Are psychiatric disorders overdiagnosed?

[Q_Goest]

There's an interesting editorial in Psychiatric Times that's been reprinted (in part) http://www.medpagetoday.com/Blogs/2...ilyHeadlines&utm_source=mSpoke&userid=212048". I'll repost below for convenience.

It all sounds very logical. For example, I remember one guy I worked with (about 50 years old) telling me he was recently diagnosed with ADD, and had he been a child, he'd have been put on medication. Being an adult, he was not given medication or anything else, and he felt he made it through his childhood just fine without it. In other cases, I've known parents that swear by the benefits of medication given to their kids with ADD (or ADHD).

Do you think psychiatric disorders are overdiagnosed? Are we spending too much time and money on these things? What's been your experience?

"Fads in psychiatric diagnosis come and go and have been with us as long as there has been psychiatry. The fads meet a deeply felt need to explain, or at least to label, what would otherwise be unexplainable human suffering and deviance. In recent years the pace has picked up and false "epidemics" have come in bunches involving an ever-increasing proportion of the population. We are now in the midst of at least 3 such epidemics -- of autism, attention deficit, and childhood bipolar disorder. And unless it comes to its senses, DSM-5 threatens to provoke several more (hypersexuality, binge eating, mixed anxiety depression, minor neurocognitive, and others).

Fads punctuate what has become a basic background of overdiagnosis. Normality is an endangered species. The National Institute of Mental Health estimates that, in any given year, 25 percent of the population (that's almost 60 million people) has a diagnosable mental disorder. A prospective study found that, by age thirty-two, 50 percent of the general population had qualified for an anxiety disorder, 40 percent for depression, and 30 percent for alcohol abuse or dependence. Imagine what the rates will be like by the time these people hit fifty, or sixty-five, or eighty. In this brave new world of psychiatric overdiagnosis, will anyone get through life without a mental disorder?
...
The "epidemics" in psychiatry are caused by changing diagnostic fashions -- the people don't change, the labels do. There are no objective tests in psychiatry -- no X-ray, laboratory, or exam that says definitively that someone does or does not have a mental disorder. What is diagnosed as mental disorder is very sensitive to professional and social contextual forces. Rates of disorder rise easily because mental disorder has such fluid boundaries with normality.
...
The media feeds off and feeds the public interest in mental disorders. This happens in two ways. Periodically, the media becomes obsessed with one or another celebrity whose public meltdown seems related to a real or imagined mental disorder. The mental disorder is then endlessly commented on and dissected by the media. The latest example is the Tiger Woods media frenzy which will likely lead to an "epidemic" of "sexual addiction."
...
There is no objective way to determine what should be the proper rate of mental disorder in the general population. My view is that DSM-IV is almost certainly overinclusive, but I would not recommend tightening the criteria until we have clear evidence this would do more good than harm. The DSM-5 bias to thrust open the diagnostic floodgates is supported only by flimsy evidence that does not come close to warranting its great risks of harmful unintended consequences. It is too bad that there is no advocacy group for normality that could effectively push back against all the forces aligned to expand the reach of mental disorders."

 

[alxm]

Depends on the disorder. ADD/ADHD is a neuropsychiatric disorder, and there's a constantly increasing amount of evidence as to the real, objective neurological causes of it. I don't feel it's a 'fad diagnosis' as much as a quite real thing of which our knowledge has increased rapidly, and where societal attitudes are still trailing scientific knowledge.

You only need to go back a few decades to find a highly similar situation regarding (for instance) dyslexia. Few would be as unenlightened to label a dyslexic child as simply 'stupid' or 'undisciplined' today, but it's apparently fair game to raise the same stupid ideas against ADD/ADHD.

As someone who was diagnosed with ADHD as an adult (and who grew up when it was still quite unknown), I have to say I'm not worried at all about overdiagnosis in that particular case. There's a great asymmetry between the 'false negative' and 'false positive' scenarios. The latter would, in the worst case, result in a kid getting medication which he/she didn't need, and which did not have any significant effect. But the drugs do not have any significant adverse effects. I don't view it as very likely that any of them would continue on the medication for very long, seeing as it shouldn't have any significant positive effects.

The 'false negative' scenario means a kid not being able to concentrate, to do things even though they want to. Failures at studying, an increased school drop-out rate, an increased likelihood of dropping out of society, becoming criminal, ending up with alcohol or other substance-abuse problems. Even in the best of scenarios they will still be met with constantly having to take responsibility for actions that they ultimately can't control, leading to frustration and bad self-esteem, etc. The apparent 'normalcy' of ADD/ADHD is in a way more of a curse than a blessing. Few people would conclude that someone with OCD just 'really likes washing their hands', since there's obviously something 'wrong' with doing it 5 times in a row. But it's a completely normal reaction (subconscious even) to assume not listening to you is a sign of disinterest - which is not the case for someone with ADD.

Similarly, there's likely not much overdiagnosis going on over 'heavy' disorders like schizophrenia or psychosis.

On the other hand, there are disorders such as "sex addiction" which are quite subjective. But I don't really view 'is it overdiagnosed' as a good question to ask. It implies a certain kind of black-and-white thinking, along the lines of "If a disorder is 'real', then there should be some kind of absolute true-or-false way of determining if someone has it, and if someone has it, they are 'sick' and should be treated."

For instance, my back is crooked. I have a very slight scoliosis. So minor, that I have never really had any adverse effects of it at all. Nor received any treatment. Am I 'sick'? Should I have treatment? Of course not - because it's not impeding my quality of life one bit. This is a more useful criteria. If somebody, for instance, is displaying a compulsive, addictive behavior, which they lack control of (or feel they lack control of), and it's having strongly adverse effects on their quality of life - then they need help, whether it's a substance abuse problem, or a gambling addiction or 'sex addiction' or whatever.

Certainly not all of the people who need help have distinct physiological conditions from people without them, so their 'disorder' cannot be objectively defined. And not everyone who has a objectively defined 'disorder' requires help. What matters is that the people who need help are getting help. How you decide to label the 'disorder' in question isn't unimportant, but it's not the most important thing.

 

[nismaratwork]

There is misdiagnosis of major psychotic disorders, such as someone in an acute manic state being diagnosed as schizophrenic, but otherwise alxm covered this completely.

 

[RonL]

As one diagnosed ADD and OCD at a very late time in life, it has been a great relief to know why it was so hard to study and retain things when others did well and it seemed to be easier for them.
I have taken ritalin for long enough to know it has an affect that can be felt, but as alxm stated, there can be the false positive as to how well it works in the long run.

I feel that if at a younger age had it been known what was causing my inability to concentrate or stay focused, things might have been quite different in what was accomplished in my life. My life has been good for the most part, but deep inside I know it could have been so much more.


What is below or above normal should always be carefully observed by those in roles as teachers or instructors, when dealing with young minds in their sphere of influence. Might be just a small bit of special attention, in some simple area that changes a life in a good way and brings out a talent that otherwise goes unused throughout a lifetime.

You might not put everyone on meds, but if someone is just barely getting by they should be looked at closely.

Ron

 

[Evo]

This reminded me of the scam that is going on with parents getting their kids falsely diagnosed with learning disorders in order to get more time to take their SAT tests.

Does Loophole Give Rich Kids More Time on SAT?

Educators Say More Wealthy Students Get Diagnosed With Learning Disabilities to Get More Time on Test

When Ali Hellberg, 19, was in prep school, she said several of her classmates obtained notes from psychologists diagnosing them with learning disabilities, even though they didn't have any learning problems.

They faked learning disabilities to get extra time to take the Scholastic Aptitude Test, or SAT, in the hopes of getting a higher score, she said.

"I had a friend who is a good math student but is no math brain, and she got extended time and got a perfect score on her math SAT," Hellberg said.

That friend now attends an Ivy League school.

http://abcnews.go.com/Nightline/story?id=1787712&page=1

 

[NeoDevin]

I was diagnosed with ADHD as a child, the doctor recommended ritalin. My dad chose not to, and I turned out just fine.

 

[nismaratwork]

I was diagnosed with ADHD as a child, the doctor recommended ritalin. My dad chose not to, and I turned out just fine.

This is a bit misleading; you could have ADHD and "turn out fine" without medication. You could be misdiagnosed as well, but there's no way of knowing based on how your life has panned out. The other element is that diagnosis of ADHD really cannot be made in a cursory exam, but is meant to be diagnosed through about 3-5 hours of (oral/written/observed) neurological testing. You could contract an infection, be recommended antibiotics (which may be the wise choice) and refuse them, but recover completely... does that mean you never had an infection?

 

[skeptic2]

Some instances of ADD may be attributable to the influence of children's television programs. Kids programs attempt to maintain attention by bright colors, rapid dialog, explosive sounds and quickly changing scenes. Even the highly rated PBS Kids does this. After having become accustomed to that type of format, school by comparison is boring. It is difficult for a child to maintain interest in studying math or even reading a book after growing up with kid's programs.

Yes there may be ADD but some of what is attributed to it may be due to the home environment.

 

[nismaratwork]

Some instances of ADD may be attributable to the influence of children's television programs. Kids programs attempt to maintain attention by bright colors, rapid dialog, explosive sounds and quickly changing scenes. Even the highly rated PBS Kids does this. After having become accustomed to that type of format, school by comparison is boring. It is difficult for a child to maintain interest in studying math or even reading a book after growing up with kid's programs.

Yes there may be ADD but some of what is attributed to it may be due to the home environment.

This runs contrary to the neurological basis of ADHD when in confirmed cases... is this a personal opinion or is there a study or two on this that I'm unaware of?

 

[NeoDevin]

This is a bit misleading; you could have ADHD and "turn out fine" without medication. You could be misdiagnosed as well, but there's no way of knowing based on how your life has panned out. The other element is that diagnosis of ADHD really cannot be made in a cursory exam, but is meant to be diagnosed through about 3-5 hours of (oral/written/observed) neurological testing.

It wasn't a cursory exam, it was multiple hour+ visits to a specialist.

 

[nismaratwork]

It wasn't a cursory exam, it was multiple hour+ visits to a specialist.

Then you probably have ADHD and managed to compensate with behavioural and cognitive means. Maybe Ritalin would have been useful, but as you say, you've turned out well so it's a moot point. Untreated, it's not as though ADHD dooms someone unless there is severe hyperactivity and an uncaring environment. Obviously your father cared enough to have you tested extensively, and made a decision regarding medication. That implies a devoted and very present parental figure, which is critical in how one "turns out".

This doesn't mean that you were misdiagnosed, just that you didn't require medication to manage.

 

[skeptic2]

This runs contrary to the neurological basis of ADHD when in confirmed cases... is this a personal opinion or is there a study or two on this that I'm unaware of?

The opinion is that of Jane M. Healy based on a study by Dimitri A. Christakis, MD, MPH, Frederick J. Zimmerman, PhD, David L. DiGiuseppe, MSc, and Carolyn A. McCarty, PhD
http://scholar.google.com/scholar?start=0&q=jane+m.+healy&hl=en&as_sdt=4000

I didn't understand the title question to refer to confirmed cases and I don't believe the average family physician sends the child for a PET scan for his diagnosis. Indeed I understand PET scans are only indicators but not conclusive. Instead I think it much more common for frustrated teachers and administrators to make a case for ADD to the parents who then take their kid to the doctor. Most of the time I suspect the doctor listens to the description of the symptoms and if they sound like ADD, he writes a prescription.

Are there other things that may cause symptoms similar to ADD? The above psychologist believes there are.

 

[skeptic2]

This runs contrary to the neurological basis of ADHD when in confirmed cases... is this a personal opinion or is there a study or two on this that I'm unaware of?

Here is that study.
http://pediatrics.aappublications.org/cgi/content/abstract/113/4/708

The link shows it has been cited 49 times including by JAMA, Journal of Attention Disorders, American Behavioral Scientist, and the Journal of Pediatric Psychology.

 

[Evo]

This doesn't mean that you were misdiagnosed, just that you didn't require medication to manage.

Or missed out on his true potential. I was watching a show on a 10 year old boy that was put on ritalin that went from special ed classes to gifted classes thanks to ritalin.

I believe that way too many children are misdiagnosed, and the medicine can't help a condition that doesn't exist, but those times that they get it right, the medicine makes the difference between night and day.

 

[NeoDevin]

Or missed out on his true potential. I was watching a show on a 10 year old boy that was put on ritalin that went from special ed classes to gifted classes thanks to ritalin.

I believe that way too many children are misdiagnosed, and the medicine can't help a condition that doesn't exist, but those times that they get it right, the medicine makes the difference between night and day.

I was already in the gifted classes...

 

[Evo]

I was already in the gifted classes...

Sounds like you didn't need anything. It only helps children with learning disablities. Why were you even tested?

 

[NeoDevin]

Sounds like you didn't need anything. It only helps children with learning disablities. Why were you even tested?

I was tested before I was in school (when I was 3, I think), based on my behavior in preschool.

 

[nismaratwork]

I was tested before I was in school (when I was 3, I think), based on my behavior in preschool.

Diagnosing a 3 year old is iffy, just plain iffy.

 

[RonL]

Diagnosing a 3 year old is iffy, just plain iffy.

I believe my insurance co. thought the same thing about me at 63, they gave my Dr. a hard time about perscribing Ritalin to someone my age.
Being aware of ADD has helped explain why so many of my odd or irrational decisions or actions were made and I can tell that the medicine helps when I try to do things that involve keeping my mind focused, but the reasons and desires of what I see for my short future are so different than if I was 20 or 30 years old.

I don't think I would have moved into gifted classes or anything, but I have left several businesses just when they started to flourish, I just decided to do something else. As I stated before, my life has been good but I can see a reason why my focus changed in the ways it did.

The part that OCD has played, I hoard things in excess, everything can be used in some way so tossing something in the trash is almost an impossible task, even when I think how sick I am in this area.
These are the things that need long term training and if signs can be picked up early enough that is best, but like alcohalics one needs to acknowledge there is a problem and that their life is being affected in a negative way.
Just my thoughts.

Ron

 

[nismaratwork]

I believe my insurance co. thought the same thing about me at 63, they gave my Dr. a hard time about perscribing Ritalin to someone my age.
Being aware of ADD has helped explain why so many of my odd or irrational decisions or actions were made and I can tell that the medicine helps when I try to do things that involve keeping my mind focused, but the reasons and desires of what I see for my short future are so different than if I was 20 or 30 years old.

I don't think I would have moved into gifted classes or anything, but I have left several businesses just when they started to flourish, I just decided to do something else. As I stated before, my life has been good but I can see a reason why my focus changed in the ways it did.

The part that OCD has played, I hoard things in excess, everything can be used in some way so tossing something in the trash is almost an impossible task, even when I think how sick I am in this area.
These are the things that need long term training and if signs can be picked up early enough that is best, but like alcohalics one needs to acknowledge there is a problem and that their life is being affected in a negative way.
Just my thoughts.

Ron

Well, insurance companies are vicious bastards to the last. You can diagnose a 5 year old child with some high confidence, but 1-3 is a very tough age; you're still dealing with infantile amnesia, and the ability to communicate is limited. Going undiagnosed or partially diagnosed until age 63 doesn't present a problem for the diagnosis, just for people to accept that you've been living with this for years.

ADHD often appears with co-morbidities which include depressive and anxiety disorders (of which OCD is most certainly a member). I was diagnosed with ADD (back when it was just ADD) and took Ritalin for a few years, then the dosage curve became such that I felt the "zombie" effect and went off the medication under doctor's supervision. I have some mild anxiety which I learned to manage with CBT, which is highly effective. To be blunt, my case is mild, with the major co-morbidity being the inability to work with paired-word association, and needing immersion to learn languages other than English.

I think your point about early detection is well made, and my personal and professional experiences bear that out. Early detection allows the use of medication if needed, some minor accommodations by schools if needed, but most importantly it allows for the time to learn positive coping strategies such as making lists, CBT methods, and focus. That said, when ADHD presents with anxiety disorders or other co-morbidities people tend not to "grow out it", and need medication or therapeutic methods to cope.

The problem is that ADHD is not a simple disorder, but seems to be very much what its original name implied "Minimal Brain Damage" which was dropped for sounding pejorative. Imaging makes it clear that the frontal lobe and the rest of the executive system is involved in people with ADHD, and that can range from behavior that is truly out of control, to something relatively mild. People, even doctors often fail to understand this, and the constellation of symptoms which mark this.

As a result you have over-diagnosis in many areas, which leaves those who truly need the help pigeon-holed unless they have the intellectual and monetary resources to find a talented psychiatrist. On the other hand you have children without ADHD being given these powerful amphetamines, which carry a risk of addiction in populations with and without ADHD. Until the disorder is better understood and the diagnosis can be made swiftly and accurately, I'm afraid this state of affairs is to be with us for some time.

I admit, that OCD and GAD-NOS could explain the symptoms you describe; OCD being a terrible burden is by its very nature a drain on the attentional capacity of the sufferer. OCD is also a disorder involving executive functioning, so it may be some measure of overlap, or... who knows. I'm truly glad that you've found that the medication aids you (not a bad sign that it's a good diagnosis), and especially that you don't find that it increases your anxiety. That is another issue, given the handmaidens that anxiety disorders and ADHD often are, the medications for ADHD carry the risk of increased anxiety.