DSM Disorders Disappear in Statistical Clustering of Psychiatric Symptoms (2024)(psychiatrymargins.com)
psychiatrymargins.com
DSM Disorders Disappear in Statistical Clustering of Psychiatric Symptoms (2024)
https://www.psychiatrymargins.com/p/traditional-dsm-disorders-dissolve?r=2wyot6&triedRedirect=true
117 comments
I have had such bad experiences with psychiatrists and psychologists being contrarian and demanding filling in generic tests leading to no working solutions (aka you're depressed here's a prescription for an SSRI. Still depressed? We'll up the dose).
My current psychiatrist figured out my main issues after talking to me for 15 minutes. Sent me off to a psychologist back up his assumptions before prescribing anything. Recommended therapists who specialize in the area I needed support in.
The psychologist I went to was great as well (after seeing one that was a terrible). She did a lot of testing (three sittings lasting around two hours) but said the tests were really just to rule out other things. The important part were the conversations.
My life improved tremendously after that.
My current psychiatrist figured out my main issues after talking to me for 15 minutes. Sent me off to a psychologist back up his assumptions before prescribing anything. Recommended therapists who specialize in the area I needed support in.
The psychologist I went to was great as well (after seeing one that was a terrible). She did a lot of testing (three sittings lasting around two hours) but said the tests were really just to rule out other things. The important part were the conversations.
My life improved tremendously after that.
My ex was on antidepressants which had a huge impact on her life. If she missed her meds or (god forbid) was late on her prescription, it was terrifyingly bad.
Orthogonally, she also had sensitivities to light and epileptic symptoms. She told the doctor this, and the doctor doubled her dose of antidepressants. Just one of many, many stories. I've come to consider the higher-level of medicine quite scientific, but the on-the-ground doctors as unscientific. They mostly don't have time or enough feedback to make good decisions in most cases I've seen. That's a profession that shouldn't work on faith.
Orthogonally, she also had sensitivities to light and epileptic symptoms. She told the doctor this, and the doctor doubled her dose of antidepressants. Just one of many, many stories. I've come to consider the higher-level of medicine quite scientific, but the on-the-ground doctors as unscientific. They mostly don't have time or enough feedback to make good decisions in most cases I've seen. That's a profession that shouldn't work on faith.
How does one find a good psychiatrist/psychologist? My experiences have ranged from "very bad" to "OK at best" and I think finding someone a bit more invested into figuring things out might help a lot.
It is definitely not easy. Specially because you cannot "see" their past work or results except from someone telling you about it.
I practice psychoanalysis (lacanian if you gotta give it a name) and really liked your wording: "finding someone a bit more invested into figuring things out".
Feel free to hit me up (gerhn cupipo com) if interested in starting an analysis (or anyone reading this). We can have up to 4 sessions which you won't have to pay for unless you think we are up to something and decide to continue.
And how do you, as a first-time patient, assess the quality of psych* you are seeing?
One thing you can do to become a tiny(!) bit more informed is take some psych classes yourself. PSYC1030 is a popular (free) one and gives you the first glimpses into social, clinical and developmental psychology. It doesn’t give you any particular qualification but it does at least demystify some of the processes. That makes it easier to recognise the hucksters
If you’re focused in particular on getting a diagnosis for something, I’d also recommend reading relevant parts of “Psychopathology and Mental Distress” which is a tomb of a book that aggregates both DSM and ICD diagnostic criteria, but also provides current meta surveys on relevant research, from multiple perspectives. It’s reasonably easy to read but definitely better after getting the basic thinking tools from a proper course on clinical psych.
If you’re focused in particular on getting a diagnosis for something, I’d also recommend reading relevant parts of “Psychopathology and Mental Distress” which is a tomb of a book that aggregates both DSM and ICD diagnostic criteria, but also provides current meta surveys on relevant research, from multiple perspectives. It’s reasonably easy to read but definitely better after getting the basic thinking tools from a proper course on clinical psych.
This. Studying your own psyche from an (as possible) outside perspective can help enlighten you on the who, why and especially -- when. Uncovering latent trauma isn't fun but it is important.
You enter with an open mind, try their process for a bit, and see if you feel better. You can even have conversations with them about the timeline they expect for improvement or what they think can actually be achieved -- "goals of care" isn't just for terminal patients. You can be aware of red-flags, if something feels wrong or misaligned you can discuss it or try someone else, but at the end of the day, you can't know for sure if a modality or a relationship will work for you if you don't try it, and give it some time.
I mean, it's the same question as "How do I assess whether my plumber or mechanic or electrician knows what they're doing." Sure, sometimes there's an easy, obvious difference, but you can't really know for sure whether or not your electrician is grounding your entire house to your hot-water pipes unless you have enough skill and expertise not to need one. After a point, working with any professional requires a weird blend of faith and of assessment you don't have the expertise to actually do.
I mean, it's the same question as "How do I assess whether my plumber or mechanic or electrician knows what they're doing." Sure, sometimes there's an easy, obvious difference, but you can't really know for sure whether or not your electrician is grounding your entire house to your hot-water pipes unless you have enough skill and expertise not to need one. After a point, working with any professional requires a weird blend of faith and of assessment you don't have the expertise to actually do.
I found mine by word of mouth. Other than that, the only way I can think of is trying till you find a good one.
The DSM is not designed as a list of questions to use to ask patients, it’s designed to describe disorders.
Asking you “do you have trouble concentrating?” is lazy (at least, on its own. Asking a patient to perform a self-assessment is not bad medicine necessarily). A doctor should also be evaluating your concentration in other ways.
Asking you “do you have trouble concentrating?” is lazy (at least, on its own. Asking a patient to perform a self-assessment is not bad medicine necessarily). A doctor should also be evaluating your concentration in other ways.
This. Clinical symptoms are latent descriptors of manifest variables, ie it is not expected that a person can verbalize or even introspect the symptom descriptions. If the (prospective) patient could do this themselves, the clinical assessment would not be necessary.
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> I'm happy to see such results be "properly" recognized. The DSM is imo helpful only as a baseline, especially in contexts where without it, doctors might have (significant) personal bias. And... this might ruffle some feathers with the "live and die by the book" crowd, but a good, perceptive doctor doesn't need the DSM to diagnose anything.
My own personal experience with psychologists and psychiatrists, is most of them don’t go by the text of the DSM, they go by the understanding of various disorders they’ve received from their teachers, mentors, supervisors, colleagues-which at times has a rather loose relationship with what the text of the DSM actually says-and once they’ve made their minds up as to what is the correct diagnosis, then-when required for a formal report-they look at the DSM text and work out how to justify their diagnostic decision by relating what the text says to the evidence at hand
My own personal experience with psychologists and psychiatrists, is most of them don’t go by the text of the DSM, they go by the understanding of various disorders they’ve received from their teachers, mentors, supervisors, colleagues-which at times has a rather loose relationship with what the text of the DSM actually says-and once they’ve made their minds up as to what is the correct diagnosis, then-when required for a formal report-they look at the DSM text and work out how to justify their diagnostic decision by relating what the text says to the evidence at hand
The point is to make a differential diagnosis which isn't possible in 5 minutes. So if someone concludes after 5 minutes your psychiatric diagnosis, you can be almost sure they aren't following good practice for their profession. Or to use another word - malpractice.
> I've also had a 45 minute "by the book" DSM-based session where boxes were being ticked... and the questions were f---ing terrible
The DSM isn’t the source of those question inventories. There are different question sets for different conditions that each have their own source, often a set of researchers or an institution that has put in some work to study and test them. Some of the more obscure question inventories are even paid material that clinicians (or their offices, more accurately) are supposed to license.
I caution against the clinicians who do rapid-fire diagnostics and slap a label on the patient within minutes of talking to them. Some patients like this when the diagnosis matches what they already self-diagnosed or they want to hear, but in these cases some clinicians are just picking up on the hints the patient gave and mirroring it back to them.
This rapid diagnostic method is an easy way to improve your patient satisfaction scores (important for performance measures at some clinics, especially when PE or corporate gets involved) and it’s an obvious way to free up some time in a clinician’s busy day.
There is a growing problem of lazy providers who try to speedrun the diagnosis and send patients on their way with a prescription for something and a request for a follow up appointment. During COVID when controlled substance prescribing rules were loosened for remote appointments there were even pill mills that would advertise for specific diagnoses on TikTok and then incentivize the providers to see as many patients per day and prescribe them all Adderall because it turned them into repeat customers for the recurring prescriptions. There was a whistleblower who revealed that they were measured on their rates of prescribing controlled substances and discouraged from prescribing alternatives with lower abuse/addiction potential even when patients admitted to having drug abuse problems. This is an extreme example but don’t discount the incentive for your provider to shorten your appointment for selfish reasons, not because the patient’s condition is obvious and easy to diagnose accurately within minutes.
The DSM isn’t the source of those question inventories. There are different question sets for different conditions that each have their own source, often a set of researchers or an institution that has put in some work to study and test them. Some of the more obscure question inventories are even paid material that clinicians (or their offices, more accurately) are supposed to license.
I caution against the clinicians who do rapid-fire diagnostics and slap a label on the patient within minutes of talking to them. Some patients like this when the diagnosis matches what they already self-diagnosed or they want to hear, but in these cases some clinicians are just picking up on the hints the patient gave and mirroring it back to them.
This rapid diagnostic method is an easy way to improve your patient satisfaction scores (important for performance measures at some clinics, especially when PE or corporate gets involved) and it’s an obvious way to free up some time in a clinician’s busy day.
There is a growing problem of lazy providers who try to speedrun the diagnosis and send patients on their way with a prescription for something and a request for a follow up appointment. During COVID when controlled substance prescribing rules were loosened for remote appointments there were even pill mills that would advertise for specific diagnoses on TikTok and then incentivize the providers to see as many patients per day and prescribe them all Adderall because it turned them into repeat customers for the recurring prescriptions. There was a whistleblower who revealed that they were measured on their rates of prescribing controlled substances and discouraged from prescribing alternatives with lower abuse/addiction potential even when patients admitted to having drug abuse problems. This is an extreme example but don’t discount the incentive for your provider to shorten your appointment for selfish reasons, not because the patient’s condition is obvious and easy to diagnose accurately within minutes.
Sounds like the field needs to acknowledge the weakness of prescriptivism similar to software engineering with design patterns. The need for diagnostic criteria is understandable - but it definitely should be up to the discretion of the doc.
> "Do you have trouble concentrating" is terribly vague and can always be justified either way
To be fair, for the practitioner this shouldn't be a question about objective capital-letter Truth, it's one throw of darts representing a self-reported aspect of self-experience and self-perception.
As someone who has designed questionnaires for a public health agency, reading the article made me feel we should've fully randomized the order of appearance of individual questions, including the 'front-matter' stuff like self-reported gender, age, education, marital status.
As someone who got quite upset about a particular questionnaire's formulations at the tender age of 10, I'd now say let's not get too wrought up about this, a questionnaire can be a valid tool but it will also always be a somewhat blunt tool, so let's use it bluntly: don't fret, put your mark into one of those five boxes, move on to the next question, done, over, out. If it's about me then it's about how I feel about it, now, and I can choose to feel extremely good or bad or fairly somewhat well-nigh indifferent about sh*t, just here and now. As the one being questionnaired, I also have the right to lean into the questions and bend the outcome as I see fit. Been there, done that.
To be fair, for the practitioner this shouldn't be a question about objective capital-letter Truth, it's one throw of darts representing a self-reported aspect of self-experience and self-perception.
As someone who has designed questionnaires for a public health agency, reading the article made me feel we should've fully randomized the order of appearance of individual questions, including the 'front-matter' stuff like self-reported gender, age, education, marital status.
As someone who got quite upset about a particular questionnaire's formulations at the tender age of 10, I'd now say let's not get too wrought up about this, a questionnaire can be a valid tool but it will also always be a somewhat blunt tool, so let's use it bluntly: don't fret, put your mark into one of those five boxes, move on to the next question, done, over, out. If it's about me then it's about how I feel about it, now, and I can choose to feel extremely good or bad or fairly somewhat well-nigh indifferent about sh*t, just here and now. As the one being questionnaired, I also have the right to lean into the questions and bend the outcome as I see fit. Been there, done that.
> don't fret, put your mark into one of those five boxes, move on to the next question, done, over, out
That is not always seen as an option for some patients. Having observed a family member take a specific autism questionnaire, I can tell you that as for some people - often exactly the people who should be dianosed - it does not always feel possible to pick an option that to them is wrong.
In said case, they ended up getting diagnosed with autism elsewhere, because that one question on the first questionnaire was one they felt impossible to move past, and so it was never submitted.
Thankfully they had another option that wasn't being gatekept with a broken quesionnaire.
This might not be directly relevant to the article, but I think it's worth mentioning it in the general context of questionnaire design.
That is not always seen as an option for some patients. Having observed a family member take a specific autism questionnaire, I can tell you that as for some people - often exactly the people who should be dianosed - it does not always feel possible to pick an option that to them is wrong.
In said case, they ended up getting diagnosed with autism elsewhere, because that one question on the first questionnaire was one they felt impossible to move past, and so it was never submitted.
Thankfully they had another option that wasn't being gatekept with a broken quesionnaire.
This might not be directly relevant to the article, but I think it's worth mentioning it in the general context of questionnaire design.
For nerdsnipers who would like see if DSM-IV is "better" the wiki is
https://www.ncbi.nlm.nih.gov/books/NBK519711/
Going back to DSM-III TFA has a good link
https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2...
>This is unproblematic as long as DSM criteria are understood to index rather than constitute psychiatric disorders.
With "index" taken to mean:
>a pragmatic and well-validated way to identify [a] syndrome
I.e. "Do DSM Compress?"
https://www.ncbi.nlm.nih.gov/books/NBK519711/
Going back to DSM-III TFA has a good link
https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2...
>This is unproblematic as long as DSM criteria are understood to index rather than constitute psychiatric disorders.
With "index" taken to mean:
>a pragmatic and well-validated way to identify [a] syndrome
I.e. "Do DSM Compress?"
Here's the thing. As much as the quality of professionals vary a lot, the practical aspects of understanding DSM (or even medical issues) plays an important part
This is probably exacerbated by the closure of mental institutions where you could see in person what the textbook means exactly.
Trying to understand diseases just by the text (and not even considering differential diagnosis) is an exercise in frustration. And I feel more professionals lately are just "Chinesing room" it instead of having actual experience
This is probably exacerbated by the closure of mental institutions where you could see in person what the textbook means exactly.
Trying to understand diseases just by the text (and not even considering differential diagnosis) is an exercise in frustration. And I feel more professionals lately are just "Chinesing room" it instead of having actual experience
Ive been saying this forever. Even with single disorder like ADHD, per the DSM two individuals can be diagnosed whilst sharing only 3 of the 9 symptoms, whichs admits that each of the symptoms can have a cause that is not from ADHD.
So if someone has 6 symptoms how do you know theyre not all independently caused? Given a large enough population it's a guarantee
> per the DSM two individuals can be diagnosed whilst sharing only 3 of the 9 symptoms, whichs admits that each of the symptoms can have a cause that is not from ADHD.
To be clear, ADHD, despite having "disorder" in the name, is actually a syndrome: a complex of symptoms that, when recognized together, indicate that a certain set of interventional treatments will likely be applicable.
Diagnosing someone with a syndrome does not indicate any knowledge is available on the cause (etiology) of the symptoms. Many different things can cause the same set of symptoms. But if a certain treatment ameliorates anything qualifying as that syndrome, regardless of the upstream cause, then the diagnosis of the syndrome (and so the existence of the syndrome as a concept) is useful, even if it's not informative.
The DSM actually covers two very different categories of what we might call "mental" illnesses: neurocognitive illnesses, and neuroendocrine (or neurohormonal) illnesses.
Neurocognitive illnesses — structural problems with the brain or its cells (think Parkinson's Disease, or ALS, or Lewy Body dementia) — are usually traceable to specific etiologies, as each one usually has either a very unique presentation of signs and symptoms, or has unique markers that can be assayed/biopsied for.
Neuroendocrine illnesses, on the other hand, are almost always syndromes. Many different upstream problems (genetic, toxic, nutritive, auto-immune, etc) can potentially cause the same small menagerie of messenger-chemicals to get out of whack, and due to this, many different upstream problems end up looking like the same few "templates" of symptoms. If you can put the particular out-of-whack messenger-chemicals back into whack with drugs that do that, then you've fixed the symptoms — which doesn't fix the upstream problem (if it even can be fixed), but does fully compensate downstream for the upstream problem.
To be clear, ADHD, despite having "disorder" in the name, is actually a syndrome: a complex of symptoms that, when recognized together, indicate that a certain set of interventional treatments will likely be applicable.
Diagnosing someone with a syndrome does not indicate any knowledge is available on the cause (etiology) of the symptoms. Many different things can cause the same set of symptoms. But if a certain treatment ameliorates anything qualifying as that syndrome, regardless of the upstream cause, then the diagnosis of the syndrome (and so the existence of the syndrome as a concept) is useful, even if it's not informative.
The DSM actually covers two very different categories of what we might call "mental" illnesses: neurocognitive illnesses, and neuroendocrine (or neurohormonal) illnesses.
Neurocognitive illnesses — structural problems with the brain or its cells (think Parkinson's Disease, or ALS, or Lewy Body dementia) — are usually traceable to specific etiologies, as each one usually has either a very unique presentation of signs and symptoms, or has unique markers that can be assayed/biopsied for.
Neuroendocrine illnesses, on the other hand, are almost always syndromes. Many different upstream problems (genetic, toxic, nutritive, auto-immune, etc) can potentially cause the same small menagerie of messenger-chemicals to get out of whack, and due to this, many different upstream problems end up looking like the same few "templates" of symptoms. If you can put the particular out-of-whack messenger-chemicals back into whack with drugs that do that, then you've fixed the symptoms — which doesn't fix the upstream problem (if it even can be fixed), but does fully compensate downstream for the upstream problem.
If we fully admit that the DSM is merely a tool for treatment, a stastical tool to say "this drug might help the issues youre feeling" fine, however this is not the view Ive commonly seen in phycitatric literature, which points at ADHD being a "real disorder", as something definite one "has". Patients also commonly believe they have a definite disorder, saying things like how they finally "discovered" they have ADHd or even that they might "have undiagnosed ADHD". If we agree that the diagnosis is not informative, thst it is merely putting a name to something one already knows about themselves, do we then agree that this kind of talk is invalid?
If so, and if this view is really prevalent in psychiatry, somehow it's completely lost on the general public and media.
If so, and if this view is really prevalent in psychiatry, somehow it's completely lost on the general public and media.
> saying things like how they finally "discovered" they have ADHd or even that they might "have undiagnosed ADHD"
This is not in contradiction to something being syndrome. Plus patients usually do not understand and do not have to understand technical nuts and bolts of whatever issues they have.
You cant require people to talk in clunky language qualifying every single nuance each time they speak about issues or diagnoses they have. You would just render them unable to express what they need to express.
> If so, and if this view is really prevalent in psychiatry, somehow it's completely lost on the general public and media.
General public and media are completely lost on eating disorders, OCD, psychosis and pretty much any other psychiatric/psychological problem. They are equally lost on AI, HIV and economic policy.
This is not in contradiction to something being syndrome. Plus patients usually do not understand and do not have to understand technical nuts and bolts of whatever issues they have.
You cant require people to talk in clunky language qualifying every single nuance each time they speak about issues or diagnoses they have. You would just render them unable to express what they need to express.
> If so, and if this view is really prevalent in psychiatry, somehow it's completely lost on the general public and media.
General public and media are completely lost on eating disorders, OCD, psychosis and pretty much any other psychiatric/psychological problem. They are equally lost on AI, HIV and economic policy.
I don't think I am being pedantic. There is a monumental difference in how you perceive your condition between "I have some troublesome behaviors which these drugs can sometimes alleviate" and "I have an inherently disordered brain that cannot function properly". Perhaps the HN crowd is different, but the latter fits most people's understanding of what Ive seen
What is the qualitative difference between "having some troublesome behaviors" and "having an inherently disordered brain" in your opinion?
Behaviours are what you do - how you interact with the world. Having disordered brain is about how your brain functions. If I yell at you, it is behavior not am "inherently disordered brain".
If I feel sad all the time, it is not a behavior. It is a feeling. If I am forgetting a lot, it is a brain function too, not a behavior. Behavior can be used to mitigate the disordered brain, it can be result of it, it can be completely intendent of it.
Behavior can be something positive or neutral. Eating is behavior, giving a gift is a behavior.
If I feel sad all the time, it is not a behavior. It is a feeling. If I am forgetting a lot, it is a brain function too, not a behavior. Behavior can be used to mitigate the disordered brain, it can be result of it, it can be completely intendent of it.
Behavior can be something positive or neutral. Eating is behavior, giving a gift is a behavior.
I understand what behaviours are, but "having troublesome behaviours" implies something kinda systemic right? Something that someone does habitually (otherwise you probably wouldn't seek out medication for it). What is it that causes that habit, and if it is a mental cause, how does that differ from having a "disordered brain"?
Having troubles in your life does not imply something systemic no. The qualitive difference is one a name for a group of symptoms, the other claims to be a cause of those symptoms.
You may be losing things often because your place is a complete mess. You may not keep attention in conversations because you spend all your time playing video games and cant relate to anybody, or because regular people simply bore you and you need to find your own crowd.
These kind of explanations are far different than "My brain is inherently and permanently incapable of 'proper executive function'. and the REASON Im like xyz is because of ADHD". Take a look at /r/ADHD if you get a chance. I saw a top thread that read "Does anyone else have trouble keeping eye contact during sex?" with everyone going "wow me too! I didnt know this was an adhd thing!"
You may be losing things often because your place is a complete mess. You may not keep attention in conversations because you spend all your time playing video games and cant relate to anybody, or because regular people simply bore you and you need to find your own crowd.
These kind of explanations are far different than "My brain is inherently and permanently incapable of 'proper executive function'. and the REASON Im like xyz is because of ADHD". Take a look at /r/ADHD if you get a chance. I saw a top thread that read "Does anyone else have trouble keeping eye contact during sex?" with everyone going "wow me too! I didnt know this was an adhd thing!"
Right, but both ADHD and Autism don't have clear neuromarkers, we diagnose people largely based on their symptoms (or the results of their symptoms). The stuff you describe (being bored by regular people, your place being a complete mess) can have "ordinary" reasons, but can also themselves be symptoms of neural disorders. If you have a bunch of symptoms that you've dealt with for years and that you also (succesfully!) take the same medication for that people with the disorder take, I think it can actually be difficult to clearly delineate what is causing it.
Also your example is kinda dumb! You don't have to have Alzheimers to be forgetful, it's actually quite common. But if you post "anyone else here keep forgetting things?" on r/Alzheimers obviously people on there are going to be like "yeah me too".
Also your example is kinda dumb! You don't have to have Alzheimers to be forgetful, it's actually quite common. But if you post "anyone else here keep forgetting things?" on r/Alzheimers obviously people on there are going to be like "yeah me too".
I am not sure what your point is. Mine is precisely that there is no clear definition nor diagnostic criteria for ADHD, and that merely having more than an average collection of these otherwise ordinary behaviors, does not automatically constitute a new neurological disorder.
>Also your example is kinda dumb! You don't have to have Alzheimers to be forgetful, it's actually quite common. But if you post "anyone else here keep forgetting things?" on r/Alzheimers obviously people on there are going to be like "yeah me too".
What I was trying to demonstrate is that people DO have the belief that ADHD is a causative thing in itself, and not merely a name for a collection of symptoms used to make treatment easier, as was suggested is the case.
>Also your example is kinda dumb! You don't have to have Alzheimers to be forgetful, it's actually quite common. But if you post "anyone else here keep forgetting things?" on r/Alzheimers obviously people on there are going to be like "yeah me too".
What I was trying to demonstrate is that people DO have the belief that ADHD is a causative thing in itself, and not merely a name for a collection of symptoms used to make treatment easier, as was suggested is the case.
Yes, and it's likely due to low-intensity disorder showing up as something one can control, manage, compensate for, and find a place for oneself in society, but if somehow the dial gets fiddled with, things start to fall apart as we move up the sigmoid curve, positive feedback loops turn negative, and a state sponsored suite soon seems sensible.
In other words people with mental illnesses/conditions/disorders/syndromes doubt their own diagnosis, because sometimes it "just feels like an adorably tiresome behavioral `oh you` that everyone laughs at", and other times the wolves are howling inside and suddenly you understand every and all kinds of disability, escapism, compulsion, and serial killers, as you are trying to cancel plans, make up excuses, ask for help, while - by definition - fail to do any and all of those as a headwind of hurt hurls heavy and hopeless.
In other words people with mental illnesses/conditions/disorders/syndromes doubt their own diagnosis, because sometimes it "just feels like an adorably tiresome behavioral `oh you` that everyone laughs at", and other times the wolves are howling inside and suddenly you understand every and all kinds of disability, escapism, compulsion, and serial killers, as you are trying to cancel plans, make up excuses, ask for help, while - by definition - fail to do any and all of those as a headwind of hurt hurls heavy and hopeless.
I think you should re-read the parent comment, and try to read what is written instead of what you are looking to read.
First and foremost, DSM is a classification tool. It is to set up the jargon and coding of the disorders
I wish this were more common knowlegdge. Every time I see someone whether ADHD "exists" I think to myself "Dude, we decided that certain traits falling in a certain range on a spectrum warrant their own category because it might facilitate research and treatment. Whether it's real or not isn't even a question."
I just want to know whether my issues are normal and I'm gaslighting myself into thinking I'm broken or a loser, or if my specific issues are actually falling outside the norm. This way I know what treatment modalities might help, and which literature I can peruse instead of wasting my time reading up productivity advice meant for neurotypical people that will try to solve the wrong issue for me and just make me feel worse.
I just want to know whether my issues are normal and I'm gaslighting myself into thinking I'm broken or a loser, or if my specific issues are actually falling outside the norm. This way I know what treatment modalities might help, and which literature I can peruse instead of wasting my time reading up productivity advice meant for neurotypical people that will try to solve the wrong issue for me and just make me feel worse.
Slate Star Codex' take on Adderall (and ADHD) is a good read: https://slatestarcodex.com/2017/12/28/adderall-risks-much-mo...
In short: no-one "has" ADHD. We just decided that people on the lower end of the spectrum in the "ability to concentrate" trait deserve a bit of a boost from otherwise illegal drugs to function in the society. Being in this lower end is called "having ADHD".
In short: no-one "has" ADHD. We just decided that people on the lower end of the spectrum in the "ability to concentrate" trait deserve a bit of a boost from otherwise illegal drugs to function in the society. Being in this lower end is called "having ADHD".
I'm a bit wary about arguing with a psychiatrist, especially if it is Scott Alexander, but ADHD is clearly not just "low ability to concentrate". It is hard to explain to normal people without phrases like "executive function paralysis" but it is a severe illness, and not some variation of a norm.
I would also challenge his premise about boring monotonous work is ill suited for humans, hence the ones with ADHD are people who can't do it (as good as others). ADHD people can do boring monotonous work for hours, month after month, and often not even struggle with that. On the other hand some banal easy (and short!) tasks, which won't even register as a task for normal human, will leave ADHD person in shambles, unable to even think about it.
There is lots of bad shit going in on the ADHD brain, it is certainly not just "20% worse concentration" debuff.
I would also challenge his premise about boring monotonous work is ill suited for humans, hence the ones with ADHD are people who can't do it (as good as others). ADHD people can do boring monotonous work for hours, month after month, and often not even struggle with that. On the other hand some banal easy (and short!) tasks, which won't even register as a task for normal human, will leave ADHD person in shambles, unable to even think about it.
There is lots of bad shit going in on the ADHD brain, it is certainly not just "20% worse concentration" debuff.
There’s no such thing as advice for “neurotypical” people.
There’s advice for people.
Sometimes it will help you, and sometimes it won’t.
Regardless of the number of people it helped and didn’t help, and what labels apply to them.
There’s advice for people.
Sometimes it will help you, and sometimes it won’t.
Regardless of the number of people it helped and didn’t help, and what labels apply to them.
As someone taking adhd meds, I think you’re missing this person’s bigger point.
You can be stuck for decades, as I was, taking advice that won’t work for you, until you figure out that you can get a medical solution that instantly enables all of those pieces of advice becoming usable.
It is not a coincidence that those pieces of advice weren’t working, they were never going to work unless preceded by medical help.
Many people pre diagnosis suffer the equivalent of taking years of running advice and wondering why the stay behind before noticing they’re missing a leg and it won’t work until they get prosthetics.
You can be stuck for decades, as I was, taking advice that won’t work for you, until you figure out that you can get a medical solution that instantly enables all of those pieces of advice becoming usable.
It is not a coincidence that those pieces of advice weren’t working, they were never going to work unless preceded by medical help.
Many people pre diagnosis suffer the equivalent of taking years of running advice and wondering why the stay behind before noticing they’re missing a leg and it won’t work until they get prosthetics.
If it’s not optimal, it’s useless, isn’t it? You can’t run as fast as the others, so why bother running at all? You just can’t do it. None of the advice about running will ever apply to you unless you can afford a prosthetic that works with your ailment that you can wear all the time.
That’s not true, of course. You are not relegated to a category of defunct by simply existing without a leg. You can learn to get by without it — many do — and you can learn to excel without it.
When you exclude yourself based on blankets of labels, you miss good advice. Much advice about “running” has little to do with having 2 legs: Breathing, clothing, hydration, nutrition, time of day. Pacing advice can even apply when you run with an implement.
For some people this is their entire reality, having to fight against categorizations that split them into complete ability and disability.
For some others, they don’t even know there’s a fight to be had. They give up before knowing they had any chance at all.
It’s troubling for something like ADHD, where a constellation of symptoms are possible and some do not apply to you personally.
You can’t read because you have ADHD? It may be true. It may also be true that you have been forced to read things you’re not interested in, something rendered practically impossible by this disorder, and someone has labeled you as a non-reader due to your differences. It may also be true that you haven’t discovered Terry Pratchett, and you’re actually quite the reader with the right material.
For some even more others, they feel able with their medication and useless without. Luckily for them, their medication lasts all day, medication shortages do not exist, and their psychiatrist will always prescribe their medications forever.
That’s not true, of course. You are not relegated to a category of defunct by simply existing without a leg. You can learn to get by without it — many do — and you can learn to excel without it.
When you exclude yourself based on blankets of labels, you miss good advice. Much advice about “running” has little to do with having 2 legs: Breathing, clothing, hydration, nutrition, time of day. Pacing advice can even apply when you run with an implement.
For some people this is their entire reality, having to fight against categorizations that split them into complete ability and disability.
For some others, they don’t even know there’s a fight to be had. They give up before knowing they had any chance at all.
It’s troubling for something like ADHD, where a constellation of symptoms are possible and some do not apply to you personally.
You can’t read because you have ADHD? It may be true. It may also be true that you have been forced to read things you’re not interested in, something rendered practically impossible by this disorder, and someone has labeled you as a non-reader due to your differences. It may also be true that you haven’t discovered Terry Pratchett, and you’re actually quite the reader with the right material.
For some even more others, they feel able with their medication and useless without. Luckily for them, their medication lasts all day, medication shortages do not exist, and their psychiatrist will always prescribe their medications forever.
>For some even more others, they feel able with their medication and useless without. Luckily for them, their medication lasts all day, medication shortages do not exist, and their psychiatrist will always prescribe their medications forever.
The sarcasm there is unwarranted. Need for a treatment, when it exists, is orthogonal to its convenience. If you need an organ transplant to live, you need it regardless of whether you have donors and hospitals available or whether the lifelong meds they require can run dry at some point.
As for your larger point, to be clear, I understand the idea you’re trying to convey. Diagnoses can be limiting for some people either internally (limiting self perception) or by external judgement.
I don’t deny that, what I’m saying is that I feel you’re (probably unintentionally) falling into a different extreme that is just as damaging to others, which is to deny the need or convenience of treatment for those for which _there is no successful alternative_.
Shutting down a person through a label is harmful, dismissing their limitations because that would be labelling is harmful as well.
For the point of advice, advice can and will be harmful when it assumes realities that don’t apply to you.
To leave the analogy aside and give actual examples, methods to keep organization and accountability like checkboxes or diaries will not only be failed tries to those who need meds, but also reinforce a feeling of inadequacy as the user now feels lacking in discipline to commit to the method. Lack of self steem and negative self perception (lazy, messy, uncaring, etc) is a way too common comorbility with ADHD for a reason.
The sarcasm there is unwarranted. Need for a treatment, when it exists, is orthogonal to its convenience. If you need an organ transplant to live, you need it regardless of whether you have donors and hospitals available or whether the lifelong meds they require can run dry at some point.
As for your larger point, to be clear, I understand the idea you’re trying to convey. Diagnoses can be limiting for some people either internally (limiting self perception) or by external judgement.
I don’t deny that, what I’m saying is that I feel you’re (probably unintentionally) falling into a different extreme that is just as damaging to others, which is to deny the need or convenience of treatment for those for which _there is no successful alternative_.
Shutting down a person through a label is harmful, dismissing their limitations because that would be labelling is harmful as well.
For the point of advice, advice can and will be harmful when it assumes realities that don’t apply to you.
To leave the analogy aside and give actual examples, methods to keep organization and accountability like checkboxes or diaries will not only be failed tries to those who need meds, but also reinforce a feeling of inadequacy as the user now feels lacking in discipline to commit to the method. Lack of self steem and negative self perception (lazy, messy, uncaring, etc) is a way too common comorbility with ADHD for a reason.
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Also if its just meant to serve as a stastical tool, isnt manually making up these classifications complety outdated? Why not just feed people's data into a machine and find statsical corrolations for what helps?
> diagnosed whilst sharing only 3 of the 9 symptoms, whichs admits that each of the symptoms can have a cause that is not from ADHD
It does not logically follow that different symptoms -> different causes.
(Fire can cause smoke, heat, soot, etc. Depending on the wind and other conditions, only some of them may be observable.)
One root cause can manifest in different ways depending on interactions with other factors.
The genetic basis for ADHD is well studied and points to a single set of core causes.
It does not logically follow that different symptoms -> different causes.
(Fire can cause smoke, heat, soot, etc. Depending on the wind and other conditions, only some of them may be observable.)
One root cause can manifest in different ways depending on interactions with other factors.
The genetic basis for ADHD is well studied and points to a single set of core causes.
I have symptoms 1-6, you have symptoms 4-9. We only share 4,5,6. Or I have 1,3,5,6,7,8, you have 2,4,6,7,8,9.
Surely then, each of the symptoms (precieved, subjective symptoms) at that, can exist without ADHD.
So my question is, how do you know I simply dont have multiple completely independent things that together present the 6 symptoms? Even if we are to agree its a genetic condition, the diagnosis of sny particular individual isnt based on genes so theres room for criticism of the diagnostic process
Surely then, each of the symptoms (precieved, subjective symptoms) at that, can exist without ADHD.
So my question is, how do you know I simply dont have multiple completely independent things that together present the 6 symptoms? Even if we are to agree its a genetic condition, the diagnosis of sny particular individual isnt based on genes so theres room for criticism of the diagnostic process
We don't know, but epidemiological data hints at which one is more likely.
ADHD diagnosis requires "onset" before age 14, yet there is such a thing as acquired ADHD (due to brain damage).
And of course the genes don't change during the latter, nor did they change when the age of onset criteria was raised from 12.
And even though both autism and ADHD was described more than a 100 (and 200) years ago it took a long time for AuDHD to be noticed. (2013)
The maps we have are bad, the territory is treacherous, and even if we assume the genes are unchanging the environment they find themselves in does seemingly faster and faster.
ADHD diagnosis requires "onset" before age 14, yet there is such a thing as acquired ADHD (due to brain damage).
And of course the genes don't change during the latter, nor did they change when the age of onset criteria was raised from 12.
And even though both autism and ADHD was described more than a 100 (and 200) years ago it took a long time for AuDHD to be noticed. (2013)
The maps we have are bad, the territory is treacherous, and even if we assume the genes are unchanging the environment they find themselves in does seemingly faster and faster.
That's where the math ends and clinical diagnosis starts because those number games take you only so far. Furthermore, ADHD is classified into different subtypes so it was never a question of meeting all 9 but only the subset relevant for your own subtype. It's also not diagnosed by ticking of the trait list from the DSM with your doctor but by using recognized clinical questionnaires.
The personal questionnaires, aside from the fact that they're ridiculously easy to game and hardly ever throughly verified, are pointed to answer the crtieria defined by the DSM.
If the DSM isnt what defines ADHD, what is?
If the DSM isnt what defines ADHD, what is?
The DSM is an international expert collection of acknowledged diseases - it just answers briefly the "what is this?" question, nothing more while the medical societies in your respective country implement the actual guidelines on how to diagnose and treat the diseases by using the recent scientific conclusions. So a MD isn't using the DSM to diagnose and treat you - this is a common misconception.
Yes I understand that. My point is all these guidelines and their implementations are based on the definitions of the DSM.
The shallowly buried truth here is that ADHD, CFS, and other common conditions are not standalone random diseases,
but diagnostic names for groupings of common symptoms,
caused by seemingly completely unrelated stuff ranging from childhood trauma, to a staph infection or mercury leak in a tooth root.
but diagnostic names for groupings of common symptoms,
caused by seemingly completely unrelated stuff ranging from childhood trauma, to a staph infection or mercury leak in a tooth root.
I don't think ADHD in particular is caused by unrelated stuff. The heritability findings are pretty strong.
> A study of 894 ADHD probands and 1135 of their siblings aged 5–17 years old found a ninefold increased risk of ADHD in siblings of ADHD probands compared with siblings of controls [2]. Adoption studies suggest that the familial factors of ADHD are attributable to genetic factors rather than shared environmental factors [3, 4] with the most recent one reporting rates of ADHD to be greater among biological relatives of non-adopted ADHD children than adoptive relatives of adopted ADHD children. The adoptive relatives had a risk for ADHD like the risk in relatives of control children [4].
> Twin studies rely on the difference between the within-pair similarities of monozygotic (MZ) twin pairs, who are genetically identical, and dizygotic (DZ) twin pairs, who share, on average, 50% of their segregating genes. The mean heritability across 37 twin studies of ADHD or measures of inattentiveness and hyperactivity is 74% (Fig. 1). A similar heritability estimate of around 80% was seen in a study of MZ and DZ twins, full siblings, and maternal and paternal half-siblings [5]. The heritability is similar in males and females and for the inattentive and hyperactive-impulsive components of ADHD [6,7,8].
https://www.nature.com/articles/s41380-018-0070-0
> A study of 894 ADHD probands and 1135 of their siblings aged 5–17 years old found a ninefold increased risk of ADHD in siblings of ADHD probands compared with siblings of controls [2]. Adoption studies suggest that the familial factors of ADHD are attributable to genetic factors rather than shared environmental factors [3, 4] with the most recent one reporting rates of ADHD to be greater among biological relatives of non-adopted ADHD children than adoptive relatives of adopted ADHD children. The adoptive relatives had a risk for ADHD like the risk in relatives of control children [4].
> Twin studies rely on the difference between the within-pair similarities of monozygotic (MZ) twin pairs, who are genetically identical, and dizygotic (DZ) twin pairs, who share, on average, 50% of their segregating genes. The mean heritability across 37 twin studies of ADHD or measures of inattentiveness and hyperactivity is 74% (Fig. 1). A similar heritability estimate of around 80% was seen in a study of MZ and DZ twins, full siblings, and maternal and paternal half-siblings [5]. The heritability is similar in males and females and for the inattentive and hyperactive-impulsive components of ADHD [6,7,8].
https://www.nature.com/articles/s41380-018-0070-0
"ADHD has been clearly linked with numerous environmental risk factors, particularly around the prenatal and perinatal period. Some of the most robust risk factors identified are maternal prenatal health conditions and psychological distress (e.g. hypertension, obesity, pre-eclampsia, immune activation), in utero exposure to poor diet (with critical factors still being determined), teratogenic effects of certain medications (e.g. acetaminophen) and environmental exposures (e.g. lead), as well as neonatal factors such as prematurity and low birth weight [27]. Other extreme exposures in the postnatal environment (such as extreme infant emotional neglect) have also been associated with an ADHD syndrome [28, 29]."
Cecil, C. A. M., & Nigg, J. T. (2022). Epigenetics and ADHD: Reflections on Current Knowledge, Research Priorities and Translational Potential. Molecular diagnosis & therapy, 26(6), 581–606. https://doi.org/10.1007/s40291-022-00609-y
"The convincing evidence for genes as risk factors for ADHD does not exclude the environment as a source of etiology. The fact that twin estimates of heritability are less than 100% asserts quite strongly that environmental factors must be involved. ADHD’s heritability is high, and that estimate encompasses gene by environment interaction. Thus, it is possible that such interactions will account for much of ADHD’s etiology. Environmental risk factors likely work through epigenetic mechanisms, which have barely been studied in ADHD [148]. The importance of the environment can also be seen in the fact that, as for other complex genetic disorders, much of ADHD’s heritability is explained by SNPs in regulatory regions rather than coding regions [149]."
Faraone, S. V., & Larsson, H. (2019). Genetics of attention deficit hyperactivity disorder. Molecular psychiatry, 24(4), 562–575. https://doi.org/10.1038/s41380-018-0070-0
Cecil, C. A. M., & Nigg, J. T. (2022). Epigenetics and ADHD: Reflections on Current Knowledge, Research Priorities and Translational Potential. Molecular diagnosis & therapy, 26(6), 581–606. https://doi.org/10.1007/s40291-022-00609-y
"The convincing evidence for genes as risk factors for ADHD does not exclude the environment as a source of etiology. The fact that twin estimates of heritability are less than 100% asserts quite strongly that environmental factors must be involved. ADHD’s heritability is high, and that estimate encompasses gene by environment interaction. Thus, it is possible that such interactions will account for much of ADHD’s etiology. Environmental risk factors likely work through epigenetic mechanisms, which have barely been studied in ADHD [148]. The importance of the environment can also be seen in the fact that, as for other complex genetic disorders, much of ADHD’s heritability is explained by SNPs in regulatory regions rather than coding regions [149]."
Faraone, S. V., & Larsson, H. (2019). Genetics of attention deficit hyperactivity disorder. Molecular psychiatry, 24(4), 562–575. https://doi.org/10.1038/s41380-018-0070-0
Isnt this explained simply by families who are aware of, willing, capable of disgnosing their children are more likely to tske another child to a diagnosis vs a random child?
Granted they did have a control for adopted siblings
Granted they did have a control for adopted siblings
Twin studies are explicitly about scrolling for this kind of family bias.
"twin studies fail to separate the effects of genes and the prenatal environment. This failure casts doubt on claims of the relative effects of genes and environment on intelligence, psychiatric disorders, personality and other psychological variables, and other conditions."
https://www.psychologytoday.com/gb/blog/looking-in-the-cultu...
"Although many twin studies have been conducted (which is quite an understatement; there are almost 9,000 hits for “twin study” on PubMed!), there have long been critics who argue that they are scientifically worthless."
Smith, Jinkinson. (2020). The debate over twin studies: an overview. http://dx.doi.org/10.22541/au.159674847.78026661
"Because heritability is defined by both genetic and environmental influences, it is not a fixed characteristic of a disease or trait, but a population-specific estimate, analogous to, for example, the mean height, cholesterol level or life expectancy in a population. It also cannot be interpretated at the family or individual level."
Kaprio J. (2012). Twins and the mystery of missing heritability: the contribution of gene-environment interactions. Journal of internal medicine, 272(5), 440–448. https://doi.org/10.1111/j.1365-2796.2012.02587.x
https://www.psychologytoday.com/gb/blog/looking-in-the-cultu...
"Although many twin studies have been conducted (which is quite an understatement; there are almost 9,000 hits for “twin study” on PubMed!), there have long been critics who argue that they are scientifically worthless."
Smith, Jinkinson. (2020). The debate over twin studies: an overview. http://dx.doi.org/10.22541/au.159674847.78026661
"Because heritability is defined by both genetic and environmental influences, it is not a fixed characteristic of a disease or trait, but a population-specific estimate, analogous to, for example, the mean height, cholesterol level or life expectancy in a population. It also cannot be interpretated at the family or individual level."
Kaprio J. (2012). Twins and the mystery of missing heritability: the contribution of gene-environment interactions. Journal of internal medicine, 272(5), 440–448. https://doi.org/10.1111/j.1365-2796.2012.02587.x
(How) did they control for parental influence vs. genetic heritability? I grew up with a pathologically anxious mother. I still remember having to counteract her behaviour to avoid it leaking into my world, before I managed to move out. She is still a trigger for me, 30 years later. I can only stand having her around me for at max. 2 hours, then my vessel is full. IMO, I am not convinced that a sibling study rules out environmental influences.
They had a control for adoptive siblings. The critic in me says, ok what was their age of adoption, do parents perhaps treat adopted children differently, do adopted children perhaps grow behaviors unindicative of ADHD, does the knowledge that its genetic influence the diagnoses themself?
The age of adoption seems crucial to rule out early childhood trauma induced by the parents. I actually know mine, although it took me 35 years to get my mother to admit what happened. My point, I am very skeptical when it comes to parents reflecting on the bad influences they might have had on the development of their child. After all, bad parenting has a pretty harsh stigma in society (and it should!)
Yes but if the SAME behaviour emerges regardless of parenting style then that is significant
The twin studies would largely control for that.
"twin studies fail to separate the effects of genes and the prenatal environment. This failure casts doubt on claims of the relative effects of genes and environment on intelligence, psychiatric disorders, personality and other psychological variables, and other conditions."
https://www.psychologytoday.com/gb/blog/looking-in-the-cultu...
"Although many twin studies have been conducted (which is quite an understatement; there are almost 9,000 hits for “twin study” on PubMed!), there have long been critics who argue that they are scientifically worthless."
Smith, Jinkinson. (2020). The debate over twin studies: an overview. http://dx.doi.org/10.22541/au.159674847.78026661
"Because heritability is defined by both genetic and environmental influences, it is not a fixed characteristic of a disease or trait, but a population-specific estimate, analogous to, for example, the mean height, cholesterol level or life expectancy in a population. It also cannot be interpretated at the family or individual level."
Kaprio J. (2012). Twins and the mystery of missing heritability: the contribution of gene-environment interactions. Journal of internal medicine, 272(5), 440–448. https://doi.org/10.1111/j.1365-2796.2012.02587.x
https://www.psychologytoday.com/gb/blog/looking-in-the-cultu...
"Although many twin studies have been conducted (which is quite an understatement; there are almost 9,000 hits for “twin study” on PubMed!), there have long been critics who argue that they are scientifically worthless."
Smith, Jinkinson. (2020). The debate over twin studies: an overview. http://dx.doi.org/10.22541/au.159674847.78026661
"Because heritability is defined by both genetic and environmental influences, it is not a fixed characteristic of a disease or trait, but a population-specific estimate, analogous to, for example, the mean height, cholesterol level or life expectancy in a population. It also cannot be interpretated at the family or individual level."
Kaprio J. (2012). Twins and the mystery of missing heritability: the contribution of gene-environment interactions. Journal of internal medicine, 272(5), 440–448. https://doi.org/10.1111/j.1365-2796.2012.02587.x
Ahem, sorry for being slow and/or stupid, but how? Aren't both twins exposed to the same parental style?
In studies of monozygotic twins (shared genetic predisposition), typically the twins were raised in different environments (adoption, etc.). If behavior among the twins is divergent then environmental factors are likely predominant. OTOH if concordance of traits is strongly evident, behavior is attributable to genetic factors.
My understanding is that separating children from their biological parents has wide-reaching consequences, even if done in a non-traumatic way, and even if they are ultimately raised by a different set of parents. I would imagine the trauma originating from having to be adopted could be a uniquely triggering factor for genetic predisposition in the case of only one of the twins. How would twin studies be able to account for that?
I agree. Also, the prenatal environment (9 months of development!) and circumstances of birth, which both twins share, is not accounted for at all. Or rather, it is accounted for as "heritability" by twin studies, which is plainly wrong.
https://williamjbarry.substack.com/p/the-first-1000-days
https://williamjbarry.substack.com/p/the-first-1000-days
No need for family separation. You simply compare the correlation between monozygotic ("identical") twins vs dizygotic ("non-identical") twins.
For example, monozygotic twins will always have the same eye color (99+% correlation), while dizygotic twins do not. Thus we can conclude eye color is genetic. Both twins are raised by their respective parents, so it's unlikely parenting is causing this difference in eye-color-correlation.
For example, monozygotic twins will always have the same eye color (99+% correlation), while dizygotic twins do not. Thus we can conclude eye color is genetic. Both twins are raised by their respective parents, so it's unlikely parenting is causing this difference in eye-color-correlation.
Not if they’re raised in different families.
That's understood by physicians and is also the reason why they are doing many questionnaire's with you (if they follow diagnostic guidelines) which might seem first confusing to the patient like unrelated to your actual symptoms but it's to rule out many other common diseases.
Unrelated? Theyre so in your face its ridicously easy to get the diagnosis you're looking for
That is why we do differential diagnosis.
Any ADHD diagnosis includes checking for any other mental or physical issue that could explain the symptoms. Any when anything else is ruled out AND it can be established that the person always struggled with those symptoms (ideally that they were present in childhood) will you get a diagnosis.
Furthermore we know that ADHD has a genetic link. You have a 40% chance to have it when your parent has it. While we don't know every detail about how ADHD develops, we know it is something you are born with.
I am so sick that people pretend that ADHD is some vague concept. No, it is vague for you because you are ignorant about it.
Yes, ADHD can show up very differently in people. Which is not surprising because people happen to be different. Covid-19 can have widely different symptoms between people, doesn't mean it is not real.
As an ADHD person when I interact with other with ADHD people, yes there are huge differences but there is always a shared understanding. I never have the feeling the person has a completely different thing. There is always shared understanding.
Any ADHD diagnosis includes checking for any other mental or physical issue that could explain the symptoms. Any when anything else is ruled out AND it can be established that the person always struggled with those symptoms (ideally that they were present in childhood) will you get a diagnosis.
Furthermore we know that ADHD has a genetic link. You have a 40% chance to have it when your parent has it. While we don't know every detail about how ADHD develops, we know it is something you are born with.
I am so sick that people pretend that ADHD is some vague concept. No, it is vague for you because you are ignorant about it.
Yes, ADHD can show up very differently in people. Which is not surprising because people happen to be different. Covid-19 can have widely different symptoms between people, doesn't mean it is not real.
As an ADHD person when I interact with other with ADHD people, yes there are huge differences but there is always a shared understanding. I never have the feeling the person has a completely different thing. There is always shared understanding.
The paper described makes a statistically rigorous attempt to recover common psychiatric diagnoses (like major depressive disorder MDD) from raw unbiased data about people’s experiences. And seems to conclude that the Venn diagram for common presentations of these conditions doesn’t line up well with the official diagnoses. Not that the conditions don’t exist. But that we are grouping together distinct conditions under the same name. They give examples of anhedonia and suicidality as distinct clusters in their data even though both would be considered MDD under the DSM.
To me this begs the question of whether the DSM authors might actually know something real and useful that the data don’t show. For example that anhedonia often progresses to suicidality even though the two might not coexist in the same person often. (Doesn’t sound right to me, but that’s how I read the article.) I think it’s plausible that the direct implication of this research is actually wrong. The obvious conclusion is that the DSM is full of it and doesn’t match real people’s experiences. But I suspect it might be that the DSM captures useful correlations and progressions that this method didn’t collect. Perhaps because the data here are from a single point in time, not a progression.
To me this begs the question of whether the DSM authors might actually know something real and useful that the data don’t show. For example that anhedonia often progresses to suicidality even though the two might not coexist in the same person often. (Doesn’t sound right to me, but that’s how I read the article.) I think it’s plausible that the direct implication of this research is actually wrong. The obvious conclusion is that the DSM is full of it and doesn’t match real people’s experiences. But I suspect it might be that the DSM captures useful correlations and progressions that this method didn’t collect. Perhaps because the data here are from a single point in time, not a progression.
To me the conclusion is that the DSM is out of date. Not the document, or specific iteration itself but the mindset driving it. When DSM was simpler and we didn’t know as much about mental illness, then what DSM was trying to achieve wasn’t such a tall order, and it was a useful diagnostic companion. However it seems to me it’s gone from being merely useful to being considered canon, and through successive iterations has tried to fill those boots to the point where people are calling out the DSM as being entirely flawed when in fact what is going on is it’s just stepping out of its bounds.
Even still, wouldn't youvwant to separate X & Y are the same thing from X eventually progresses to Y.
I think the most obvious conclusion is not that the DSM is bunk, but that some of things it groups together might be better to group separately. The real question of course is which grouping corresponds better to the group responding the same way to a similar intervention. After all the point diagnosing is to put people into groups so we can learn from the patterns of similar people to figure out better treatments.
I think the most obvious conclusion is not that the DSM is bunk, but that some of things it groups together might be better to group separately. The real question of course is which grouping corresponds better to the group responding the same way to a similar intervention. After all the point diagnosing is to put people into groups so we can learn from the patterns of similar people to figure out better treatments.
Fair point. I agree. If there’s structure in people, the DSM should capture it. MDD phase 1,2,3 would be a useful update.
Important to note the various limitations of this approach:
> It relies only on self-reported symptoms, and features requiring clinician observation are missing; symptoms are decontextualized (e.g., insomnia due to substance withdrawal isn’t differentiated from insomnia due to anxiety); all symptoms were assessed using a 12-month time scale, even though different symptom patterns exist at different time scales.
In particular, I’m not sure how this would identify somebody with the traditional schizophrenia + anosognosia combo, which requires another person to help diagnose.
> It relies only on self-reported symptoms, and features requiring clinician observation are missing; symptoms are decontextualized (e.g., insomnia due to substance withdrawal isn’t differentiated from insomnia due to anxiety); all symptoms were assessed using a 12-month time scale, even though different symptom patterns exist at different time scales.
In particular, I’m not sure how this would identify somebody with the traditional schizophrenia + anosognosia combo, which requires another person to help diagnose.
Could it be that everything we call mental illness is just natural variation of people's psyche, at the ends of the bell curve?
Many of the mental illnesses are of course bad, but in an evolutionary perspective it makes sense that we have these variations in a population, to optimise adaptation.
Many of the mental illnesses are of course bad, but in an evolutionary perspective it makes sense that we have these variations in a population, to optimise adaptation.
What do you mean by "natural variation?" A great many of mental health issues develop as a result of trauma. You could say that a broken leg is a natural variation of a leg, as it happens naturally as the result of physical trauma, but does that help you understand it or treat it better?
Every time I read a part of the DSM-V, as a layman, I'm flabbergasted how vague and redundant and arbitrary symptoms and diagnostics are made (e.g. "if 6 out of 10 then..."). It just seems that on its face, while psychiatry has improved and began doing more good than harm since deinstitutionalization, it still lacks the rigor found in other applied scientific fields such as cardiology and oncology for example.
This study is a very good step in the right direction. The other direction is more quantitative methods such as measuring the brain waves response to a retinal laser flash to detect mental disorders (look it up, it's real)
This study is a very good step in the right direction. The other direction is more quantitative methods such as measuring the brain waves response to a retinal laser flash to detect mental disorders (look it up, it's real)
Another paper I like which reaches similar conclusions, but with a rather different methodology - https://pmc.ncbi.nlm.nih.gov/articles/PMC6880188/ - looking at the biological validity of the ASD-vs-ADHD-vs-OCD distinction in children and adolescents - it concludes the boundaries between the three disorders (and between the disorders and “normality”) are a poor model of what is really going on
This is a good start, but it still clusters based on symptoms
It’s like going to the doctor and getting an HIV diagnosis because you’ve got a runny nose.
It’s like going to the doctor and getting an HIV diagnosis because you’ve got a runny nose.
It's like going to the doctor and getting a runny nose diagnosis because you've got a runny nose.
In the end, a diagnosis only helps the patient if it enables a treatment, hopefully an effective one. If you have a cluster of symptoms with two possible causes, and there is no difference in the care for the patient, what's the point of further differential diagnosis?
In the end, a diagnosis only helps the patient if it enables a treatment, hopefully an effective one. If you have a cluster of symptoms with two possible causes, and there is no difference in the care for the patient, what's the point of further differential diagnosis?
That's how all diagnosis starts, what did you expect?
Start. But in psychology, it’s the end of it.
With actual doctors, they will take blood work, perform tests to find the actual virus, bacteria or other cause.
They find the cause, not just a list of symptoms.
Psychology and psychiatry is only now starting to actually research causes.
With actual doctors, they will take blood work, perform tests to find the actual virus, bacteria or other cause.
They find the cause, not just a list of symptoms.
Psychology and psychiatry is only now starting to actually research causes.
This is very much in line with the research-alternative to DSM— the so-called RDoC — which takes a clustering vs category approach:
https://www.nimh.nih.gov/research/research-funded-by-nimh/rd...
https://www.nimh.nih.gov/research/research-funded-by-nimh/rd...
Psychiatry is loosely based on science and 90% of the drugs they prescribe are net harmful
I really like the approach, this is exactly what statistical tools are for. I like it all the way up to the very end, where I feel this report drops the ball, in trying to derive a hierarchy from the results.
Hierarchies don't exist. Nothing in nature is organized in trees (data structures), not even actual trees (the other kind). Organization, relationships, form directed graphs (or the continuous domain equivalent). Hierarchies are deceptively simple because they planarize, meaning you can draw them on paper without crossing lines, or introducing indirect references. But that's often as deceiving as it is helpful.
Think of the "tree of life" - there is no one tree of life, its shape depends on which aspects of phenotype or genotype you select and organize around. Think of corporations and governments - you can either accept there's a lot of "dotted lines" in the org chart, turning it into a dense DAG, or never understand why people do what they do. And so here, it's also quite apparent there are correlations cutting across the proposed hierarchy, clearly visible even on Figure 2 - the one that urges us to disregard the left-to-right ordering of the constructs.
I mean, the researchers are likely perfectly aware of this. My worry is that 90%+ of the insight of the proposed model will get lost in final planarization into a hierarchy that gets into the next DSM.
Hierarchies don't exist. Nothing in nature is organized in trees (data structures), not even actual trees (the other kind). Organization, relationships, form directed graphs (or the continuous domain equivalent). Hierarchies are deceptively simple because they planarize, meaning you can draw them on paper without crossing lines, or introducing indirect references. But that's often as deceiving as it is helpful.
Think of the "tree of life" - there is no one tree of life, its shape depends on which aspects of phenotype or genotype you select and organize around. Think of corporations and governments - you can either accept there's a lot of "dotted lines" in the org chart, turning it into a dense DAG, or never understand why people do what they do. And so here, it's also quite apparent there are correlations cutting across the proposed hierarchy, clearly visible even on Figure 2 - the one that urges us to disregard the left-to-right ordering of the constructs.
I mean, the researchers are likely perfectly aware of this. My worry is that 90%+ of the insight of the proposed model will get lost in final planarization into a hierarchy that gets into the next DSM.
I'm very happy that they are trying to re-classify the DSM, it's probably the sign of a maturing medical field. Let's also hope that re-clustering will help with the reproduction crisis.
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wow. thats mind bending right there... I'd love to see it with some additional dimensions to it. even a 3D graph would be super interesting no doubt
The raw data are in hundreds of dimensions. To visualize it meaningfully I think you’d need to run a t-SNE clustering, which would be fine in 2D. Raw PCA or anything like that which preserves the original structure probably wouldn’t show much even in 3D. But it would be fun to see the clusters more directly.
That’s interesting. Aren’t there some social contagions that are listed in DSM? I would think those basically require large groups of varying symptoms.
Not an expert, but I don’t think - and cursory googling seems to agree - there are any “social contagions” in the dsm. The concept is not exactly proven science, and it’s worth mentioning that it’s also a bit of a dogwhistle term used to undermine a lot of queer and gender identities.
Fwiw I think it’s patently obvious behaviors can influence people, but in my mind they influence the avenue of expression - they don’t create disorders from scratch. So like e.g. body image would be the underlying disorder, and if it expresses as bulimia or anorexia or cutting could be somewhat “socially contagious”.
Fwiw I think it’s patently obvious behaviors can influence people, but in my mind they influence the avenue of expression - they don’t create disorders from scratch. So like e.g. body image would be the underlying disorder, and if it expresses as bulimia or anorexia or cutting could be somewhat “socially contagious”.
They are correct in terms of eating disorders, bulimia is socially contagious.
But what does that mean? Like if you spend time around someone with bulimia there’s a chance you’ll get it too? That doesn’t seem right to me.
What does seem right to me is if you feel fucked up about your body and your attractiveness, how you express that can be influenced by what you see other people doing. But if you feel confident about yourself there is no amount of hanging out with people with eating disorders that will give you one…
What does seem right to me is if you feel fucked up about your body and your attractiveness, how you express that can be influenced by what you see other people doing. But if you feel confident about yourself there is no amount of hanging out with people with eating disorders that will give you one…
Just looking at this specific paper, it suggests that eating disorders are part of a general emotional dysfunction spectrum. In practice, we're probably not talking about confident people.
From my anecdotal experience with people I've known, it makes sense that the other symptoms in that spectrum, like bloating and anxiety, could make someone more receptive to unrealistic body standards and "solutions" to achieve those standards and regain control. That's what it's really about: not feeling in control.
From my anecdotal experience with people I've known, it makes sense that the other symptoms in that spectrum, like bloating and anxiety, could make someone more receptive to unrealistic body standards and "solutions" to achieve those standards and regain control. That's what it's really about: not feeling in control.
Read up, there's plenty of literature, there's no need for something to make sense before you actually read up on it.
You seem confident of your statement that bulimia is socially contagious. I am asking you to clarify what that means to you specifically.
If you’d like to link a paper that has informed your understanding, i’d be happy to read it. But telling me to “read up on it” is a weird dodge of a direct question. Have you read up on it?
I have read a little, not a lot - but what i have read makes a case for some influence of social groups but doesn’t make a case for eating disorders being contagious like viruses.
If you’d like to link a paper that has informed your understanding, i’d be happy to read it. But telling me to “read up on it” is a weird dodge of a direct question. Have you read up on it?
I have read a little, not a lot - but what i have read makes a case for some influence of social groups but doesn’t make a case for eating disorders being contagious like viruses.
I mean when I was a kid nobody did it, when I was in highschool all the classes had at least 3 girls doing it and nowadays nobody does it anymore at those rates (I have 2 friends who now teach at the highschool we went to). Thats what it means to me. And there's plenty of papers documenting this rise and fall which happened to line up with my generation. Regarding papers I read some when this topic came up in a podcast and was convinced and there were a lot of results for a query like "social contagion bulimia papers".
The DSM exists to satisfy US medical insurance industry which requires the patient be diagnosed with a specific "condition" before they will pay for anything.
That’s one reason. Another less cynical reason is to ensure professionals mean the same thing when they use specific words. Brains are complicated, of course. Making predictions about how one person will react to medication based on their experiences is very difficult. Being able to collect data and group it consistently makes this prediction task much easier. “We known that many people who answer these questions with these answers improve after taking this medicine.” That’s genuinely useful, needs the DSM or something like it, and has nothing to do with insurance.
you've checkboxed two fallacies with one stone: motivated reasoning, and attribution of malice. I am defending reasoning and logic here, not insurance industry. what you said might be true but you need to back up your claims.
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In 2022 psychiatrist Chris Palmer MD [0] published Brain Energy [1], which shares his discovery of the 70+ years of science establishing that the behavioral/mental symptoms traditionally given 'psychiatric' labels are caused by metabolic problems. When you fix the body's metabolism the symptoms go away.
Dr. Palmer recommends the ketogenic diet, but not all people need this specific intervention to improve their metabolism. I think the best place to start for most people is simply eliminating their consumption of white flour, or at the least, fortified white flour [2].
Dr. Palmer tweeted about anemia and Vitamin B-12 deficiency [3]. Many patients are prescribed synthroid (T4) for their thyroid, but they often still have all the symptoms of hypothyrodism because their body doesn't activate T4 -> T3. Adding a source of T3 to patients' Synthroid treatment can make a big difference in their behavioral symptoms.
I have a book by some psychiatrists who were active in the 1940's -> 1950's, which is before the first 'psychiatric' medications were released. I didn't know this book was compiled by psychiatrists when I ordered it - I thought it was going to be a general book about the pro-metabolic intervention.
It's unfortunate that the prescription drug industry never figured out why some of their chemicals help with the symptoms labeled 'depression'. The MAOIs were reasonably-effective at helping acutely-depressed people out of bed. Each generation of antidepressants was less effective than the previous, until the SSRI's arrived. Now we're stuck with antidepressants that have always been known to cause people to commit suicide. At least the psychiatrists are now revisiting MAOIs as an option for people who don't respond well to the suicide pills (SSRIs).
Antipsychotics are a tragedy: anti-dopamine drugs make patients feel terrible. The one exception to the anti-treatment received by psychotics is an anti-serotonin drug approved for parkinsons psychosis [4].
[0] https://www.chrispalmermd.com/ https://twitter.com/ChrisPalmerMD/
[1] https://brainenergy.com/
[2] Flour manufacturers tend to use the cheapest fortifications possible. For example, the type of iron used for fortification is usually simply 'iron shavings', which usually becomes rust by the time it's absorbed.
[3] https://twitter.com/ChrisPalmerMD/status/1903071654328111413
[4] https://pmc.ncbi.nlm.nih.gov/articles/PMC5819716/
Dr. Palmer recommends the ketogenic diet, but not all people need this specific intervention to improve their metabolism. I think the best place to start for most people is simply eliminating their consumption of white flour, or at the least, fortified white flour [2].
Dr. Palmer tweeted about anemia and Vitamin B-12 deficiency [3]. Many patients are prescribed synthroid (T4) for their thyroid, but they often still have all the symptoms of hypothyrodism because their body doesn't activate T4 -> T3. Adding a source of T3 to patients' Synthroid treatment can make a big difference in their behavioral symptoms.
I have a book by some psychiatrists who were active in the 1940's -> 1950's, which is before the first 'psychiatric' medications were released. I didn't know this book was compiled by psychiatrists when I ordered it - I thought it was going to be a general book about the pro-metabolic intervention.
It's unfortunate that the prescription drug industry never figured out why some of their chemicals help with the symptoms labeled 'depression'. The MAOIs were reasonably-effective at helping acutely-depressed people out of bed. Each generation of antidepressants was less effective than the previous, until the SSRI's arrived. Now we're stuck with antidepressants that have always been known to cause people to commit suicide. At least the psychiatrists are now revisiting MAOIs as an option for people who don't respond well to the suicide pills (SSRIs).
Antipsychotics are a tragedy: anti-dopamine drugs make patients feel terrible. The one exception to the anti-treatment received by psychotics is an anti-serotonin drug approved for parkinsons psychosis [4].
[0] https://www.chrispalmermd.com/ https://twitter.com/ChrisPalmerMD/
[1] https://brainenergy.com/
[2] Flour manufacturers tend to use the cheapest fortifications possible. For example, the type of iron used for fortification is usually simply 'iron shavings', which usually becomes rust by the time it's absorbed.
[3] https://twitter.com/ChrisPalmerMD/status/1903071654328111413
[4] https://pmc.ncbi.nlm.nih.gov/articles/PMC5819716/
There are countless examples of past doctors claiming that psychiatric disorders are caused by some simple dietary issue. You can find people claiming that everything can be fixed by ketogenic diets, vegan diets, carnivore diets, Vitamin B12, niacin, magnesium, fish oil, you name it. For any vitamin or diet there is someone out there making passionate claims that it solves everything.
None of these hold up under actual studies. It’s the domain of wishful thinking that sadly preys upon people desperate for answers. Some times the placebo effect works for a while, but usually people just end up with a cabinet full of supplement bottles and a history of fad diets with no progress on their condition.
None of these hold up under actual studies. It’s the domain of wishful thinking that sadly preys upon people desperate for answers. Some times the placebo effect works for a while, but usually people just end up with a cabinet full of supplement bottles and a history of fad diets with no progress on their condition.
The dietary issue is infection (usually two or more, basic shit like candida in the gut, mold exposure, EBV recurrence, Lyme, parasites, more) causing systemic malnourishment, and lack of homeostasis, causing nervous and endocrine issues/misfires,
(at which point you'll often notice immunodeficiencies, minor "unexplainable" abnormalities in bloodwork),
and indeed cognitive issues, depression, anxiety, and other more severe brain malfunctions.
(at which point you'll often notice immunodeficiencies, minor "unexplainable" abnormalities in bloodwork),
and indeed cognitive issues, depression, anxiety, and other more severe brain malfunctions.
> None of these hold up under actual studies
I agree with you overall, but interestingly, research really has found a link between lower Vitamin B12/B6/B2 levels and ADHD. Also lower Vitamin D, and delayed circadian rhythm. You certainly can't use supplements as a replacement for stimulants but they may help.
I agree with you overall, but interestingly, research really has found a link between lower Vitamin B12/B6/B2 levels and ADHD. Also lower Vitamin D, and delayed circadian rhythm. You certainly can't use supplements as a replacement for stimulants but they may help.
A sizable (3-10%) part of the population can either not digest lactose or has a significantly reduced ability to absorb fructose in the gut. The resulting fermentation and low dosing of low quality alcohol can cause cognitive symptoms which can be totally alleviated by appropriate diet.
It is easy to test (drink a sugar challenge drink and measure H2 in breath) but as it is time consuming and not profitable rarely done.
It is easy to test (drink a sugar challenge drink and measure H2 in breath) but as it is time consuming and not profitable rarely done.
Are you conflating lactose intolerance with autobrewery syndrome? O.o
I find the "autobrewery" term hilarious and great.
Imagine being able to be constantly buzzed just by eating some random fruits. it almost seems too good to be true.
In all seriousness I'm sure that people suffering from it don't appreciate it that much, but at first glance it seems like a positive problem to have!
The diabetes and cancer are probably far from a giggle.
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I've had video calls with a doc who took maybe 5 minutes at most of hearing subjective experiences to confidently reach a conclusion. I've also had a 45 minute "by the book" DSM-based session where boxes were being ticked... and the questions were f---ing *terrible*, if you pardon my French. "Do you have trouble concentrating" is terribly vague and can always be justified either way. Not to mention, it takes maybe a few moments to "catch on" on how to answer which questions; which seems to be a terrible way of introducing bias into the answers (as also mentioned in the article). Having someone describe their personal life is in many ways much better because it cannot be a rigid yes/no question.
And all this talk is without mentions of other aspects that also need addressing, like the continuous spectrum of many conditions...