I thought they should. I hope you will excuse me for adding one of those responses here.
*************************
From earlier reply re "stimulants."
As you may have noticed in my earlier notes, the term "stimulant" is tantamount to calling ibuprofen "kidney damage pills." Stim is a side effect of above optimal or incorrect dopamine enhancement, not a desired effect. Calling it stim is bad science and should be ditched for "dopamine enhancers," or "Da/Ne enhancers" (dopamine norepinephrine) or NE enhancers.
Not only is it bad science but it is great advertising. Who wouldn't like a stim for stim? Using it for stim, a side effect of too much dopamine or no real need for enhancement seems so much more "attractive" than what it is really is. Kinda of dull to call it what it is -- dopamine enhancer. Also, stim was a class of drugs that was named that way because the scientists had no idea of what it was actually doing. Now the legacy keeps staying alive, somehow, to the disadvantage of those who are actually using a dopamine enhancer for anything but stim.
In my book I write a lot about using stims if you are in threat related activities, like flying jets, and how that can really mess you up. See the case of the jet pilot who killed a bunch of Canadian soldiers with a 500 pound guided bomb against orders because he could not task switch due to above optimal dopamine generated by his "go-pills." 2002 Tanak Farm Incident, Afganistan. Wikipedia has a pretty good report on it.
Excellent piece. The emotional component of ADHD and stimulants, which you mention, is extremely important and so often overlooked. People often have the idea that problems labeled ADHD exist solely in some purely cognitive domain. It's both illuminating and practical to explore with people how, eg, their focus challenges are related to their feelings (and not just as a downstream consequence).