Adult ADD – Going Beyond The DSM

The DSM is the Diagnostic and Statistical Manual of the American Psychiatric Association – and it the manual used to diagnose psychiatric disorders – including ADD and ADHD.
The DSM criteria used to diagnose ADHD were developed with children as the focus. The criteria have been criticized in how poorly they help in the assessment and diagnosis of adult ADHD (or ADD).

Here is an article from the American Journal of Psychiatry which documents this issue in depth.

This article begins by summarizing the history of the diagnosis of ADHD.
It then criticizes the limitations of the diagnostic criteria for adults with ADHD.
One of the examples cited is the age of onset criteria – i.e. having to have symptoms before the age of 7 is often limiting. It is problematic, because it is often hard to establish this early history in an older adult. New research is showing that the age of onset is also too restrictive (this paper cites two new research papers which challenge this criterion).
Another criticism is that the description of impairment is done from the perspective of childhood ADHD and is not appropriate for the impairment that adults with ADHD experience.
Furthermore, the diagnostic threshold (i.e. 6 out of 9 symptoms) doesn’t reflect several lines of research which document that adults with fewer symptoms are still quite impaired from their ADHD.

The DSM-V is due out in 2011. Many researchers are working to improve the DSM criteria for adult ADD/ADHD. This is particulary needed because many doctors are not comfortable with the diagnosis of adult ADHD, and they need to have diagnostic criteria which will help them to diagnose this condition more easily. Also, new research has shown that 4.4% of american adults have ADD/ADHD. So there is a lot of need out there, and ‘new and improved’ DSM criteria are needed.

Please share your thoughts and comments below.

Dr. Kenny

[tags] Adult ADD, Adult ADHD, DSM, Diagnosis [/tags]

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Comments

  1. Too much medicine is based on innovative diagnosis prompted by marketing efforts of the pharmaceutical industry.

    Financial conflicts of interests make for bad medicine.

    Check out this article from the French national newspaper Le Monde about selling drugs to the “Worried Well”

    http://mondediplo.com/2006/05/16bigpharma

    For the more scientifically oriented, we have a whole collection of papers from a conference on disease mongering. (i.e., pushing diseases for fun and profit)

    http://collections.plos.org/plosmedicine/diseasemongering-2006.php

    All of which contributes greatly to my skepticism about proposed treatments for ADD/ADHD

  2. This is a big problem for the doctors who do not understand the mechanism of AD/HD. It all comes right back to the patient since doctors seem to express themselves freely with the patient. It is not particularly hilarious to listen to the negative comments on ADD from the doctor who should help you with your difficulties.

    The requirement of actual memories from somebodies childhood is absurd. It is difficult to believe how it has not been corrected before. It has been known amongst clinical professionals for a long time already that the inattentive subtype doesn’t show so well. The child can appear totally normal to the family and at school but still experiencing many difficulties the adults are not aware of.

    Another thing is the age of onset. In the inattentive cases the behaviors can change as late as in the teen ages. This has been very difficult for doctors to comprehend and many patients have suffered from the narrow way of understanding ADD. Only future tells how widely the misdiagnosis of depression has been has been made to the ADD-adults with later onset w/o lacking knowledge of childhood behavior related to attentional problems.

  3. While the wheels grid slowly, others use what is on the table
    See http://www.racp.edu.au/index.cfm?objectid=6EBAB63E-FFF9-2CED-52102DC3369183AB
    Where a draft Guideline for ADHD in Australia is presented for comment. I feel that the rules of evidence based medicine which constrain this effort may be too constrictive.This does not come to grips with many of the controversial issues facing ADHD today, especially those driven by tabloid journalism relating to so-called over-diagnosis and over-medication

  4. I certainly hope the DSM-V makes strides forward and not stay stagnant or backpaddle. There are so many factions fighting to discredit psychiatry in general and as a result disorders such as ADHD. Thank you Mr. Cruise et. al. I for one will attempt to stay out of fringe religions regardless of the aggravation caused by these attacks. Turn the other cheek as they say.

    I know with a very comfortable (for me at least) margin for error that ADHD exists (in both children and adults) and that I have ADHD. As with most things it’s easy to see the signs looking back. I just wish that the Canada I grew up in (I was 7 in 1974) was more progressive and that I had had the options I do today. I can only imagine what possibilities would have opened up for a focused, controlled me!

    I have to imagine that much of the reluctance of MDs to prescribe meds to ADHDers both young and old comes from the many patients that commit fraud and gain stimulants by pretending to have ADHD (or as heinous as it seems to me – to use one’s own child to do that). But to condemn the truly ADHD for the few who pretend is comparable to withdrawing availability to powerful med tools such as oxycodone or coedine for reasons such as that patients come into MD’s offices and pretend that they have serious chronic injuries like back or neck pain that require those medications. They instead control the release of these meds carefully using monitored prescription methods. Perfect? hardly but what is?

    I wait as patiently as any ADHDer can – 2011 seems awfully far away to me.

  5. Adult ADD – Going Beyond The DSM…

    The DSM is the Diagnostic and Statistical Manual of the American Psychiatric Association and it the manual used to diagnose psychiatric disorders including ADD and ADHD….

  6. Adult ADD – Going Beyond The DSM | ADD ADHD Blog.com…

    The DSM is the Diagnostic and Statistical Manual of the American Psychiatric Association and it the manual used to diagnose psychiatric disorders including ADD and ADHD….

  7. Adult ADD – Going Beyond The DSM | ADD ADHD Blog.com…

    The DSM is the Diagnostic and Statistical Manual of the American Psychiatric Association and it the manual used to diagnose psychiatric disorders including ADD and ADHD….

  8. I was finally diagnosed when I was 30, and tested a few years later, which quantified and supported the diagnosis.

    The doctor that originally diagnosed was actually a family friend, he was my father’s best friend. Because of this, and my father’s very strong feelings against any type of medication, it was not until I went back to this doctor, as an adult, after my father was dead, that the doctor told me that he had believed I had ADHD and that was the actual cause of my difficulties as a child and young adult.

    I went through formal testing after changing doctors and the new doctor wanted more than just someone else’s diagnosis. Fortunately, my mother had saved my report cards from my entire elementary and middle school years and some of the report cards from high school. Even in kindergarten, the teacher made mention of “daydreaming” and teacher comments every year were similar. The grades and testing that established an IQ that was far higher than my grades would expect, also helped to support this.

    I find it extremely frustrating when people say things doubting that ADHD is real or that it is a crutch or excuse and so on. These folks clearly have no clue what they are talking about. I welcome them to walk a mile in my shoes, well I would if I could find my shoes.

    As a child, I was told that I was lazy and I was abused because the adults in my life found me to be frustrating…how about what it is like to be ME! Trust me, it is no picnic! I remember being in 3rd grade and being frustrated that my classmates could manage to be so good, and it was so easy for them, they could get their work done, they always remembered where their supplies were, they always had what they needed when they needed it and it was so easy for them!

    I never even knew the words for what I was feeling! When I was in my 30s and the psychologist was giving me the results of the ADHD testing, at one point he had written a word on the test graph and I could not read his handwriting, “overwhelmed, that was when you were feeling overwhelmed” he told me. I started to cry…that was what I had been feeling, but I never had a word for it, up until that point that feeling meant “failure” or “being bad” and “guilty”. But, those were wrong, I was overwhelmed by a simple task of clicking or not clicking on a mouse when shown a picture of a box that was filled in or not filled in. But, it was not my fault, and I was not being lazy, my brain does not work right and it gets overwhelmed by tasks that some folks find easy.

    Anyway…I am definitely looking forward to a diagnostic criteria that makes sense for adults and hopefully that will help lead to more testing and treatment options for adults who are trying to survive with ADHD.

    Thanks.

  9. When I was in first grade I was playing with two other girls at recess. Until this particular day, I had been the model “good girl,” shy, always working hard to do as I was told. Never in trouble. Never really noticed, I’m guessing.

    But in an early lesson on the concept of time (it doesn’t stop when you get absorbed in something), I suddenly realized the other two girls were running at full speed back to the classroom and the playground was empty. We breathlessly ran into class, with everyone staring. Mrs. Heron believed in shaming young children to teach them lessons. Clearly we were in trouble, but I wasn’t sure why. Mrs. Heron told us that we had been very bad by ignoring the rule of never being late. It hadn’t even occurred to me to think about time. We were just playing. I was deeply embarrassed. To ensure the depth of that shame, the elderly teacher made the three of us stand in front of the room, in front of the blackboard while she drew rabbit ears above our heads. The other children laughed and laughed, while a seed of self hate was planted in my chest. The teacher surely was not wrong. I knew I had done something very wrong and very stupid.

    That seed of self hate has grown over the years. It turned into depression, that I fought as a teenager with drugs and alcohol to ease it’s firm grip within my chest. My parents never learned of the rabbit ears. They did learn and become deeply disappointed by my average grades, occasional lying about my whereabouts, and seeming lack of ambition. They both had their Phds (despite their own incredible lack of household organization — which, as the oldest — I was charged with attempting to maintain [and actually did, because it was clear & tangible stuff -- liking creating a schedule for me and my siblings to take turns with chores]}.

    That core of self hate still managed to grow, even after finding an outlet for my passion with language and politics. I achieved amazing things (brief, intense, deadline-driven work is good for those of us w/add!) My parents seemed to think I was ok during that time. But it came to an end and I’ve struggled along with my passions as motivation (which doesn’t pay as well as financial motives). So I ‘ve been broke a lot, needed financial help a lot. And naturally, been mildly to extremely depressed a lot.

    When I met someone in the mid 90s who told me about ADD, and the books by Hallowell and others, I ran to my doctor, who quickly and unequivocally, diagnosed me, I felt enormous relief. Most interesting to me was my concept of time. The first time I took a tablet of methylphenidate I felt nothing unusual. I went to work as usual (in my home office), got absorbed into something, and some time later gasped and looked at clock, expecting that once again I’d lost several hours and missed an appointment. Nope. Only 20 minutes had passed! Wow. I could work (or play, or learn, or converse) and the rest of my brain was still working enough to let me know that time was passing. I’ve learned, slowly, how to bring some discipline into my life and say, ‘that’s enough,’ and finished, and move on to the next project.

    In 2003 I entered grad school. I finished in 2 years with a double major and a 3.9. I still don’t make much money, but I realize now, that is not the primary indicator of someone’s worth or capability.

    I moved to a different state 1 and ½ years ago. It’s a much smaller town and doctors here are scared to death to prescribe stimulants, especially, to adults!!! I have been humiliated, shamed, and infuriated by the insensitive, ignorant, labels that have been thrown my way. I have been accused of being an addict and order into ‘treatment,’ by a psych resident. I stood up and left. He didn’t give me time to tell him that I have been an active member of aa, with 24 years of continuous sobriety. I have always taken my medication with great care. But now I am being denied it, simply because, as one doctor, and one pharmacist told me, “I could lose my license.” What???? Another doctor told me I am too reliant upon my medication (antidepressant and methylphenidate) and should try meditation and yoga instead. I told him, that as a matter of fact, I use prayer and meditation, and have, for 24 years, as part of my program to treat my alcoholism and that it has worked wonderfully. But some conditions, I said, require more. For instance, I doubted he would suggest to an MS patient that they give up their prescriptions in favor of yoga.

    Speaking of prayer, I hope anyone who uses it, might remember me, and ask that I might be blessed with a caring, knowledgeable, specifically informed psychiatrist. I can probably struggle on without the meds, but the disdain, accusations, and lack of compassion will eventually crush me beyond caring. Thank you, doctor, for this site, and helping to educate many, many people. Thanks to those who take the time to share your stories, so we don’t feel so alien and alone.

  10. Friends,

    I just created a petition: Director NIMH: Meaningful NIMH recognition of ADHD as a lifelong disorder, because I care deeply about this very important issue.

    I’m trying to collect 100 signatures, and I could really use your help.

    To read more about what I’m trying to do and to sign my petition, click here:
    http://www.change.org/petitions/director-nimh-meaningful-nimh-recognition-of-adhd-as-a-lifelong-disorder?share_id=ArUbFifAIApe=d2e

    It’ll just take a minute!

    Once you’re done, please ask your friends to sign the petition as well. Grassroots movements succeed because people like you are willing to spread the word!

    Collin

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