Ive been saying this forever. Even with single disorder like ADHD, per the DSM two individuals can be diagnosed whilst sharing only 3 of the 9 symptoms, whichs admits that each of the symptoms can have a cause that is not from ADHD. So if someone has 6 symptoms how do you know theyre not all independently caused? Given a large enough population it's a guarantee
> per the DSM two individuals can be diagnosed whilst sharing only 3 of the 9 symptoms, whichs admits that each of the symptoms can have a cause that is not from ADHD.
To be clear, ADHD, despite having "disorder" in the name, is actually a syndrome: a complex of symptoms that, when recognized together, indicate that a certain set of interventional treatments will likely be applicable.
Diagnosing someone with a syndrome does not indicate any knowledge is available on the cause (etiology) of the symptoms. Many different things can cause the same set of symptoms. But if a certain treatment ameliorates anything qualifying as that syndrome, regardless of the upstream cause, then the diagnosis of the syndrome (and so the existence of the syndrome as a concept) is useful, even if it's not informative.
The DSM actually covers two very different categories of what we might call "mental" illnesses: neurocognitive illnesses, and neuroendocrine (or neurohormonal) illnesses.
Neurocognitive illnesses — structural problems with the brain or its cells (think Parkinson's Disease, or ALS, or Lewy Body dementia) — are usually traceable to specific etiologies, as each one usually has either a very unique presentation of signs and symptoms, or has unique markers that can be assayed/biopsied for.
Neuroendocrine illnesses, on the other hand, are almost always syndromes. Many different upstream problems (genetic, toxic, nutritive, auto-immune, etc) can potentially cause the same small menagerie of messenger-chemicals to get out of whack, and due to this, many different upstream problems end up looking like the same few "templates" of symptoms. If you can put the particular out-of-whack messenger-chemicals back into whack with drugs that do that, then you've fixed the symptoms — which doesn't fix the upstream problem (if it even can be fixed), but does fully compensate downstream for the upstream problem.
If we fully admit that the DSM is merely a tool for treatment, a stastical tool to say "this drug might help the issues youre feeling" fine, however this is not the view Ive commonly seen in phycitatric literature, which points at ADHD being a "real disorder", as something definite one "has". Patients also commonly believe they have a definite disorder, saying things like how they finally "discovered" they have ADHd or even that they might "have undiagnosed ADHD". If we agree that the diagnosis is not informative, thst it is merely putting a name to something one already knows about themselves, do we then agree that this kind of talk is invalid?
If so, and if this view is really prevalent in psychiatry, somehow it's completely lost on the general public and media.
> saying things like how they finally "discovered" they have ADHd or even that they might "have undiagnosed ADHD"
This is not in contradiction to something being syndrome. Plus patients usually do not understand and do not have to understand technical nuts and bolts of whatever issues they have.
You cant require people to talk in clunky language qualifying every single nuance each time they speak about issues or diagnoses they have. You would just render them unable to express what they need to express.
> If so, and if this view is really prevalent in psychiatry, somehow it's completely lost on the general public and media.
General public and media are completely lost on eating disorders, OCD, psychosis and pretty much any other psychiatric/psychological problem. They are equally lost on AI, HIV and economic policy.
I don't think I am being pedantic. There is a monumental difference in how you perceive your condition between "I have some troublesome behaviors which these drugs can sometimes alleviate" and "I have an inherently disordered brain that cannot function properly". Perhaps the HN crowd is different, but the latter fits most people's understanding of what Ive seen
What is the qualitative difference between "having some troublesome behaviors" and "having an inherently disordered brain" in your opinion?
Behaviours are what you do - how you interact with the world. Having disordered brain is about how your brain functions. If I yell at you, it is behavior not am "inherently disordered brain".
If I feel sad all the time, it is not a behavior. It is a feeling. If I am forgetting a lot, it is a brain function too, not a behavior. Behavior can be used to mitigate the disordered brain, it can be result of it, it can be completely intendent of it.
Behavior can be something positive or neutral. Eating is behavior, giving a gift is a behavior.
I understand what behaviours are, but "having troublesome behaviours" implies something kinda systemic right? Something that someone does habitually (otherwise you probably wouldn't seek out medication for it). What is it that causes that habit, and if it is a mental cause, how does that differ from having a "disordered brain"?
Having troubles in your life does not imply something systemic no. The qualitive difference is one a name for a group of symptoms, the other claims to be a cause of those symptoms.
You may be losing things often because your place is a complete mess. You may not keep attention in conversations because you spend all your time playing video games and cant relate to anybody, or because regular people simply bore you and you need to find your own crowd.
These kind of explanations are far different than "My brain is inherently and permanently incapable of 'proper executive function'. and the REASON Im like xyz is because of ADHD". Take a look at /r/ADHD if you get a chance. I saw a top thread that read "Does anyone else have trouble keeping eye contact during sex?" with everyone going "wow me too! I didnt know this was an adhd thing!"
Right, but both ADHD and Autism don't have clear neuromarkers, we diagnose people largely based on their symptoms (or the results of their symptoms). The stuff you describe (being bored by regular people, your place being a complete mess) can have "ordinary" reasons, but can also themselves be symptoms of neural disorders. If you have a bunch of symptoms that you've dealt with for years and that you also (succesfully!) take the same medication for that people with the disorder take, I think it can actually be difficult to clearly delineate what is causing it.
Also your example is kinda dumb! You don't have to have Alzheimers to be forgetful, it's actually quite common. But if you post "anyone else here keep forgetting things?" on r/Alzheimers obviously people on there are going to be like "yeah me too".
I am not sure what your point is. Mine is precisely that there is no clear definition nor diagnostic criteria for ADHD, and that merely having more than an average collection of these otherwise ordinary behaviors, does not automatically constitute a new neurological disorder.
>Also your example is kinda dumb! You don't have to have Alzheimers to be forgetful, it's actually quite common. But if you post "anyone else here keep forgetting things?" on r/Alzheimers obviously people on there are going to be like "yeah me too".
What I was trying to demonstrate is that people DO have the belief that ADHD is a causative thing in itself, and not merely a name for a collection of symptoms used to make treatment easier, as was suggested is the case.
Yes, and it's likely due to low-intensity disorder showing up as something one can control, manage, compensate for, and find a place for oneself in society, but if somehow the dial gets fiddled with, things start to fall apart as we move up the sigmoid curve, positive feedback loops turn negative, and a state sponsored suite soon seems sensible.
In other words people with mental illnesses/conditions/disorders/syndromes doubt their own diagnosis, because sometimes it "just feels like an adorably tiresome behavioral `oh you` that everyone laughs at", and other times the wolves are howling inside and suddenly you understand every and all kinds of disability, escapism, compulsion, and serial killers, as you are trying to cancel plans, make up excuses, ask for help, while - by definition - fail to do any and all of those as a headwind of hurt hurls heavy and hopeless.
I think you should re-read the parent comment, and try to read what is written instead of what you are looking to read.
First and foremost, DSM is a classification tool. It is to set up the jargon and coding of the disorders
I wish this were more common knowlegdge. Every time I see someone whether ADHD "exists" I think to myself "Dude, we decided that certain traits falling in a certain range on a spectrum warrant their own category because it might facilitate research and treatment. Whether it's real or not isn't even a question."
I just want to know whether my issues are normal and I'm gaslighting myself into thinking I'm broken or a loser, or if my specific issues are actually falling outside the norm. This way I know what treatment modalities might help, and which literature I can peruse instead of wasting my time reading up productivity advice meant for neurotypical people that will try to solve the wrong issue for me and just make me feel worse.
Slate Star Codex' take on Adderall (and ADHD) is a good read: https://slatestarcodex.com/2017/12/28/adderall-risks-much-mo...
In short: no-one "has" ADHD. We just decided that people on the lower end of the spectrum in the "ability to concentrate" trait deserve a bit of a boost from otherwise illegal drugs to function in the society. Being in this lower end is called "having ADHD".
I'm a bit wary about arguing with a psychiatrist, especially if it is Scott Alexander, but ADHD is clearly not just "low ability to concentrate". It is hard to explain to normal people without phrases like "executive function paralysis" but it is a severe illness, and not some variation of a norm.
I would also challenge his premise about boring monotonous work is ill suited for humans, hence the ones with ADHD are people who can't do it (as good as others). ADHD people can do boring monotonous work for hours, month after month, and often not even struggle with that. On the other hand some banal easy (and short!) tasks, which won't even register as a task for normal human, will leave ADHD person in shambles, unable to even think about it.
There is lots of bad shit going in on the ADHD brain, it is certainly not just "20% worse concentration" debuff.
There’s no such thing as advice for “neurotypical” people.
There’s advice for people.
Sometimes it will help you, and sometimes it won’t.
Regardless of the number of people it helped and didn’t help, and what labels apply to them.
As someone taking adhd meds, I think you’re missing this person’s bigger point.
You can be stuck for decades, as I was, taking advice that won’t work for you, until you figure out that you can get a medical solution that instantly enables all of those pieces of advice becoming usable.
It is not a coincidence that those pieces of advice weren’t working, they were never going to work unless preceded by medical help.
Many people pre diagnosis suffer the equivalent of taking years of running advice and wondering why the stay behind before noticing they’re missing a leg and it won’t work until they get prosthetics.
If it’s not optimal, it’s useless, isn’t it? You can’t run as fast as the others, so why bother running at all? You just can’t do it. None of the advice about running will ever apply to you unless you can afford a prosthetic that works with your ailment that you can wear all the time.
That’s not true, of course. You are not relegated to a category of defunct by simply existing without a leg. You can learn to get by without it — many do — and you can learn to excel without it.
When you exclude yourself based on blankets of labels, you miss good advice. Much advice about “running” has little to do with having 2 legs: Breathing, clothing, hydration, nutrition, time of day. Pacing advice can even apply when you run with an implement.
For some people this is their entire reality, having to fight against categorizations that split them into complete ability and disability.
For some others, they don’t even know there’s a fight to be had. They give up before knowing they had any chance at all.
It’s troubling for something like ADHD, where a constellation of symptoms are possible and some do not apply to you personally.
You can’t read because you have ADHD? It may be true. It may also be true that you have been forced to read things you’re not interested in, something rendered practically impossible by this disorder, and someone has labeled you as a non-reader due to your differences. It may also be true that you haven’t discovered Terry Pratchett, and you’re actually quite the reader with the right material.
For some even more others, they feel able with their medication and useless without. Luckily for them, their medication lasts all day, medication shortages do not exist, and their psychiatrist will always prescribe their medications forever.
>For some even more others, they feel able with their medication and useless without. Luckily for them, their medication lasts all day, medication shortages do not exist, and their psychiatrist will always prescribe their medications forever.
The sarcasm there is unwarranted. Need for a treatment, when it exists, is orthogonal to its convenience. If you need an organ transplant to live, you need it regardless of whether you have donors and hospitals available or whether the lifelong meds they require can run dry at some point.
As for your larger point, to be clear, I understand the idea you’re trying to convey. Diagnoses can be limiting for some people either internally (limiting self perception) or by external judgement.
I don’t deny that, what I’m saying is that I feel you’re (probably unintentionally) falling into a different extreme that is just as damaging to others, which is to deny the need or convenience of treatment for those for which _there is no successful alternative_.
Shutting down a person through a label is harmful, dismissing their limitations because that would be labelling is harmful as well.
For the point of advice, advice can and will be harmful when it assumes realities that don’t apply to you.
To leave the analogy aside and give actual examples, methods to keep organization and accountability like checkboxes or diaries will not only be failed tries to those who need meds, but also reinforce a feeling of inadequacy as the user now feels lacking in discipline to commit to the method. Lack of self steem and negative self perception (lazy, messy, uncaring, etc) is a way too common comorbility with ADHD for a reason.
Also if its just meant to serve as a stastical tool, isnt manually making up these classifications complety outdated? Why not just feed people's data into a machine and find statsical corrolations for what helps?
> diagnosed whilst sharing only 3 of the 9 symptoms, whichs admits that each of the symptoms can have a cause that is not from ADHD
It does not logically follow that different symptoms -> different causes.
(Fire can cause smoke, heat, soot, etc. Depending on the wind and other conditions, only some of them may be observable.)
One root cause can manifest in different ways depending on interactions with other factors.
The genetic basis for ADHD is well studied and points to a single set of core causes.
I have symptoms 1-6, you have symptoms 4-9. We only share 4,5,6. Or I have 1,3,5,6,7,8, you have 2,4,6,7,8,9.
Surely then, each of the symptoms (precieved, subjective symptoms) at that, can exist without ADHD.
So my question is, how do you know I simply dont have multiple completely independent things that together present the 6 symptoms? Even if we are to agree its a genetic condition, the diagnosis of sny particular individual isnt based on genes so theres room for criticism of the diagnostic process
We don't know, but epidemiological data hints at which one is more likely.
ADHD diagnosis requires "onset" before age 14, yet there is such a thing as acquired ADHD (due to brain damage).
And of course the genes don't change during the latter, nor did they change when the age of onset criteria was raised from 12.
And even though both autism and ADHD was described more than a 100 (and 200) years ago it took a long time for AuDHD to be noticed. (2013)
The maps we have are bad, the territory is treacherous, and even if we assume the genes are unchanging the environment they find themselves in does seemingly faster and faster.
That's where the math ends and clinical diagnosis starts because those number games take you only so far. Furthermore, ADHD is classified into different subtypes so it was never a question of meeting all 9 but only the subset relevant for your own subtype. It's also not diagnosed by ticking of the trait list from the DSM with your doctor but by using recognized clinical questionnaires.
The personal questionnaires, aside from the fact that they're ridiculously easy to game and hardly ever throughly verified, are pointed to answer the crtieria defined by the DSM.
If the DSM isnt what defines ADHD, what is?
The DSM is an international expert collection of acknowledged diseases - it just answers briefly the "what is this?" question, nothing more while the medical societies in your respective country implement the actual guidelines on how to diagnose and treat the diseases by using the recent scientific conclusions. So a MD isn't using the DSM to diagnose and treat you - this is a common misconception.
Yes I understand that. My point is all these guidelines and their implementations are based on the definitions of the DSM.
The shallowly buried truth here is that ADHD, CFS, and other common conditions are not standalone random diseases,
but diagnostic names for groupings of common symptoms,
caused by seemingly completely unrelated stuff ranging from childhood trauma, to a staph infection or mercury leak in a tooth root.
I don't think ADHD in particular is caused by unrelated stuff. The heritability findings are pretty strong.
> A study of 894 ADHD probands and 1135 of their siblings aged 5–17 years old found a ninefold increased risk of ADHD in siblings of ADHD probands compared with siblings of controls [2]. Adoption studies suggest that the familial factors of ADHD are attributable to genetic factors rather than shared environmental factors [3, 4] with the most recent one reporting rates of ADHD to be greater among biological relatives of non-adopted ADHD children than adoptive relatives of adopted ADHD children. The adoptive relatives had a risk for ADHD like the risk in relatives of control children [4].
> Twin studies rely on the difference between the within-pair similarities of monozygotic (MZ) twin pairs, who are genetically identical, and dizygotic (DZ) twin pairs, who share, on average, 50% of their segregating genes. The mean heritability across 37 twin studies of ADHD or measures of inattentiveness and hyperactivity is 74% (Fig. 1). A similar heritability estimate of around 80% was seen in a study of MZ and DZ twins, full siblings, and maternal and paternal half-siblings [5]. The heritability is similar in males and females and for the inattentive and hyperactive-impulsive components of ADHD [6,7,8].
https://www.nature.com/articles/s41380-018-0070-0
"ADHD has been clearly linked with numerous environmental risk factors, particularly around the prenatal and perinatal period. Some of the most robust risk factors identified are maternal prenatal health conditions and psychological distress (e.g. hypertension, obesity, pre-eclampsia, immune activation), in utero exposure to poor diet (with critical factors still being determined), teratogenic effects of certain medications (e.g. acetaminophen) and environmental exposures (e.g. lead), as well as neonatal factors such as prematurity and low birth weight [27]. Other extreme exposures in the postnatal environment (such as extreme infant emotional neglect) have also been associated with an ADHD syndrome [28, 29]."
Cecil, C. A. M., & Nigg, J. T. (2022). Epigenetics and ADHD: Reflections on Current Knowledge, Research Priorities and Translational Potential. Molecular diagnosis & therapy, 26(6), 581–606. https://doi.org/10.1007/s40291-022-00609-y
"The convincing evidence for genes as risk factors for ADHD does not exclude the environment as a source of etiology. The fact that twin estimates of heritability are less than 100% asserts quite strongly that environmental factors must be involved. ADHD’s heritability is high, and that estimate encompasses gene by environment interaction. Thus, it is possible that such interactions will account for much of ADHD’s etiology. Environmental risk factors likely work through epigenetic mechanisms, which have barely been studied in ADHD [148]. The importance of the environment can also be seen in the fact that, as for other complex genetic disorders, much of ADHD’s heritability is explained by SNPs in regulatory regions rather than coding regions [149]."
Faraone, S. V., & Larsson, H. (2019). Genetics of attention deficit hyperactivity disorder. Molecular psychiatry, 24(4), 562–575. https://doi.org/10.1038/s41380-018-0070-0
Isnt this explained simply by families who are aware of, willing, capable of disgnosing their children are more likely to tske another child to a diagnosis vs a random child?
Granted they did have a control for adopted siblings
Twin studies are explicitly about scrolling for this kind of family bias.
"twin studies fail to separate the effects of genes and the prenatal environment. This failure casts doubt on claims of the relative effects of genes and environment on intelligence, psychiatric disorders, personality and other psychological variables, and other conditions."
https://www.psychologytoday.com/gb/blog/looking-in-the-cultu...
"Although many twin studies have been conducted (which is quite an understatement; there are almost 9,000 hits for “twin study” on PubMed!), there have long been critics who argue that they are scientifically worthless."
Smith, Jinkinson. (2020). The debate over twin studies: an overview. http://dx.doi.org/10.22541/au.159674847.78026661
"Because heritability is defined by both genetic and environmental influences, it is not a fixed characteristic of a disease or trait, but a population-specific estimate, analogous to, for example, the mean height, cholesterol level or life expectancy in a population. It also cannot be interpretated at the family or individual level."
Kaprio J. (2012). Twins and the mystery of missing heritability: the contribution of gene-environment interactions. Journal of internal medicine, 272(5), 440–448. https://doi.org/10.1111/j.1365-2796.2012.02587.x
(How) did they control for parental influence vs. genetic heritability? I grew up with a pathologically anxious mother. I still remember having to counteract her behaviour to avoid it leaking into my world, before I managed to move out. She is still a trigger for me, 30 years later. I can only stand having her around me for at max. 2 hours, then my vessel is full. IMO, I am not convinced that a sibling study rules out environmental influences.
They had a control for adoptive siblings. The critic in me says, ok what was their age of adoption, do parents perhaps treat adopted children differently, do adopted children perhaps grow behaviors unindicative of ADHD, does the knowledge that its genetic influence the diagnoses themself?
The age of adoption seems crucial to rule out early childhood trauma induced by the parents. I actually know mine, although it took me 35 years to get my mother to admit what happened. My point, I am very skeptical when it comes to parents reflecting on the bad influences they might have had on the development of their child. After all, bad parenting has a pretty harsh stigma in society (and it should!)
Yes but if the SAME behaviour emerges regardless of parenting style then that is significant
The twin studies would largely control for that.
"twin studies fail to separate the effects of genes and the prenatal environment. This failure casts doubt on claims of the relative effects of genes and environment on intelligence, psychiatric disorders, personality and other psychological variables, and other conditions."
https://www.psychologytoday.com/gb/blog/looking-in-the-cultu...
"Although many twin studies have been conducted (which is quite an understatement; there are almost 9,000 hits for “twin study” on PubMed!), there have long been critics who argue that they are scientifically worthless."
Smith, Jinkinson. (2020). The debate over twin studies: an overview. http://dx.doi.org/10.22541/au.159674847.78026661
"Because heritability is defined by both genetic and environmental influences, it is not a fixed characteristic of a disease or trait, but a population-specific estimate, analogous to, for example, the mean height, cholesterol level or life expectancy in a population. It also cannot be interpretated at the family or individual level."
Kaprio J. (2012). Twins and the mystery of missing heritability: the contribution of gene-environment interactions. Journal of internal medicine, 272(5), 440–448. https://doi.org/10.1111/j.1365-2796.2012.02587.x
Ahem, sorry for being slow and/or stupid, but how? Aren't both twins exposed to the same parental style?
In studies of monozygotic twins (shared genetic predisposition), typically the twins were raised in different environments (adoption, etc.). If behavior among the twins is divergent then environmental factors are likely predominant. OTOH if concordance of traits is strongly evident, behavior is attributable to genetic factors.
My understanding is that separating children from their biological parents has wide-reaching consequences, even if done in a non-traumatic way, and even if they are ultimately raised by a different set of parents. I would imagine the trauma originating from having to be adopted could be a uniquely triggering factor for genetic predisposition in the case of only one of the twins. How would twin studies be able to account for that?
I agree. Also, the prenatal environment (9 months of development!) and circumstances of birth, which both twins share, is not accounted for at all. Or rather, it is accounted for as "heritability" by twin studies, which is plainly wrong.
https://williamjbarry.substack.com/p/the-first-1000-days
Not if they’re raised in different families.
That's understood by physicians and is also the reason why they are doing many questionnaire's with you (if they follow diagnostic guidelines) which might seem first confusing to the patient like unrelated to your actual symptoms but it's to rule out many other common diseases.
Unrelated? Theyre so in your face its ridicously easy to get the diagnosis you're looking for
That is why we do differential diagnosis.
Any ADHD diagnosis includes checking for any other mental or physical issue that could explain the symptoms. Any when anything else is ruled out AND it can be established that the person always struggled with those symptoms (ideally that they were present in childhood) will you get a diagnosis.
Furthermore we know that ADHD has a genetic link. You have a 40% chance to have it when your parent has it. While we don't know every detail about how ADHD develops, we know it is something you are born with.
I am so sick that people pretend that ADHD is some vague concept. No, it is vague for you because you are ignorant about it.
Yes, ADHD can show up very differently in people. Which is not surprising because people happen to be different. Covid-19 can have widely different symptoms between people, doesn't mean it is not real.
As an ADHD person when I interact with other with ADHD people, yes there are huge differences but there is always a shared understanding. I never have the feeling the person has a completely different thing. There is always shared understanding.