This may overstate the point a little bit. But there's a kernel of truth here: if you don't require some degree of significant impairment of functioning, a whole lot of criteria for mental illness would apply to huge swaths of the population. E.g. this is why the diagnostic criteria for ADHD include: "There is clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning."
Wouldn't this just tell us that these categories are completely meaningless?
On the contrary, mental disorders are labels expressely intended to inform and enable treatment of distress. Disorder and treatment are inextricably linked.
This is all according to how the DSM defines things, of course. Others may have opinions on how mental disorders should be defined.
Heaven help you if the effort or circumstance becomes unsustainable, when you could've had years to treat the underlying problem but medicine denied it was a problem.
As for your point w.r.t. circumstances: yes, this seems to be by design. Someome who might be diagnosed with schizophrenia in the US could easily be considered just quirky or even revered as a sort of spiritual guru in other cultures where symptoms have fewer/no negative impacts (and thus do not present so "horribly").
If someone has low occupational functioning, you could call that a disorder. But why would you call it "ADHD"? Why would you call it ADHD for some people and OCD for other people? Suppose you have two lists of symptoms:
Attention Deficit Hyperactivity Disorder
- Patient has an active mind.
- Patient has a crummy job.
Borderline Personality Disorder
- Patient rubs me the wrong way.
- Patient has a crummy job.
What did you learn about the reasons why people with bad jobs (your primary diagnostic criterion, after all!) have bad jobs?
The criteria is essentially ‘you meet these criteria AND it causes clear problems with your ability to live your life’.
It doesn’t mean you have a bad job and X, therefore you have ADHD. Rather, you show ADHD traits and they get in the way (and cause you distress) in doing a job you otherwise would be entirely capable of doing. Or consistently fail (and have distress) on social environments you’d otherwise be perfectly fine in, etc.
If you don’t have a criteria like that, there is no useful criteria at all, since practically all medicine is oriented towards fixing things that aren’t working correctly/causing problems.
It’s the same type of criteria used for evaluating everything from heart disease to stroke to a broken bone. Or in other words ‘if it ain’t broken, then it isn’t broken.’
I'm diagnosed with bipolar disorder. Sometimes I feel axnious and euphoric, other times depressed and lethargic, both at extremes noticably deviant from the average person. This has caused all sorts of turbulence and distress in my personal and academic life. Being diagnosed allowed me access to therapy and prescriptions.
There exist plenty of people who oscillate between distinctively high and low moods, but have never found themselves in serious distress because of it. Thus, they have not been diagnosed with bipolar disorder. Whether or not they "are bipolar" is a subjective question that mainstream psychiatry doesn't seem to have an opinion on.
But it's still a thing. Maybe you can't refer to it as a disorder, but you are hallucinating stuff. It's a set of material facts about your mental state.
Some of Donald Trump's various disorders have objectively rewarded him, generously. But he has those conditions. He doesn't not have narcissism just because his narcissism is good for his bottom line.
I think the issue is that medical criteria are functional- what should doctors do about this. If it's not even bad, they shouldn't do anything! And this gets translated as "nothing is there to treat" but shouldn't be translated as "nothing is there to notice"
Which makes the idea of "bipolar disorder" meaningless. That person demonstrates that your problems are not caused by bipolar disorder. But the disorder is defined by you having problems, even though the problems come from somewhere else.
Your argument seems to hinge on this idea that a good life => no distress, which, if you've interacted with anyone diagnosed with a mental disorder, is obviously not true.
My life is great. If I didn't take a mood stabilizer, it'd probably still be good, but not as good. Regardless, my mood swings can negatively affect me and those around me.
If one day I reach a point where I can live without meds or therapy and reap no negative consequences, then yes, it would be fair at that point to say that I no longer had bipolar disorder.
> That person demonstrates that your problems are not caused by bipolar disorder. But the disorder is defined by you having problems, even though the problems come from somewhere else.
Bingo. My symptoms (mood swings) + my problems ARE the cause my bipolar disorder diagnosis. Until I had problems, I had no disorder.
What causes the mood swings, then? Genetics, upbringing, life experiences, diet, idk. Nobody knows for sure. It's an active area of research, but there is no one known cause. For all we know, there may be five independent and unrelated risk factors that lead to someone developing bipolar disorder.
It's like you get it, but you're still dismissing it for some reason. I'm curious what ulterior point you're trying to make.
In discussing whether they'd need to try to correct this movement via surgery, the doctor very much said "it's a problem if it's a problem". When it fully healed the person had full use of their arm, so the doctor was satisfied with the outcome.
The doctor did also say that different countries had different philosophies on what they expected a healed bone to look like. In their experience Canadians were more likely to be OK with an imperfect solution, but Australians were more likely to want the break healed in a "like new" condition.
And circumstances make this different - a sports star is going to want to do everything to improve performance, whereas an office worker may just want functionality.
My response is, mental illness is something more personal than a broken bone and at present diagnosis needs to be cruder, which does make the categories a bit more "meaningless" but I don't think it gets all the way there.
So, like, take depression for example. I am being slightly unfair but hopefully on-the-nose when I say that DSM defines depression essentially as "you are too sad, too often, and you are not in a situation like mourning a parent or spouse where that level of sadness would be expected." The point is, it's a symptomatic diagnosis.
Other symptomatic diagnoses include “migraine” or “hypertension” or “diabetes” being symptomatic is not necessarily something that excludes meaningfulness, I think we could agree? But it also means that there is a difficulty with treatment. This medicine might work for your migraine but not her migraine; whereas my hypertension is caused by not getting a good night's sleep due to mild apnea and can be cured by a CPAP machine, his hypertension is caused by the fact that he weighs 350 pounds and CPAP therapy will fail.
OK, so like diabetes there is not just one major depression, and maybe some day we will distinguish between "type 1 depression, type 2 depression, gestational depression, predepression" and have specific causes subsumed as different "types" of the symptoms. Maybe not. But the label still has some sort of meaning, just like we can have "migraine medicine" as a group of things worth trying if you have migraines, or like how we can use insulin to handle diabetes in general and so on.
But then combine this with another question which is, "for mental illness, what does cured or managed even look like?" and that's where this occupational functioning criterion starts to look quite reasonable. Because the deal is that if "depression" isn't going to single out a particular cause, the causes of your depression will still likely be around, just like "we have you using insulin" has technically fixed your diabetes (that is, the symptom -- the hypoglycemia) but the cause is still not addressed. That these illnesses take place in the mind makes them harder to quantify. So we need a qualitative criterion, a "how bad is the pain from 1 to 10?", so that we can measure if the intervention is improving things.
Asking questions about your occupational functioning is thus a reasonable qualitative scale to indicate the severity of the symptoms and the success of treatment, even though it says nothing about cause. The different "buckets" of symptoms still make sense as they suggest categories of things-going-wrong and clusters of treatments-for-those-things.
If the success has a lot more ADHD-tendency than the failure, how do we defend the idea that the failure has ADHD, and the success doesn't?
It's just shorthand for "this is something we'd like to fix".
The criteria is more like “but for this tendency, the patient would be/feel better, all else being equal.” A software engineer making $$$ could meet the criteria if their inability to focus keeps costing them promotions, launch their own company, or whatever their goal might be. A neurotypical buggy whip maker who can’t find or hold a job doesn’t qualify, even if he is obviously worse off overall.
You have two people with ADHD-like tendencies. One person feels they have found their own ways to adapt to their ADHD-like tendencies and that they are successful. Another person feels that they have not found ways to adapt to their ADHD-like tendencies and their life could be better if they found ways to adapt.
In this case, the actual magnitude is less important than how individuals adapt.
And it's not like you can just count them or something. It's not like you can say "5.2 distracto-particles is normal, but 5.3 distracto-particles is ADHD".
And traditionally, "too distracted to hold a job" is a common place you might draw the line between "normal" and "ADHD".
So yeah, you might have to draw the line somewhere arbitrary, but that doesn't mean that the thing it's trying to measure doesn't exist. Any line you draw between "short" and "tall" will be arbitrary, but that doesn't mean height doesn't exist.
ADHD is a category of psychiatric diagnosis; psychiatric diagnoses exist to address deficiencies in function. Separating the one from the other, as you perceive, renders it meaningless -- or perhaps, useless. If one happens to have some of the traits of ADHD but it doesn't affect their life negatively, so what?
[1] https://slatestarcodex.com/2014/11/21/the-categories-were-ma...
Because ADHD is a real situation for some people, and for others it's a way to legally take class-B stimulants.
Yes, people really do try their friends' ADHD medication, enjoy it, and then shop around doctors to find someone who will prescribe it. It's called "drug seeking," and doctors do flag patients who do it.
This, BTW, is what happens with medical marijuana. There are people who really need it, there are people who think they need it, and then there are people who who tell everyone but their doctor that it's recreational.
The fact that I have to call someone and get a prescription every month just makes it so that I go untreated for months at a time (kind of a cruel irony that ADHD treatment is gated behind the wherewithal to make a monthly phone call). And honestly I think modern life is probably such that most people could benefit from 10-20 mg of Adderall.
Taken for a short period each morning at a low dose (cut an 8mg patch into sections) it offers similar stimulant effects, but with fewer side-effects. Nicotine patches are reportedly less agitating, less addictive, less expensive, and more available than Adderall. It also measurably improves cognitive ability according to some studies I've read online.
I'm almost 40 years old, and I have ADHD-inattentive. For two weeks I've been using sections of nicotine patches - about 1/4 of an 8mg patch for an hour each morning, and I have never found it more easy to be focused and productive.
Just be careful to not use too much, especially if you've never been a recreational nicotine user. I've had several nights when it's been difficult to sleep -- which has been a signal that I need to decrease the morning dose.
(I'm not a doctor, this is not medical advice)
The couple that referred me to my primary care doctor likes our doctor because it's very quick for them to renew their ADHD prescriptions.
BTW, I once tried 30 mg of Adderall and I felt like I would go crazy if I took it every day. I took it at 6:00 a.m. and I had heart palpitations, euphoria, and crazy insomnia past midnight. It's not really something that's as safe as coffee for the average person.
I was euphoric off the first 15.
In some cases it's really clear, in some others it isn't. A few of my friends did better than me in school, and they had access to Ritalin. They were pretty good student while I was a problem child. I never really explored the option during school as I didn't really know how it worked and what ADHD was. I tried it later in life and it helped with work. Ritalin probably would have helped me during school. But was it because of some "real" ADHD? Was it because it's a stimulant and it helps anyone? Was my ADHD more or less real than them? I know that for them Rilatin and ADHD was a part of their identity, so maybe they convinced themselves they couldn't work without it? I don't think there's any good and objective way to measure that. Should I feel guilt when I take Ritalin now? I can function without it, but they can too. It's just far from optimal.
ADHD meds for non-ADHD students don't really help those students perform better academically. See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3489818/
They make you feel better, but not actually perform notably better.
> These data suggest that when people are given rote-learning tasks their performance is improved by stimulants.
Rote learning was (and still is) one of my big weaknesses. Tools like Anki help but going through them is way easier when I use stimulants. So maybe it depends on the student, but I'm wary of statements like "ADHD meds for non-ADHD students don't really help", it seems more to be pushing an agenda than telling the truth.
Well, yes, and this is how it came to be allowed; the harm from the "preventing recreational use" system was so huge (see yesterday's war on drugs post etc) that it made sense to stop trying to make this distinction. The medical system provides a "fig leaf" which allows the remaining pure-puritans to accept it while at the same time the people who need it for medical use can get it, and nobody has to get their life ruined with jail.
(By "Pure-puritans" I mean those people who are against it because it's recreational, not because of alleged harms or externalities like smoke)
I also think there's a huge grey area of people with chronic pain or unhappiness problems that don't quite reach a diagnosis bucket - or they've not yet learned to speak the words that would get them there, or don't meed the social class critera - whose "drug seeking" behavior might most easily be addressed by just letting them have the drugs. As long as they're not opiates.
Regardless, this idea that one needs to "keep up", as if work were a competitive footrace, is something you have invented.
IANAP, but that sounds correct to me. I recall the DSM requiring negative impact on one's lifestyle as one of the criteria for diagnosis of any mental disorder. And even if I'm misremembering that, that's what psychiatrists look for in practice. They not only query what symptoms you're feeling, but also the impact they have on your day to day life.
Which makes total sense. Treatment of any disorder, especially mental ones, carries a (sometimes significant) risk. It would be unethical to subject someone to that risk for no possible benefit.
Let's take two people, say me and Einstein. Let's say Einstein has super-severe ADHD and thus performs so poorly that he can fairly be compared to me.
Is there really "no possible benefit" to curing that ADHD? Keep in mind that the real Einstein discovered relativity, and uh... I'm just going to say my contributions to science have been a bit less dramatic.
I don't think it's at all unreasonable to posit that there are plenty of people who are gifted enough to compensate for their mental issues, but they'd still benefit if they could fully apply themselves instead of wasting half their talent mitigating such issues.
And there doesn't seem to be a doctor in the world who considers this a problem. "Yep, it goes 0-60 in 27 seconds, just like a chevette should!" "but doc, it's a bugatti". That would be one hell of an incompetent mechanic.
> Psychiatric guidelines are very clear on this point: only give Adderall to people who “genuinely” “have” “ADHD”.
> But “ability to concentrate” is a normally distributed trait, like IQ. We draw a line at some point on the far left of the bell curve and tell the people on the far side that they’ve “got” “the disease” of “ADHD”. This isn’t just me saying this. It’s the neurostructural literature, the the genetics literature, a bunch of other studies, and the the Consensus Conference On ADHD. This doesn’t mean ADHD is “just laziness” or “isn’t biological” – of course it’s biological! Height is biological! But that doesn’t mean the world is divided into two natural categories of “healthy people” and “people who have Height Deficiency Syndrome“. Attention is the same way. Some people really do have poor concentration, they suffer a lot from it, and it’s not their fault. They just don’t form a discrete population.
> Meanwhile, Adderall works for people whether they “have” “ADHD” or not. It may work better for people with ADHD – a lot of them report an almost “magical” effect – but it works at least a little for most people. There is a vast literature trying to disprove this. Its main strategy is to show Adderall doesn’t enhance cognition in healthy people. Fine. But mostly it doesn’t enhance cognition in people with ADHD either. People aren’t using Adderall to get smart, they’re using it to focus.
From: https://slatestarcodex.com/2017/12/28/adderall-risks-much-mo...
You can't say "ADHD is this" and point at a definitive cause, tis just a bag of related symptoms that is geared more towards consistent diagnoses (i.e. you go to five different doctors and they all diagnose the same thing) rather than attachment to a common underlying cause or consistent treatment plan and success phase.
This isn't to say psychology is useless, many people find great help in it... but when it comes down to it, it is scientists (who as a whole have some of the biggest problems in being good at being scientists) trying to describe malfunctions of the highest abstraction on the most complicated class of things known to exist... and just scratching the surface.
The last D is for Disorder... it's a value judgment and the question does need to be asked: if something isn't causing significant problems, is it a disorder? The answer isn't clear cut and people are going to draw the line in the wide grey area in different places.
The solution must be neuroscience continuing to advance to higher levels and replacing the vagueries of psychology with justifiable cause and effect explanations. It is advancing but still a far way off.
There's plenty of existing and on-going research that demonstrates differences in brain structure and development in people clinically diagnosed with ADHD. In other words, ADHD is caused by parts of your brain being underdeveloped or damaged. There is on-going research applying machine learning to MRI brain scans to try to predict ADHD through brain scans rather than only clinical diagnosis.
"Substance use disorder (SUD) is complex a condition in which there is uncontrolled use of a substance despite harmful consequence."
Source: https://www.psychiatry.org/patients-families/addiction/what-...
Most organizations that deal with addiction now operate using a similar definition.
There's a law that governs the treatment of mental illness and basically, it's not against the law to be mentally ill, and as long as you're a not "a danger to self or others" they will have to leave you alone, even if you clearly need help.
This is particularly heartbreaking for many people with some form psychosis, because anosognosia is frequently correlated with it. This is basically an inability to have insight into your own mental illness (sort of like a powerful form of denial).
So there are lots of mentally ill people in california, and they usually end up homeless, or eventually in jail.
one can speculate why addiction hasn't been selected out - may be because it probably provides significant advantage when channeled right. Some achievements/mastery/etc. require tremendous focus and huge amount of persistent work which probably may be not doable on rational motivation alone, without the primal dopamine [over]drive.
are all acronyms, right?
Those same doctors are probably perfectly fine with handing out methadone prescriptions to addicts.
The other guests were various degrees of horrified.
His patients went from literally living on the street as heroin addicts to doing 3 hour gym sessions and holding down a job; and his peers thought he shouldn't be allowed to practice.
Recently I was reading a book on ADHD and the author was quite adamant that you could only be diagnosed with ADHD if your life was worse than "the norm". In this view, if you have symptoms of ADHD but can, for instance, hold down a good job then by definition you don't have ADHD. I deleted the book from my Audible account.