The last 52 years in psychiatry reflect the lack of solid scientific foundation. We need official diagnoses so we can use our insurance for medications. But diagnoses are not the "be all, end all." I tell patients I’d rather not know exactly what the problem is and be able to fix it, than understand it perfectly and be unable to do anything about it.
If you’re struggling more than you think you should be, or more than a lot of people you know – there may be help available to make things easier or enhance your quality of life. You need to find a physician or counselor who treats patients, not just symptoms or diagnoses. Two cases in point – ADHD and bipolar disorder.
A great example is the diagnosis of ADHD – one of the most important disorders in medicine because of the negative consequences to productivity and relationships and the relative ease of highly effective treatment. Ironically, in a recent survey, 15% of primary care physicians felt comfortable diagnosing and treating ADHD – in contrast to 85% anxiety and 95% depression. This lack of comfort and confidence in treating ADHD is undoubtedly related to the higher regulatory controls and requirement for written prescriptions in many states – even though pain meds (esp. hyrdrocodone) and tranquilizers (esp. butalbital, diazepam & alprazolam) are much more likely to be abused according to a recent government-funded study.
I remind patients in the office and doctors when I’m teaching that our diagnostic manual (DSM) was not given to Moses on the mount. We change it every few years. It was published in the 1930’s that hyperactivity and behavioral problems improve through use of stimulants, but the first version DSM I (1952) made no mention of the disorder.
In DSM II (1968) the diagnosis was hyperkinetic disorder of childhood, and concentration problems were thought to be due to hyperactivity. I’m frequently reminded of Yogi Berra’s comment "I wouldn’t have seen it if I hadn’t believed it." Because in 1980 (DSM III), the diagnosis was changed to attention deficit disorder with two subtypes – inattentive and hyperactive. Symptoms of impulsivity were required for both types.
In 1987 DSM IIIR, they flip flopped on panic disorder and said that agoraphobia was caused by panic attacks instead of vice versa in 1980. The diagnosis of ADHD was changed again. They eliminated subtypes and included inattention, hyperactivity, and impulsivity symptoms. You had to have at least 8 of 14, and since there were less than 8 inattentive symptoms, this subtype fell off the radar screen.
Then in 1994 a factor analysis showed there were 2 symptom clusters – inattentive symptoms and hyperactivity/impulsivity symptoms. This is reflected in our current manual DSM IV published that year. So now you can be diagnosed either inattentive, hyperactive/impulsive, or both. Each subtype requires 6 different symptoms before age 7 with significant negative consequences in at least 2 settings.
There are several reasons these criteria are problematic, the main one being that the highest levels of brain function are not fully developed until the very front of the brain is matured – but this doesn’t occur until the early 20’s. Furthermore, scattergram analysis reveals the higher the IQ, the more likely the diagnosis will not be made until early adulthood or even midlife. Fortunately the current manual includes a category ADHD NOS (not otherwise specified) for people with enough symptoms to cause problems in at least one area of their life but not enough to get a full blown diagnosis.
In a few years we’ll have DSM V and all new rules – meanwhile, we’ll make due with what we have.
