How do you rule out ADD?

Seems like it's almost as easy for adults to get a diagnosis of ADD and a stimulant these days as for Bipolar Disorder and a mood stabilizer. Probably the easiest way is to go to someone who claims to be an ADD expert, maybe get a brain scan with pretty colors. The more expertise the clinician has the more likely they will bestow the diagnosis.

But it also seems to me that an expert should excel at determining you do not have the disorder.

To further this discussion let's borrow some concepts usually applied to laboratory pathology. We call a test, like a thyroid function test, positive when it confirms the presence of the disease and negative when it rules the disease out. So if certain thyroid hormone levels in your blood exceed the normal limits we might call the test positive for hyperthyroidism; otherwise the test is negative. But like a psychiatric diagnostic examination, even including the brain scan de jour, laboratory tests can mislead, in which case we call them false:

• False positive: The test suggests the disorder is present, but it is really absent.
• False negative: The test suggests the disorder is absent, but it is really present.

You may then ask, "But how do we know for sure whether the disorder is present or absent?" This presents more of a problem for ADD than for hyperthyroidism. We can confirm or rule out the latter illness with further objective tests, but there exists no such gold standard or objective test for ADD.

What difference does it make?

One reason experts and amateurs alike tend to diagnose ADD so readily is that a false negative deprives the patient of a potentially very helpful treatment. We tend to like to avoid that by applying looser criteria. But that approach leads to more false positives.

The downside of a false positive usually involves proving someone a potentially addictive or abusable drug they may share with others or use to get high. Having such a diagnosis, even just in an old record, might also prevent you from obtaining something, like a job or insurance. Absent this downside we might just throw stimulants at everyone, and if they like them diagnose ADD, or if they don't tell them they don't have it. But we know that doesn't really avoid the false positives and negatives either. Many people who do not suffer from ADD likely experience stimulants as pleasurable or improving their cognitive functioning and alertness (false positive).

Clinicians still face this person who claims to have a problem and want help. Sometimes we can diagnose an anxiety disorder and treat that, and sometimes we feel confident the patient just wants drugs for the wrong reasons. Maybe we don't pick up a clear history of ADD dysfunction in childhood. But it's hard to say, "You don't have ADD. Go away." unless you can be very confident that you are not looking at a false negative.

I like to think the real experts should have more confidence when they rule out the disorder, but do they? 

How do you rule out ADD in adults?

or

How do you rule out ADD in adults?

Pharmacists Gone Wild

(Facts altered to disguise cases.)

• A patient relates that her pharmacist told her if the increased dose of her medication failed to produce improvement in her symptoms after 21 days at the higher dose, she should revert back to the original dose.
• A pharmacist faxes me to ask the diagnosis of a patient, even though the patient pays cash for the prescription, and there is not insurance company involvement.
• A pharmacist tells a patient that a drug I frequently prescribe can be very sedating, when in fact most patients complain that it does not sedate them enough.

Everyone seems to want to play doctor these days, but how much do we want pharmacists to get into that role? There is something to be said for having each of every patient's diagnoses accessible from the pharmacy data bank. For example, it might prevent an asthmatic patient from using a potentially fatal beta blocker. But can we trust them with psychiatric or substance use disorder diagnoses? My patients already complain about pharmacists talking about such diagnoses where other customers can hear.

The first item above appears to clearly involve exceeding the boundaries of a pharmacist's competence and authority. This probably has happened as long as their have been pharmacists, but does the current climate encourage non-physicians to take liberties, possibly to the detriment of patients?

How Psychiatry Works

An admittedly oversimplified illustration of how psychiatry works:

Scenario One

You have been suffering from loss of energy and motivation for a month or so, so you visit your primary care physician. She orders a blood test and finds that your thyroid stimulating hormone (TSH) is high. She diagnoses hypothyroidism as the most likely cause of your symptoms, rules out more serious disorders with more tests, and prescribes thyroid replacement drugs. After you start taking them you get better. She recommends that you continue taking them indefinitely.

Scenario two

What doctors call the history of present illness is the same as in Scenario One, but this time when the doctor finds that all your blood tests were normal, she tells you she cannot find a physical illness that might explain your symptoms, diagnoses some kind of depression (i.e. it's all in your head) and refers you to me, the psychiatrist.

You have become a medical leftover. Specifically treatable physical illnesses do not explain your symptoms, so in many cases the only physician who will take care you is a psychiatrist. But not to worry: Psychiatrists generally like talking to people, are fascinated by mental and emotional problems, and like helping people like you solve them. In the past you might have been locked up in an asylum or referred for psychoanalysis, but today, fortunately, we have specific forms of psychotherapy that can treat mental disorders, and we have a host of drugs that for most people are relatively safe and effective, somtimes miraculously so.

Diagnosis

After collecting lots of information about your history and your symptoms I will probably have some vague idea of your diagnosis. Given all the recent controversy about DSM V you might think this is a critical step. In fact it is somewhat important. I don't want to treat someone with schizophrenia for panic disorder or someone with social phobia for bipolar disorder, but I usually make a mental jump to the most important phase which is to choose a treatment that is most likely to help you with minimal adverse effects and minimal delay. Another nice thing about many of the drugs we have today is that, for example, antidepressants, at least most of them, often work very well for anxiety as well. That makes it less critical to determine whether you suffer from, for example, dysthymic disorder, or generalized anxiety disorder. If I prescribe paroxetine and you come back two weeks later to tell me that you feel all better, who cares how we categorize your problem? (It may be important to rule out bipolar disorder since evidence suggests many drugs with antidepressant effects can exacerbate the condition.)

Over-diagnosis

Many people that get diagnosed with bipolar disorder or attention deficit disorder may have never had either. A researcher or two publish data suggesting that we have missed a few cases, and everybody jumps on the bandwagon trying to make sure they never miss the disorder. Often we overshoot the mark and apply the diagnosis inappropriately. What's wrong with that? Delay in getting the right treatment for the right problem and exposure to adverse effects of the wrong treatment. There can be other fallout from simply having the wrong label as well. For example, if a psychiatrist evaluates your child, and you tell her that Uncle Harry has bipolar disorder, this may influence how the psychiatrist diagnoses your child. So if Uncle Harry really did not have bipolar disorder, your child may get the wrong treatment.

Under-diagnosis

Missing diagnosis can cause problems too. Once more we can have delay in appropriate treatment. But when I tell a patient I don't believe they really suffer from a mental disorder, I can add that we can monitor the symptoms over time with a plan to reassess if they worsen.

Getting It Just Right

We would like to be able to do this all the time, but it just is not possible. When I hear psychiatrists talk about patients as suffering from this or that disorder as though they are absolutely certain of the diagnosis it always makes me wonder. To me, especially if the patient has not responded very well to treatment, and even sometimes when they have, I tend to think of the diagnosis as what we call a working diagnosis. This is a provisional diagnosis we assume to be correct until proven otherwise, often by treatment failure. If I get too confident or locked in to a particular diagnosis there is a risk of barking too far up the wrong tree, usually trying treatment after treatment, all doomed to failure. Better to keep an open mind.

Drugs

You may feel like a guinea pig, but really you're the director auditioning drugs instead of actors. If we get it right with the first one that's terrific, but often patients have to try several medications before finding one that works and has acceptable side effects. Everyone seems to respond differently. Be warned though: You could keep trying different psychiatric drugs and combinations for years and never find one that makes the grade. At some point you may want to figure the solution is not in the (pill) bottle. If you haven't tried it already, consider psychotherapy. For more serious problems ECT and other biological treatments can work wonders.

Once you find a drug that works you have to decide how long to continue it. Some psychiatric drugs can prevent recurrence of your illness. You wouldn't stop oral contraceptives just because you didn't get pregnant. Many patients benefit from lifelong preventive or maintenance treatment, like for the hypothyroidism in Scenario One.

Ask your psychiatrist what to expect in the way of risk of dependence on medications and risk of adverse effects and whether there are ways to manage those risks. Sometimes additional drugs help control side effects of the primary drug. Be sure to keep the psychiatrist apprised of all other medications, conditions, symptoms, and side effects. And make sure the psychiatrist knows if you are disappointed in the effectiveness of the treatment.

Psychotherapy

It works, but not necessarily for your illness. For example, there seems to be no method of psychotherapy that treats schizophrenia, bipolar disorder, or ADHD, and certainly not Alzheimer's. But psychotherapy can help you and your family cope with any of them. Some kinds of psychotherapy actually effectively treat disorders like generalized anxiety disorder and panic disorder. Your psychiatrist may or may not provide psychotherapy. If she does, make sure it's the kind of psychotherapy that best treats your condition. If she doesn't insist that the two professionals communicate about your treatment.

Ask your psychotherapist what to expect, particularly how long the treatment lasts, how it works, and whether family members can be involved. Some kinds of psychotherapy can go on so long you can't tell whether the treatment or tincture of time got you better. Be sure to make the psychotherapist aware of any disappointment in the treatment. And if you don't like your psychotherapist, tell them so. A good one won't hold it against you, and will want to address it as just another interesting problem to work toward solving together.

Disappointment and Failure

If none of the above has produced acceptable results, ask for a consultation or second opinion, or just look for a different psychiatrist or psychotherapist. Most of us want you to get better, even if someone else gets to take some credit. And if you do get better, give yourself most of the credit.

DSM-V: A Brief Conversation With Allen Frances

Having come across his email address I could not resist posing a question, and he honored me with a reply, alas another question. I thought the conversation might deserve public exposure.

My question:

"It has seemed to me that in general DSM criteria from 3 on have been necessary but not sufficient to make a dx. The clinician must make a judgement that the pt is ill, THEN use the DSM to classify that illness.

Would it help to emphasize that fact?"

Before I record Frances' response let me elaborate. Many years ago, during a deposition, an attorney pulled out the DSM and walked me through the criteria for some disorder one by one. I had to admit most if not all seemed to be met, at least at first glance, but I still opined that the patient did not suffer from the disorder. This raised a question I might have thought would have an obvious answer: According to the DSM, if the patient meets all the criteria, does that imply they have the illness? I have looked in vein for an answer. This led me to the conclusion that, especially given the Cautionary Statement at the beginning of the book, the proper way to apply the criteria might involve a trained clinician (not an attorney) first making the judgment that the patient suffers from a mental illness, and referring to the diagnostic criteria only to classify the illness, ie to determine which diagnosis fits best.

It seems to me that inclusion of a clear statement on this issue could improve DSM-V.

I figured if anyone knows the answer it must be Dr. Frances. His response:

"Do you mean by ill that the patient has clinically significant distress or impairment?" 

Gee thanks, doc. I think he may be trying to use this as a teachable moment. I believe this question is beside the point, but of course it is very critical.

"Clinically significant distress or impairment," in my opinion, does not qualify as the definition of a mental disorder. Rather it is a threshold. I find it hard to imagine making a diagnosis of mental disorder in the absence of clinically significant distress or impairment, but I hold out the possibility it might be appropriate in some cases. I'm still wondering why he asks. Maybe he just wants to know whether the process I describe above consists of first determining that there is clinically significant distress or impairment, then applying the criteria. Fair enough.

But that is not what I do. I believe there is more to identification of a diagnositc entity than distress or impairment. A disorder must somehow hold together and have a life of its own. It can't just mean feeling really bad or not functioning 100% when things are going rough for example (or did I just define adjustment disorder?).

The term "clinically significant" bothers me too. Does that just mean the problem was so bad the patient sought professional help, or that someone else thought they should seek professional help?

A lot of this debate struggles with determining just how clear the dividing line between normal and sick should be. We lose if we say everyone is sick all the time, or that everyone has an excuse for doing bad things or failing a responsibility. We also lose if we keep those who need it from accessing treatment.

If Dr. Frances responds again, I will post here.