ADHD: een ziekte of een categoriefout?juli 30, 2019
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Jonathan Shedler’s article clears up widespread misunderstanding about psychiatric diagnoses. Psychiatric diagnoses, as I have argued before, do not name medical diseases. As Shedler points out, psychiatric diagnoses are merely a common language for clinical communication or, more often, miscommunication.
For example, a parent brings her 5-year-old son to me because their pediatrician and school counselor say the boy “has ADHD.” He doesn’t focus on his schoolwork, he forgets to turn in his homework and he speaks out of turn in class. He also won’t listen to his parents at home and sometimes hits his mother. I tell the mother, “I need to see you and your husband to get a history of your son’s experience and discover why he is behaving this way.”
The mother looks at me incredulously and says, “He is behaving this way because he has ADHD.” I then explain that ADHD is simply a list of symptoms that may be caused by any number of stressful factors in the boy’s environment. I will go about treating him by looking for the stress in his life. Is he too young for his Kindergarten classroom? Has he suffered trauma? Are his parents arguing in front of him? Does he not have enough physical exercise as an outlet for his normal childhood energy? Has one of his parents had a serious illness or lost a job? Has the family lost their home? These are some typical causes of behaviors that are labeled as ADHD.
If we speak of generalized anxiety disorder and major depressive disorder as if they are equivalent to pneumonia or diabetes, we are committing a category error.
How did this misunderstanding or “doublethink,” perpetuated in medical schools and psychiatry residencies, get started? Here is a story from my own experience. One rainy evening in the early 1990s, I attended a talk by a psychiatrist in a large lecture hall at the University of California at Berkeley. I attended the lecture because in my practice I was beginning to see more and more children diagnosed with ADHD.
I will always remember this talk as the “Ritalin Is Forever” talk. The professor said that a child diagnosed with ADHD would need to take a stimulant medication like Ritalin not only in his school years but for his entire life. The doctor compared ADHD to diabetes, and psychostimulant drugs to insulin.
I was stunned, especially since he presented no scientific evidence to support this comparison. The psychiatrist was creating a new narrative that would sell more psychostimulant drugs to children. He was also making a category error. Diabetes is a disease about which there is no dispute. All medical doctors would agree that a person has Type 1 diabetes because his pancreas is not producing insulin. Medical disorders are defined by their causes, not by their symptoms.
Was the Berkeley lecturer’s narrative paving the way for pharma to sell more drugs for children? Or was the narrative meant to raise psychiatrists to the status of medical doctors because now psychiatrists could say that they treat real diseases and prescribe medication like other medical doctors? As history has shown both of these explanations are correct.
A recent study, “Heterogeneity in psychiatric diagnostic classification,” published in the journal Psychiatry Research, reaches a similar conclusion about psychiatric diagnoses. Here are the highlights of the study’s findings:
1. The theory and practice of diagnostic assessment are central yet contentious in psychiatry.
2. DSM-5 contains heterogeneous diagnostic categories. (That is, there is an overlap between diagnoses and no universal agreement about which diagnosis should be applied.)
3. Pragmatic criteria give clinical flexibility but undermine the diagnostic model.
4. Trauma has a limited causal role in DSM-5, despite research evidence to the contrary.
The authors of the study conclude that: “a pragmatic approach to psychiatric assessment, allowing for recognition of individual experience, may therefore be a more effective way of understanding distress than maintaining commitment to a disingenuous categorical system.”
In short, looking for causes in a person’s lived experience—especially traumatic experiences—is a more effective way of helping ease mental distress than labeling the person with diagnostic categories and giving them medication for their “disorder.”
With children labeled with ADHD, or anxiety disorder, or ASD, or ODD, or any number of other so-called “disorders,” finding the cause of the behaviors in the child’s lived experience and listening carefully to the child’s story are the most effective way of resolving the symptoms.