Episode 10: The invalidity of "Adult ADD"

Hello, this is Dr. Nasir Ghaami, and you're listening to the Ghaami Psychiatry Podcast, Scientific, Humanistic, and Not the Conventional Wisdom. Hello, this is Dr. Nasir Ghaami, and welcome to my podcast. On this podcast, I'd like to talk about adult ADD, adult attention deficit disorder. What I'd like to discuss with you is to what extent it is a legitimate diagnosis in the sense that it reflects something real as opposed to a misinterpretation of real problems that really reflects something else. So, let's begin with what adult ADD means. Let's just simplify it. It basically means distractibility. You notice that I drop the H of so-called ADHD hyperactivity, which I don't believe happens in children anyway as a relation to true, possible ADD, but really reflects mania and other conditions that are the only conditions that cause hyperactivity. But even the supporters of ADD admit that it doesn't happen in adults and that you're really dealing with just the cognitive symptoms, which involve distractibility and executive dysfunction. So, really, we're talking about someone who's disorganized, has relatively poor working memory, meaning remembering things as they're going along, and is distractible and gets started on things and can't finish them up. Now, if you're an adult and you have these cognitive symptoms, let's call it, that doesn't mean you have ADD, and this is one of the biggest problems with these self-report scales that people put together that basically list these cognitive symptoms, and then people check them off, and then they say, "Oh, you have ADD," and that's how these companies that are sitting around these startups making millions and billions of dollars from venture capital and from people who see their ads on social media fill out these forms and then get mailed prescriptions for amphetamines, and that's how they function. And that's how they get in trouble with the FDA after they've made a ton of money, though, so I guess it works for them. But it's not a medically-sound way of proceeding, because that would be simply like saying, "Oh, you have shortness of breath. Well, shortness of breath, here are the symptoms. When you go upstairs, you have trouble breathing, and when you cough, you know, you can't catch your breath, and when you run, you have trouble breathing, and so you have shortness of breath syndrome. Congratulations. That's your diagnosis." Instead of doing a medical assessment, working the patient up to see whether you might have heart disease, lung disease, pneumonia, cancer, all kinds of things that can cause shortness of breath. But we don't do that in psychiatry. We say, "Oh, you have trouble with distractibility, therefore you have ADD." That's medically-unsound, scientifically-false. It has no rationale to it in the medical tradition. The reason it's done, though, is because of the DSM system, which basically sets up the diagnosis that way, to list those symptoms and allow people to make the diagnosis. Now it may turn out that they also are floridly manic and have bipolar illness. That's okay. You can diagnose bipolar illness and ADD. That's what the DSM system tells you to do. There is no specific, clear statement in the DSM criteria saying that you should not diagnose ADD if you are currently manic or currently depressed, or currently anxious, which is super common. People get diagnosed with anxiety and ADD, in other words, generalized anxiety disorder and ADD. Then they get a benzodiazepine, which is an addictive drug for the generalized anxiety disorder, so-called, and, again, aphetamine for the ADD, another addictive drug. Of course, the amphetamines cause more anxiety, so they end up on more benzodiazepines, as well. Then, of course, they often will be sad or have depressive symptoms, and they end up on a serotonin reuptake inhibitor for that. ADD, GAD, and ADD is a common trinity of diagnoses, all false, all made at the same time, to mistakenly diagnose the symptoms of distractibility, anxiety, and depression. Just like if you had pneumonia and you got diagnosed with fever syndrome, chill syndrome, and night sweat syndrome instead of pneumonia. We discussed this in a prior podcast about why the DSM system is mostly false scientifically, and it reflects this use of symptoms to jump to a diagnosis of just the symptoms, as opposed to other diagnoses that may cause those symptoms. What are those other diagnoses? Well, anxiety conditions cause distractibility, poor attention, poor concentration, executive dysfunction. So, if you have a lot of anxiety, you will have those cognitive traits. Depression, of course, causes poor concentration, executive dysfunction, and therefore will cause the same traits. Mania, as mentioned, causes distractibility and poor executive function. Psychosis, meaning the presence of delusions or hallucinations, naturally, causes cognitive impairment, especially with executive dysfunction, and often with poor attention. So, when we say someone has these symptoms, that doesn't mean they have ADD as an adult. We need to make sure they don't also have bipolar illness, meaning causing mania and depression. So-called unipolar depression, meaning severe recurrent depression, or anxiety symptoms, which are often caused by those mood states, those mood illnesses. Anxiety is part of bipolar illness. Anxiety is part of unipolar depression. More anxiety states by themselves, which can happen in some people with some conditions like obsessive-compulsive disorder, for instance. Although frequently anxiety is misdiagnosed and overdiagnosed, as I said, as a separate conditions like generalized anxiety disorder, which is another scientifically meaningless and invalid condition, which we have discussed previously as well. Well, what percentage of people with adult ADD, so-called adult ADD, actually have these other conditions? According to some prospective studies, when you look at it, which most studies don't, about one-half of people actually have these other conditions, anxiety or mood conditions in those studies, as opposed to ADD separately. So that cuts out about one-half of the adults who supposedly have adult ADD. According to various studies, the prevalence of adult ADD is supposed to be about 3 percent of the general population. That takes it down to 1.5 percent. What about the 1.5 percent? What about the half that are not diagnosable with severe mood illnesses or severe anxiety states? Well, according to some studies that have been conducted by people who look at this issue of mood temperament, and mood temperament means that you have mild mood symptoms, all the times part of your personality, the mood temperament also is present in a lot of the people who get diagnosed with adult ADD. These are things like dysthymia, which you've probably heard of, which means mild depressive symptoms all the time, or hyperthymia, which is the opposite, mild manic symptoms all the time, or cyclothymia, which is going back and forth between the two. About one-half of people with mood conditions have these mild mood symptoms all the time as part of their personality, as their temperament. A lot of people just have these mood temperaments, and they're often family members of people with mood conditions. When you have depressive symptoms all the time, you're not going to be able to concentrate well. When you have manic symptoms all the time, you're not going to be able to concentrate well. When you're constantly going back and forth between mania and depression, you're not going to be able to concentrate well. You do not have adult ADD. You have cyclothymia, or you have hyperthymia, or you might have dysthymia. Of the half of people who are not diagnosable with full-blown bipolar illness or unipolar depression, a good chunk of them are diagnosable. If anyone attempts to diagnose them, they are diagnosable with hyperthymia or cyclothymia or dysthymia, that is mood temperaments. In research that we conducted, we found that over one half of the patients with adult ADD diagnosis, in fact, were diagnosable with these mood temperaments. Half the patients have straightforward mood illnesses or sometimes anxiety conditions. Another half of the rest have mood temperaments. Now we're down to about a quarter of the patients left to supposedly have adult ADD. Now we're at a fraction of 1% of the general population. Who are those people, and what do they have? One interesting thing is there are prospective studies of children with ADD followed into adulthood. At this point, there are about half a dozen of them. Some of them are as long as 30 years of follow-up, following them into their early 40s, from age 8 or 10. Others more frequently will follow the children into young adulthood, meaning around age 18 to early 20s. What these studies find is that 80% of the children with ADD diagnosed when they were children are no longer diagnosable with it as adults, 80% 8-0. It goes away in 80% of children. This refutes the general belief that ADD persists in everyone. It doesn't. It doesn't even persist in the majority. It doesn't persist in half the people. It goes away in the majority in 80%, and only persists in 20%. And the other interesting thing, though, is that the majority of the people who were diagnosable with ADD in those prospective studies had not been diagnosable with it as children. Now remember, these are prospective studies. So they knew as children they did not have ADD. They were part of the control group that was diagnosed as not having ADD. That group, when they became adults, often was diagnosed with ADD. Of course, that can't happen because you are officially not supposed to diagnose somebody with adult ADD if they didn't have it as a child. It's not supposed to be something that happens newly when you're an adult because it's an illness of childhood. For most people, they retrospectively say, "Oh yeah, I had the ADD symptoms when I was a child. I was never diagnosed. Didn't see doctors. Maybe I was misdiagnosed." Well, in these prospective studies, the researchers carefully assessed these children and said they did not have ADD. So they really didn't have it. And yet as adults, some of them did, which means they really didn't have it because you can't have ADD as an adult if you didn't have it as a child. So what is it? 80% of the adults who were diagnosed with ADD did not have it as children. 80% of the children diagnosed with ADD did not have it as adults. In other words, the majority of the people that were saying have adult ADD don't have it. They don't have it for various reasons. As I said, they have other conditions, most commonly, mood illnesses that are being misdiagnosed as ADD or mood temperaments. Or they just don't have any of that. And they have some cognitive impairment that involves distractibility and poor executive function. Well, let me tell you, that's normal. It is not normal to have lots of good attention. You're not paying good attention to me right now in this podcast. There are times in the last 12 minutes that you weren't paying attention. You got distracted by something. Maybe you're driving and you're paying attention to the cars around you. Maybe you're doing something else, petting your dog, eating. You have to pay attention to swallowing, otherwise you'll choke. If you pay complete attention to me, you'll choke. And that's not good. And that's normal. It's normal to have selective inattention. So attention is like a normal curve. It's like height and weight. It's a normal curve, meaning it's an inverted U curve. And in the middle of that curve, which is where 50% of the population is, we are somewhat attentive and somewhat inattentive all the time. And that's normal. If you go to the extreme of the curve one way, you're attentive all the time. That's not normal. If you go to the extreme the other way, you're inattentive all the time. Well, that's not normal either. But when you're attentive all the time, when you're paying attention to everything, well, that's what happens with people who have obsessive compulsive disorder. They pay too much attention to things. And perhaps it's not surprising that amphetamines, the treatment for ADD, cause OCD. They cause obsessive compulsive disorder. Furthermore, the people that have too much attention are psychotic people. People with delusions and hallucinations. They pay too much attention to certain things. They don't have selective inattention. Again, amphetamines cause psychosis. So perhaps that's not surprising either. So many people who think they have adult ADD just have normal inattention. They're in the curve of attention where they are not always attending to things highly. And that's not abnormal. And the majority of people who think they have adult ADD and actually do have excessive inattention and cognitive problems, in fact, have mood temperaments or mood illnesses or anxiety states that can explain the ADD. The treatment is to treat the mood illness with a mood stabilizer or maybe sometimes an antidepressant or to treat the anxiety state with a benzodiazepine or some other kind of anti-anxiety treatment. But it is not to give the amphetamine, which is a treatment for the symptom and not the cause. And let me just end by saying, of course, amphetamines improve attention. Just like benzodiazepines improve anxiety, they do that in everybody whether you have ADD or not. Amphetamines improve attention in people with schizophrenia. They approve attention in normal controls who have no symptoms of anything. Just like benzodiazepines like Valium and Xanax improve anxiety, whether you have an anxiety illness or not, in normal controls, they improve anxiety. Because again, anxiety is a normal curve and it is normal to have some anxiety. That's why these drugs are abused, amphetamines are abused and benzodiazepines are abused because they affect the normal population. So yes, they improve the attention, but that doesn't mean you have ADD. It's not diagnostic of anything. And furthermore, the improvement is symptomatic and short-term. It doesn't get at the cause and that's why many people have persisting long-term problems because this kind of treatment is not a long-term solution. Thank you for your attention. And if you like this podcast, take a look at our website at psychiatryletter.com where we have webinars and free blog posts and free educational resources so you can read more about this and similar ideas. I'll see you next time. Thanks for listening to this podcast. I hope you liked it and we'll catch you next time. (upbeat music)