That brings me to the recent commentaries about adult ADHD
(1, 2). The first reference (1) doubts that adult ADHD exists for the most part
and sees the diagnosis primarily as the result of a marketing scheme by Eli
Lilly for atomoxetine and ignoring affective temperaments and other states that
may affect attention. Atomoxetine was invented as a norepinephrine reuptake
inhibiting antidepressant and like other members of this class of drugs – it
did not work for depression. Since it is not technically a stimulant it was
tested for ADHD and found to be effective. It is unique relative to other ADHD
medications and not surprisingly it was heavily marketed while on patent. The
patent expired on May 2017. The years on the market patent protected were
2002-2017. The first references to the diagnosis of adult ADHD were noted in
the 1980s. Reference 2 suggests that the diagnosis of ADHD in children in the
US is around 2-3% with adult numbers half that based on the work of one
author. Contrasting numbers of a
lifetime prevalence in adults as 8.1% and surveys estimating current prevalence
at 4.4% are described as “absurdly high” but qualified on methodology (surveys
vs interviews). Some authors have the opinion that books published about adult ADHD like Ratey and Hollowell's Driven to Distraction were a major source of public interest in the diagnosis and instrumental in getting it into the public vernacular.
Before I get started – let me say that the only stake I
have in this argument is making sure that the complexity of the situation is
adequately described. Practically all the pro/con arguments in psychiatry are
gross oversimplifications and based on what I know about the literature – I had
no reason to expect that this was any different. I am already on record on this blog
describing how to diagnose and treat ADHD and not fall into the common problems
of misdiagnosis, prescribing to people with substance use problems, or
prescribing to people who view these medications as performance enhancers. I
have successfully treated adult ADHD with both on and off label medications and
can attest to the fact that it is a valid and treatable diagnosis.
Let me start out by looking at the prevalence estimates.
These figures are very popular in the press to indict diagnosticians in the
United States compared with some European countries and sell more papers. The
problem with prevalence estimate is that the range can vary significantly due
to methodological differences in the surveys. That question was looked at (3)
and the title of that paper asked if ADHD was “an American condition”. The authors reviewed 22 studies based on
DSM-III criteria and 19 studies based on DSM-IV criteria. Twenty prevalence estimates were done on the
US and 30 were done in other countries.
They demonstrated that the range of prevalence across all studies was
approximately the same and that ADHD was not just an American condition. Since
then numerous prevalence studies have been done in other countries – more recently
using DSM-5 criteria showing similar ranges.
On the issue of adult ADHD, a recent review looked at the
issue adult ADHD and symptomatic adult ADHD prevalence by the 6 WHO
regions (4). Their overall
goal was to determine the worldwide prevalence of adult ADHD. They looked at
the issue of persistent or childhood onset ADHD and symptomatic adult ADHD with
no evidence of childhood onset and estimated the prevalence of those two groups
separately. The pooled prevalence of
persistent adult ADHD was 4.6% and for symptomatic ADHD it was 8.83%. These authors also looked at prevalence by a
list of demographic factors, diagnostic criteria, addition to geographic areas
as well as the decreasing prevalence by age groups.
|
Study |
Target Population |
Prevalence % (US vs
Non-US) ranges or pooled |
|
Faraone, et al (2002) |
DSM-III ADHD DSM-III-R ADHD DSM-IV |
(9.1-12.1) vs.
(5.8-11.2) (7.1-12.8) vs.
(3.9-10.9) (11.4-16.1) vs.
(2.4-19.8) |
|
Polanczyk, et al (2007) |
Pooled prevalence
estimates of ADHD by geographic location.
N= number of studies in each WHO designated location |
North American
(N=32) 6% Europe (N=32) 4.5% Oceana (N=6) 4.5% South American (N=9)
12% Asia (N=15) 4% Africa (N=4) 8% Middle East (N=4)
2.5% |
|
Song, et al (2021) |
Pooled estimates and
ranges of Adult ADHD worldwide by WHO designated geographic areas |
North America (N=3)
6.06% Europe (N=10) 7.12% Oceana (N=4) 9.67% South America (N=3)
6.06% Asia (N=1) 25.6% Africa (N=1) 9.17% Middle East (N=2)
16.58% |
This study raises the issue of whether ADHD can be acquired
rather than be a childhood onset illness. The reality is that there are many
paths to acquired attentional deficit that have been treated over the course of
my 35 years in the field. The best
examples are neurodegenerative diseases, strokes, and brain injuries.
Neuropsychiatrists have written about treating the associated cognitive, mood,
and motivational deficits with stimulants.
But a more relevant question is whether mechanisms exist that can result
in people with none of these acquired brain injuries. The answer comes from modern genetics.
Polygenic risk scores (of all diseases) suggest that there are high risk
individuals who show no evidence of an illness as adults. These examples of incomplete
penetrance are usually explained as environmental factors, additional
genetic dynamics such as aging or protective factors. I see no reason why these
factors could not occur in an ADHD genotype after childhood. The other
significant genetic factor is spontaneous mutation or as a recent commentator
put it: “You don’t die with the genome you were born with.” Psychiatry has
focused on familial studies for the past 50 years, but it is likely that
significant numbers of most conditions occur as the result of spontaneous
mutations rather than strictly hereditary transmission. That is borne out in
clinical practice every day.
The authors (1) make the argument that ADHD is not a
“scientifically valid” diagnosis. They explain “these symptoms have not been
shown to be the result of a scientifically valid disease (adult ADHD) and
better explained by more classic and scientifically validated psychiatric
conditions, namely diseases or abnormalities of mood, anxiety, or mood
temperament.” Mood temperament is a
stretch. It is rarely commented on in
adult psychiatry and then in extreme cases.
It is not contained in the DSM. Part of the reason is selection
bias. Psychiatrists are seeing people
who have failed multiple other treatments and I have referred to this as being
the treatment provider of last resort.
Another factor is that ADHD is a quantitative
rather than qualitative disorder – that is the cognitive symptoms are at
the extreme end of normalcy and it is difficult to draw a line to demarcate
illness from normal in many cases. A comparable example from medicine is
hypertension. The cutoff for what is
considered hypertension has varied significantly over the decades (9, 10) and
even now considers antihypertensive side effects as a qualifier for
treatment. That means that for any 2
people with the same marginally elevated blood pressure only one might get
consistently treated. At one point hypertension was considered by some
physicians to be a necessary compensatory mechanism that should not be treated
(10). On the issue of quantitative aspects of psychiatric disorders in general
– dimensional approaches are often suggested as a solution and the question is
whether they work any better than the impairment criteria used in the DSM. That is especially true in a clinical setting
where a patient is presenting with a clear problem that they are asking for
help with
On the issue of validity, studies have been done
demonstrating reliability and validity (8) on both the DSM criteria as well as
various rating scales for adult ADHD that are consistent with the diagnosis. There
have also been detailed discussions of how to approach the problem clinically
(11). Those discussions include how to
differentiate mood disorders from ADHD and how to approach the functional impairment criteria in the clinical interview.
That brings me to the issue of temperaments mentioned in
reference 1. Temperaments have been
researched in various contexts in psychiatry over the past decades. Most psychiatrists of my generation first
heard about them on child psychiatry rotations and the work of Stella and
Chess. In adults, temperaments are more descriptions of hyperthymia,
cyclothymia, and dysthymia and are generally considered in the differential
diagnosis of subclinical mood disorders.
The best example is hyperthymia and it has been referred to both as a
temperament and a personality. Hyperthymic people are generally high energy,
require less sleep, and are social, talkative, and outgoing. They may be very
productive and have increased libido relative to their peers. In clinical
interviews they may say that their friends think they are “bipolar” and need to
be treated. But careful interviewing demonstrates that they lack the symptom
severity and degree of impairment necessary for a diagnosis of bipolar
disorder. Ideally the initial interview
results in that formulation and the psychiatrist can advise the person about
why treatment is not necessary.
Reference 12 looks at the issue of temperaments in a
retrospective controlled study of patients being treated with stimulants who
were referred to a mood disorders clinic.
The authors acknowledge the selection bias in their study design. I can
not think of a better design to pick up misdiagnosed patients than this one. To
cite one example – of the 87 amphetamine treated referrals only 50% had a past
diagnosis of ADHD. The authors acknowledge that there is no standard way to
determine affective temperaments and decide to use the TEMPS-A with a cutoff of
75% of the items. If you are able to find a copy of the TEMPS-A (it is not
easy) – you will find a list of 50 true-false questions like “I’m usually in an
upbeat or cheery mood.” The questions are reminiscent of the Minnesota Multiphasic
Personality Inventory (MMPI) except there are far fewer questions. The scoring
guide suggests that the TEMPS-A can discriminate between hyperthymic,
cyclothymic, dysthymic, and irritable temperaments. It is validated in the
usual ways. The relevant question is
whether any diagnosis made with this checklist would deter you from treating a
comorbid condition - like Adult ADHD? It is one thing to survey a misdiagnosed group with the
TEMPS-A and consider the clinical implications, but another to consider the presenting problem possible ADHD and whether it should be treated.
The arguments in reference 2 about overdiagnosis, the
existence of adult ADHD, and the idea that ADHD can occur in adults without a
childhood diagnosis can be challenged with the facts and references provided here. The fact that we are in the midst of a multigenerational
drug epidemic in an increasingly intoxicant permissive society does not mean that a
diagnosis, treatment, or problem does not exist. It does mean that all
psychiatrists from the moment they enter practice must exercise extreme caution
when prescribing substances that reinforce their own use.
The most likely cause of overdiagnosis is not because adult
ADHD does not exist, not because of drug promotion (most are generic including the
non-stimulant alternatives), or because MDs are careless. There are basically two reasons. First – the difficulty of diagnosing quantitative
conditions. Second – sociocultural factors that exist in the US. Performance
enhancement is built on the myth that you can tune your brain (or any organ) with
supplements, nutrients, or medications to become a superior human being. The reality is you
can alter your conscious state to believe that – but in the case of stimulants
it is unlikely. The only real performance enhancement occurs because you
can stay awake longer to read more and there is some evidence that your
belief system is altered so that you believe you are smarter (14). These are
just two of the reinforcing properties of stimulants that can lead to
accelerated use and addiction.
That is my brief summary of the complexity of this situation.
For more on my approach to adult ADHD (I only treat adults) – see this
post.
George Dawson, MD, DFAPA
References:
1: Ruffalo ML,
Ghaemi N. The making of adult ADHD: the
rapid rise of a novel psychiatric diagnosis.
Psychiatric Times 2023 40(9): 1, 18-19.
2: Frances A. Containing The Adult ADHD Fad — With a
Rejoinder from ChatGPT. 9/21/23.
https://www.psychotherapy.net/blog/title/containing-the-adult-adhd-fad-with-a-rejoinder-from-chatgpt
3: Faraone SV,
Sergeant J, Gillberg C, Biederman J. The worldwide prevalence of ADHD: is it an
American condition? World Psychiatry. 2003 Jun;2(2):104-13. PMID: 16946911 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1525089/
4: Song P, Zha M,
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