As someone who would absolutely have been diagnosed with ADHD had it existed when I was a kid, and whose later-in-life diagnosis and medication has made me a FAR better employee (and a safer driver!), I’ve wondered about the idea of “spectrum disorders.” Not in the autism spectrum sense, exactly, but just where the edge of the natural bell curve is so maladaptive that it feels like a disorder. Vision happens along a bell curve, and when it’s bad enough it’s a problem and you need glasses. My experience of being really easily distracted to the point that I have low object permanence and get bored easily is that I get bored like anybody else, but more so, and more easily. Happiness is along a bell curve, with some people (me) being freakishly happy and others being unusually unhappy—depression.
In these cases, I wouldn’t go as far as saying that this is the social model of disability. (ADHD as culturally adaptive among hunter gatherers? BS. I would absolutely have been eaten by a lion while distracted by a pretty flower.) But I think it’s worth putting a category around when normal variation is a real problem, and if it can be addressed with medical interventions, be they eyeglasses or amphetamines, that’s not a bad thing.
Yeah, I will say speaking personally, I used to be very skeptical of the "learned helplessness" / "reverse CBT" idea and have now come around to the idea that I've succumbed to that at points in my life. But I'm still wary of the "overmedicalization" frame, because being prescribed ADHD medication was a key turning point in me getting past that. A lot of what I see people mention as the "real cure" for mental health problems (making plans with friends, eating fresh fruit, going outside and being more physically active) are things that I've been doing a lot more recently to very positive effect, but the underlying executive dysfunction is what made it hard for me to make habits of those things before. The medical / pharmaceutical approach was what most effectively addressed that core problem, and the non-medical day-to-day habits became achievable and effective in large part as a result of that.
As an internist your discussion of psychological disorders absolutely tracks. I would add that adult ADHD is often best managed through behavioral and cognitive strategies rather than stimulants anyway so that even if a diagnosis is more prevalent (and perhaps smartphones are playing a role), it can still be helpful for people to learn these cognitive strategies to improve their functioning.
When it comes to cancer or neurodegenerative diseases I think we’re in a very different place. Rather than adding to the list of generalized screening recommendations, we are now using family and personal history to recommend genetic testing for select patients that can determine whether they will benefit from additional screening. In the UK a genetic test accurately predicted which patients were at risk of aggressive prostate cancer so that the decision to pursue biopsy was much easier. It’s not hard to imagine this being applied to other cancers that are uncommon. We often do this for breast cancer already. These kind of screening tests are exciting and will continue to improve early detection. I wouldn’t lump them into the same category of “over-diagnosis” or medicalization.
"For many Americans, perhaps, what we used to call forgetfulness is now labeled ADHD. What we used to call a lack of motivation is now labeled depression. What we used to call nervousness is now clinical social anxiety. What we used to call awkwardness is now labeled autism. In this telling, it’s not our biology or our psychology that has changed. It’s our words."
Clinicians know very well how to differentiate these things.
No medical doctor is mistaking social awkwardness for autism.
Except that brains are malleable. If you keep asking people if they are doing ok, if they have anxiety or depression, you can actually change things.
Not to mention, let's not pretend that each patient is getting a ton of time from each doctor. Quite often they are in and out REALLY quickly.
You go in to your primary doctor, mention you are stressed out and worried. Doctor says you must have anxiety, you are in an out in 10 mins to 15 mins tops.
Finally, a personal anecdote. I never had anxiety or depression problems, very easy and outgoing. Around 35ish all of a sudden I got horrible anxiety and brain fog among other problems. I saw many different doctors, internists, neurologists, gastrintologists, as well as less traditional methods.
Slowly, I got a bit better but not much. Finally 5 or so years later I moved, got a new primary doctor. The new doctor tested my hormones, oops my testosterone was almost nonexistent.
Started on that and my other problems were 90%+ fixed.
My late diagnosis of ADHD came way too late to help me in school -- I had a miserable time in elementary & was always punished for failing to do the expected & constantly out of line. Then, starting in 8th grade I slowly figured.out how to overcome the problems in my mental functioning until I graduated from law school. I d/n know that everyone did not have to deal with these. I never entirely overcame my handicaps but having hyper focus & being intelligent helped.
Lack of motivation, it was a severe handicap, as was anxiety. Treatment helped but they have persisted. Sometimes I wonder how much more I could have accomplished had I not constantly trying to overcome those handicaps. But I am very grateful for the help I got from antidepressants & anti-anxiety meds. I never became addicted, but they allowed me to function.
For ADHD, I think part of the problem is that Adderall and other stimulants are very useful for lots of people. We used to achieve similar things with large amounts of cigarettes and coffee, but a turn toward health-consciousness has made that sort of behavior seem extreme rather than normal. But I think lots of modern jobs still call for powerful stimulants!
We created a weird situation though where in order to access the best and latest stimulants, you need to establish that you "have" something called ADHD.
Yeah, black coffee is fine. I think in practice the secret sauce was often the combination of coffee and cigs as a sort of complex dynamic system, and modern drugs are good enough to replace the whole system with a pill you take once a day.
I'm a psychiatrist who often writes about conceptual and philosophical issues around diagnosis. My discussion of the confusing ways in which we talk about "overdiagnosis," both professionally and publicly, may also be of interest to folks: https://www.psychiatrymargins.com/p/the-overdiagnosis-confusion
Yes, that's a fair point! I was listing conditions that O'Sullivan addressed in an overview of her work, rather than conditions that she explicitly mentioned in the context of over-diagnosis. And since I've never deeply reported out any over-diagnosis or detection in this space, I'll remove the reference to avoid confusion.
I have long pondered the very points made in this article. Sometimes putting a name to something helps a great deal but I feel medicalisation is making people collectors of unhelpful labels.
I read and read about how, past a certain age, screening for prostate cancer wasn't necessary. So, being someone who always tries to follow the science, I stopped getting PSAs.
Then we moved and I got a new family physician. She took no crap and ordered me a PSA.
I had prostate cancer. Not the kind you die with, but the kind you die from. My Gleason score was 9, which statistically predicts that only 30-50% of men are still alive five years later (and many of those will be alive with metastasis).
Basically, now, though, I'm cured. 5 1/2 years later NO evidence of metastasis. My Oncologist and Urologist are VERY pleased. I live with a lot of side effects of my treatments, but what kind of a person, who is alive, would complain about that?
So I'm not very objective on this issue of over detection. I'm perhaps an exception to the points made here, and I understand the issue of anecdotes versus data. (I'm an anecdote). There will be many men who will be overtreated if they find they have prostate cancer when they are elderly that basically won't spread or shorten their lives.
(p.s. I was a child psychologist......the over diagnosis of children these days frightens me. As I said at the start, this was another good article by Thompson)
Anecdotally it seems like ADHD is a diagnosis that helps smart, ambitious people get drugs that help them stay awake and concentrate better. In these cases it seems less like a disease than like a "condition I don't like" that is remediable with chemicals.
I'd be too embarrassed to ask a doctor for such remedies, as much as I might be able to use them. But I'm 65 and endured pretty serious untreated depression for decades because, having grown up in the Freudian era, I thought I couldn't be depressed, because I'd had a happy childhood and good parents.
Another interesting aspect is the development of hierarchies of desirability between illnesses — how do we balance the necessary, compassionate processes of de-stigmatization without simultaneously remaking labels as comfortable, implacable markers one can continually rely on to communicate their identity to the world?
Definitely agree with the autism angle. I've encountered a fair amount of adult males who used to be "a little odd" or "quirky" in the old days are now autistic.
Men and women are different. It's ridiculous that even needs to be stated.
Sometimes the guy is not autistic. He's just being a guy.
Thank you, Derek, for a thoughtful and thought-provoking article. Here's my experience with neurological diversity and a culture of diagnosis: it's nuanced and often involved hard choices (no surprise). My daughter has a relatively slight learning disability and relatively mild ADHD. ADHD is a soft diagnosis-- suspected by the educational pyschologist who tested her in grade 4-- whereas the other tests she did confirmed her struggles with abstract reasoning and keeping information in short term memory (she's terrible at math and was slow to read). These diagnosis helped me advocate for her to get accommodations in school and a medication to help with focus. She has good grades- As and Bs, takes AP classes, works very hard in school and hates math with the passion of a 1000 suns. But in spite of my very best efforts to avoid labels, she has also labeled herself.... she jokingly/seriously calls herself one of the SPED kids. Sigh. But my choice as a parent was to not get her accommodations, extra help, etc. and have her label herself as "stupid" and as a terrible student!! To have no outside explanation for the her real struggles. My hope is that, going forward, she will be able to learn strategies and techniques so she doesn't have to take ADHD meds all her life! But all those techniques require.. focus, dedication, executive function-- all the things that ADHD kids struggle with. Can't DO the training if you can't focus on the training. Can't get to the long term goal if you can't conceive of the long term goal! Again thank you.
Several of these physicians begin with the premise that healthcare is supposed to heal. That is a very old idea in medicine but not necessarily a fully relevant one. Our definition of medicine itself has broadened. We have seen the field of medicine shift gears significantly from the days when "doctor as healer" was its raison d'être. Physicians who want to resist that shift are quoted here. They are in medicine to see patients "get better." And, darn it, we all like that to happen. But it is at odds with the broadening goals of medical care and, indeed, current medical education.
In the U.S., medicine has become the front lines of social work. Many doctors have seen that shift happen during the course of their careers. Therefore, what doctors consider both the threshold for intervention and the mission of medicine has shifted (even if our health insurance and the medical field at large are running to catch up). For example, medicine is more than science; therefore, saying "There's nothing scientific about [broadening diagnoses]. We made a societal decision to increase autism diagnoses" is far from the gotcha O'Sullivan seems to believe it to be. The issue of over-diagnosis is a reflection of the fact that people no longer simply look to medicine to help them address physical suffering they can't manage independently. They want prevention, optimization, and collaborative support.
Is it ideal that our primary social safety net should be our clinics and our hospitals? No. But that vacuum is a structural issue upheld and, at times, created by the government, communities, and American culture. At the heart of the hand-wringing here is not a debate about how and why medicine is engaging with patients' growing needs. It is, instead, anxiety over the future of medicine, our shifting patient expectations, and the ongoing ambiguity of collaborative population care.
A while back I found comfort in a Twitter sub community of people suffering from similar issues as myself. At the time I saw a lot of young people who self-diagnosed, and there was a big debate about whether that was even helpful. I think some people see diagnosis as validation, rather than a treatment tool, and so anything that might threaten that diagnosis (or self-diagnosis) is seen as an absolute harm. diagnosis without treatment to me sounds meaningless since what is one supposed to do with it? But for the people who saw diagnosis as the end state, as validation of their suffering, my musings were received as minimizing their pain, which of course wasn’t my intent.
As someone who would absolutely have been diagnosed with ADHD had it existed when I was a kid, and whose later-in-life diagnosis and medication has made me a FAR better employee (and a safer driver!), I’ve wondered about the idea of “spectrum disorders.” Not in the autism spectrum sense, exactly, but just where the edge of the natural bell curve is so maladaptive that it feels like a disorder. Vision happens along a bell curve, and when it’s bad enough it’s a problem and you need glasses. My experience of being really easily distracted to the point that I have low object permanence and get bored easily is that I get bored like anybody else, but more so, and more easily. Happiness is along a bell curve, with some people (me) being freakishly happy and others being unusually unhappy—depression.
In these cases, I wouldn’t go as far as saying that this is the social model of disability. (ADHD as culturally adaptive among hunter gatherers? BS. I would absolutely have been eaten by a lion while distracted by a pretty flower.) But I think it’s worth putting a category around when normal variation is a real problem, and if it can be addressed with medical interventions, be they eyeglasses or amphetamines, that’s not a bad thing.
Yeah, I will say speaking personally, I used to be very skeptical of the "learned helplessness" / "reverse CBT" idea and have now come around to the idea that I've succumbed to that at points in my life. But I'm still wary of the "overmedicalization" frame, because being prescribed ADHD medication was a key turning point in me getting past that. A lot of what I see people mention as the "real cure" for mental health problems (making plans with friends, eating fresh fruit, going outside and being more physically active) are things that I've been doing a lot more recently to very positive effect, but the underlying executive dysfunction is what made it hard for me to make habits of those things before. The medical / pharmaceutical approach was what most effectively addressed that core problem, and the non-medical day-to-day habits became achievable and effective in large part as a result of that.
As an internist your discussion of psychological disorders absolutely tracks. I would add that adult ADHD is often best managed through behavioral and cognitive strategies rather than stimulants anyway so that even if a diagnosis is more prevalent (and perhaps smartphones are playing a role), it can still be helpful for people to learn these cognitive strategies to improve their functioning.
When it comes to cancer or neurodegenerative diseases I think we’re in a very different place. Rather than adding to the list of generalized screening recommendations, we are now using family and personal history to recommend genetic testing for select patients that can determine whether they will benefit from additional screening. In the UK a genetic test accurately predicted which patients were at risk of aggressive prostate cancer so that the decision to pursue biopsy was much easier. It’s not hard to imagine this being applied to other cancers that are uncommon. We often do this for breast cancer already. These kind of screening tests are exciting and will continue to improve early detection. I wouldn’t lump them into the same category of “over-diagnosis” or medicalization.
"For many Americans, perhaps, what we used to call forgetfulness is now labeled ADHD. What we used to call a lack of motivation is now labeled depression. What we used to call nervousness is now clinical social anxiety. What we used to call awkwardness is now labeled autism. In this telling, it’s not our biology or our psychology that has changed. It’s our words."
Clinicians know very well how to differentiate these things.
No medical doctor is mistaking social awkwardness for autism.
Except that brains are malleable. If you keep asking people if they are doing ok, if they have anxiety or depression, you can actually change things.
Not to mention, let's not pretend that each patient is getting a ton of time from each doctor. Quite often they are in and out REALLY quickly.
You go in to your primary doctor, mention you are stressed out and worried. Doctor says you must have anxiety, you are in an out in 10 mins to 15 mins tops.
Finally, a personal anecdote. I never had anxiety or depression problems, very easy and outgoing. Around 35ish all of a sudden I got horrible anxiety and brain fog among other problems. I saw many different doctors, internists, neurologists, gastrintologists, as well as less traditional methods.
Slowly, I got a bit better but not much. Finally 5 or so years later I moved, got a new primary doctor. The new doctor tested my hormones, oops my testosterone was almost nonexistent.
Started on that and my other problems were 90%+ fixed.
My late diagnosis of ADHD came way too late to help me in school -- I had a miserable time in elementary & was always punished for failing to do the expected & constantly out of line. Then, starting in 8th grade I slowly figured.out how to overcome the problems in my mental functioning until I graduated from law school. I d/n know that everyone did not have to deal with these. I never entirely overcame my handicaps but having hyper focus & being intelligent helped.
My depression definitely was NOT just a matter of
Lack of motivation, it was a severe handicap, as was anxiety. Treatment helped but they have persisted. Sometimes I wonder how much more I could have accomplished had I not constantly trying to overcome those handicaps. But I am very grateful for the help I got from antidepressants & anti-anxiety meds. I never became addicted, but they allowed me to function.
For ADHD, I think part of the problem is that Adderall and other stimulants are very useful for lots of people. We used to achieve similar things with large amounts of cigarettes and coffee, but a turn toward health-consciousness has made that sort of behavior seem extreme rather than normal. But I think lots of modern jobs still call for powerful stimulants!
We created a weird situation though where in order to access the best and latest stimulants, you need to establish that you "have" something called ADHD.
Agreed, but an important note. Coffee isn't bad for you (at least black coffee isn't)
Yeah, black coffee is fine. I think in practice the secret sauce was often the combination of coffee and cigs as a sort of complex dynamic system, and modern drugs are good enough to replace the whole system with a pill you take once a day.
I'm a psychiatrist who often writes about conceptual and philosophical issues around diagnosis. My discussion of the confusing ways in which we talk about "overdiagnosis," both professionally and publicly, may also be of interest to folks: https://www.psychiatrymargins.com/p/the-overdiagnosis-confusion
Your article very clearly and articulately describes the nuance behind “over diagnosis.” Excellent writing.
Trust me, Derek, my migraines aren’t psychological. They are neurological. No psychological or psychiatric problems here.
Yes, that's a fair point! I was listing conditions that O'Sullivan addressed in an overview of her work, rather than conditions that she explicitly mentioned in the context of over-diagnosis. And since I've never deeply reported out any over-diagnosis or detection in this space, I'll remove the reference to avoid confusion.
Thank you! I very much appreciate the good faith.
Yeah, I was disappointed to see migraine mentioned here. Migraine is more akin to epilepsy than anxiety.
Migraines are clearly neurological, not to mention heritable.
I have long pondered the very points made in this article. Sometimes putting a name to something helps a great deal but I feel medicalisation is making people collectors of unhelpful labels.
Good article.
I read and read about how, past a certain age, screening for prostate cancer wasn't necessary. So, being someone who always tries to follow the science, I stopped getting PSAs.
Then we moved and I got a new family physician. She took no crap and ordered me a PSA.
I had prostate cancer. Not the kind you die with, but the kind you die from. My Gleason score was 9, which statistically predicts that only 30-50% of men are still alive five years later (and many of those will be alive with metastasis).
Basically, now, though, I'm cured. 5 1/2 years later NO evidence of metastasis. My Oncologist and Urologist are VERY pleased. I live with a lot of side effects of my treatments, but what kind of a person, who is alive, would complain about that?
So I'm not very objective on this issue of over detection. I'm perhaps an exception to the points made here, and I understand the issue of anecdotes versus data. (I'm an anecdote). There will be many men who will be overtreated if they find they have prostate cancer when they are elderly that basically won't spread or shorten their lives.
(p.s. I was a child psychologist......the over diagnosis of children these days frightens me. As I said at the start, this was another good article by Thompson)
I did one of those random MRIs--discovered I was born with one kidney. Good to know!
Anecdotally it seems like ADHD is a diagnosis that helps smart, ambitious people get drugs that help them stay awake and concentrate better. In these cases it seems less like a disease than like a "condition I don't like" that is remediable with chemicals.
I'd be too embarrassed to ask a doctor for such remedies, as much as I might be able to use them. But I'm 65 and endured pretty serious untreated depression for decades because, having grown up in the Freudian era, I thought I couldn't be depressed, because I'd had a happy childhood and good parents.
Another interesting aspect is the development of hierarchies of desirability between illnesses — how do we balance the necessary, compassionate processes of de-stigmatization without simultaneously remaking labels as comfortable, implacable markers one can continually rely on to communicate their identity to the world?
Definitely agree with the autism angle. I've encountered a fair amount of adult males who used to be "a little odd" or "quirky" in the old days are now autistic.
Men and women are different. It's ridiculous that even needs to be stated.
Sometimes the guy is not autistic. He's just being a guy.
Thank you, Derek, for a thoughtful and thought-provoking article. Here's my experience with neurological diversity and a culture of diagnosis: it's nuanced and often involved hard choices (no surprise). My daughter has a relatively slight learning disability and relatively mild ADHD. ADHD is a soft diagnosis-- suspected by the educational pyschologist who tested her in grade 4-- whereas the other tests she did confirmed her struggles with abstract reasoning and keeping information in short term memory (she's terrible at math and was slow to read). These diagnosis helped me advocate for her to get accommodations in school and a medication to help with focus. She has good grades- As and Bs, takes AP classes, works very hard in school and hates math with the passion of a 1000 suns. But in spite of my very best efforts to avoid labels, she has also labeled herself.... she jokingly/seriously calls herself one of the SPED kids. Sigh. But my choice as a parent was to not get her accommodations, extra help, etc. and have her label herself as "stupid" and as a terrible student!! To have no outside explanation for the her real struggles. My hope is that, going forward, she will be able to learn strategies and techniques so she doesn't have to take ADHD meds all her life! But all those techniques require.. focus, dedication, executive function-- all the things that ADHD kids struggle with. Can't DO the training if you can't focus on the training. Can't get to the long term goal if you can't conceive of the long term goal! Again thank you.
Several of these physicians begin with the premise that healthcare is supposed to heal. That is a very old idea in medicine but not necessarily a fully relevant one. Our definition of medicine itself has broadened. We have seen the field of medicine shift gears significantly from the days when "doctor as healer" was its raison d'être. Physicians who want to resist that shift are quoted here. They are in medicine to see patients "get better." And, darn it, we all like that to happen. But it is at odds with the broadening goals of medical care and, indeed, current medical education.
In the U.S., medicine has become the front lines of social work. Many doctors have seen that shift happen during the course of their careers. Therefore, what doctors consider both the threshold for intervention and the mission of medicine has shifted (even if our health insurance and the medical field at large are running to catch up). For example, medicine is more than science; therefore, saying "There's nothing scientific about [broadening diagnoses]. We made a societal decision to increase autism diagnoses" is far from the gotcha O'Sullivan seems to believe it to be. The issue of over-diagnosis is a reflection of the fact that people no longer simply look to medicine to help them address physical suffering they can't manage independently. They want prevention, optimization, and collaborative support.
Is it ideal that our primary social safety net should be our clinics and our hospitals? No. But that vacuum is a structural issue upheld and, at times, created by the government, communities, and American culture. At the heart of the hand-wringing here is not a debate about how and why medicine is engaging with patients' growing needs. It is, instead, anxiety over the future of medicine, our shifting patient expectations, and the ongoing ambiguity of collaborative population care.
Recommended reading: Crazy Like Us, about the globalization of Western concepts of psychopathology and psychopharmacology.
A while back I found comfort in a Twitter sub community of people suffering from similar issues as myself. At the time I saw a lot of young people who self-diagnosed, and there was a big debate about whether that was even helpful. I think some people see diagnosis as validation, rather than a treatment tool, and so anything that might threaten that diagnosis (or self-diagnosis) is seen as an absolute harm. diagnosis without treatment to me sounds meaningless since what is one supposed to do with it? But for the people who saw diagnosis as the end state, as validation of their suffering, my musings were received as minimizing their pain, which of course wasn’t my intent.