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Adult Diagnosis & Treatment This forum is for the discussion of issues related to the diagnosis of AD/HD

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  #1  
Old 09-19-05, 08:47 PM
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Note on the DSM-IV and Diagnosis

I thought it would be important to point this out to people about the DSM, because for too long I've seen people either misuse DSM criteria for their diagnoses (or self-diagnoses) or not understand what that list really is.

The DSM is not an arbitrary list of things that if you meet, you have ADHD. Those criteria are not made up, and the disorder based on the criteria. The criteria are generated by what symptoms an individual with a disorder are statistically likely to have. An individual who has the symptoms doesn't have ADHD. An individual who has ADHD, however, does have the symptoms.

The diagnostic tool is that it allows trained professionals to determine whether or not an individual is likely to have a disorder based on the symptoms. The symptoms don't make the disorder, however; the disorder makes the symptoms.

The DSM was written by evaluating individuals with ADHD, and determining the symptoms those individuals were most likely to demonstrate; not vice versa. This is important to know for individuals who say "if you meet the criteria, you have the disorder." In fact, the exact opposite is true: if you have the disorder, you meet the criteria.

That makes it difficult for people to read a list and determine if they have something, and in fact it should. The DSM is not to be used alone to make diagnoses based on checklists. If that were the case, I guarantee I could make any individual meet virtually any disorder.

Instead, the criteria are used by clinicians to help them determine, through vasts amounts of training and experience, what the most likely and best diagnosis is. This is one of the reasons I get very upset when non-psychiatric professionals (general practitioners, pediatricians, etc.) without formal psychiatric/psychological schooling, make ADHD diagnoses: the fact is, with some exceptions (those who have taken training on diagnosis of psychiatric disorders), they don't have the training or experience necessary to make a reliable judgment.

Please always bear in mind: symptoms don't make disorders. Disorders make symptoms.

A little information is a bad thing. The criteria from the DSM people so often look at online is not complete. Another important part of the DSM that is not included in online criteria is the indepth information and the "differential diagnosis" section. This section is specifically designed to ensure that it is the diagnosis being made, and not a similar disorder. This is important because in many cases, the comorbid disorders talked about a lot here and other places are actually either aspects of the ADHD diagnosis (and not another disorder) or the actual problem (and ADHD is not present.) For example, individuals with Asperger's Disorder who demonstrate ADHD like symptoms do not have ADHD. They have Asperger's Disorder. That the symptoms are similar does not mean both conditions exist.

I am debating whether I should type up the entire entry on ADHD in the DSM (it's 3 or 4 pages long) and post it here. Part of me wants to, to allow people a more accurate look of what symptoms are often attributed to ADHD. The other part, however, tells me not to, because it will just let people misdiagnose further, or cause other problems. I'd like to know what you guys want from that, or if you want to flay me because I'm railing against self-diagnosis, etc...
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Old 09-19-05, 08:51 PM
mctavish23 mctavish23 is offline
 

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K.Miller,

First of all, welcome back.

Secondly, thank you for that post. Excellent points.

I've posted on this before, and I know I've read some of Barkley's comments on the subject that scuro has posted.

I can not agree more. Without the diagnostic criteria being met, the symptoms are meaningless.

As I've said many times before, "The clinical threshold is impairment.No impairment,no disorder."
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Old 09-19-05, 09:01 PM
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Impairment, as well as clinical diagnostic criteria which, most importantly, cannot be assessed based on the criteria list alone. Most of the important details concerning the definitions of the terms are not on the short list of diagnostic criteria seen most often online. Though that list is part of the criteria, and lists the major parts, meeting 9 of 14 criteria alone does not make a viable diagnosis.
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Old 09-19-05, 10:42 PM
mctavish23 mctavish23 is offline
 

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I agree.

When I get the chance, I'll be glad to post some of the information presented by Russ Barkley in a March teleconference on ADHD in Adults.

He points out how , for adults, the symptoms need to be "age referenced," meaning they need to apply to adult activities.

He has some lists of the different comparison's between the symptoms and how they'd be manifested by an adult with ADHD.

Thanks again.
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Old 09-19-05, 10:50 PM
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I think another important thing to go with is that things in the DSM are what they are. One of the things I've noticed a lot of, especially since Strattera came along, are the use of the term "ADD" and especially "Adult ADD." Clinically, neither of those things exist. They both fall under "ADHD" and the terms aren't even used. ADD is an older term for ADHD without Hyperactivity. "Adult ADD" was invented entirely by Lilly to push Strattera. If they invent Adult ADD, then they can market their drug as the "only drug approved" to treat it.

In this circle, the use of the term ADD and Adult ADD is not detrimental...but it does cause loss of clarity. It also establishes a lot of differences where there should be none, and mostly hurts diagnosis. Calling ADHD "ADD" is not a problem. Believing one has "ADD" and not "ADHD" is. ADD works as a shorthand for Attention Deficit/Hyperactivity Disorder Predominantly Inattentive Type (AD/HD-PI) but it isn't it's own real diagnosis.
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Old 09-19-05, 11:08 PM
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Quote:
Originally Posted by KMiller
ADD works as a shorthand for Attention Deficit/Hyperactivity Disorder Predominantly Inattentive Type (AD/HD-PI) but it isn't it's own real diagnosis.
I know it's the accepted term, but I don't like it. Attention Deficit/Hyperactivity Disoder without hyperactivity? What the heck is that? Is it something like a steak sandwich without the steak?

At any rate, looking at some of the posts on this list (by scuro in particular) and mainstream stuff by Barkely et al, there seems to be a move toward giving this type its own diagnosis anyway (SCT; cf Is Inattentive AD/HD Really Another Type of Disorder?).

Another thing: about self diagnosis. When the main center for adult diagnosis in my country of residence stopped accepting new patients after its waiting list reached 10 years, I realized that I was going to have to muddle through a lot of this on my own. I will probably sit myself in front of a head shrinker at some point, but in the meantime I'll do what I can to find out what is wrong with me, and what I can do to improve it.
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Old 09-19-05, 11:13 PM
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Your case is somewhat unique, Uminchu, with no access to a pdoc. But self-diagnosis has a place. Provided you understand that a self-diagnosis is not 100% certain, and that it's more an approximation, then it's well placed. But don't generalize things onto yourself based on that diagnosis.

ADHD without Hyperactivity isn't a diagnosis anymore. Now there's a "Predominantly" scale. But I do believe Inattentive ADHD is likely another disorder. It appears to be very different in that it demonstrates a difference in the way the dopamine receptors are affected, at the least.
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Old 09-20-05, 01:40 PM
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If you go back and look at the history of what we now call ADHD, you'll see a progession of different name changes ,as well as changes in the direction of theories,etc.

A perfect example is the DSM. With each subsequent revision, there were evidenced based changes made. In other words, the new symptoms came about as a result of the research and not vice versa.

ADHD and the Nature of Self-Control (1997) is a very complicated but equally interesting book. It's geared more for professionals and you have to reeeaally like to read this stuff.

The history part in the beginning is excellent. It's not diifcult in the least and is actually quite fascinating in terms of how we've gotten where we are now.

What is currently being found more and more often is a new appreciation of George Still's original (1902) research study on ADHD

He's really very close in his theory to what is being said now about "self-regulation."

Good luck and please keep us posted.

take care

mctavish23 (Robert)

Last edited by Andi; 09-24-05 at 03:59 PM..
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Old 09-20-05, 07:27 PM
Uminchu Uminchu is offline
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Quote:
Originally Posted by KMiller
But self-diagnosis has a place. Provided you understand that a self-diagnosis is not 100% certain, and that it's more an approximation, then it's well placed. But don't generalize things onto yourself based on that diagnosis.
Yes, I think that's an important point. Reading the various books on ADD, and reading these forums, I see lots of things that don't describe me at all -- but I can see how easy it would be for someone to assume they had those problems because "I'm ADD too."

Quote:
ADHD without Hyperactivity isn't a diagnosis anymore. Now there's a "Predominantly" scale.
But it still doesn't explain how someone who is not hyperactive could have a hyperactivity disorder.

Apparently, not even the professional community is all that happy with the term "AD/HD." For instance, Delivered from Distraction uses "ADD." So I feel like I'm in good company continuing to use it.

I also think that "adult ADD" is a useful term, not as a diagnosis but when looking for psychiatrists/psychologists willing to treat you.

Quote:
But I do believe Inattentive ADHD is likely another disorder. It appears to be very different in that it demonstrates a difference in the way the dopamine receptors are affected, at the least.
It will be interesting to see how it turns out.
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Old 09-20-05, 08:14 PM
mctavish23 mctavish23 is offline
 

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Okay,

The DSM -IV uses different nomenclature based on research results.

ADHD-Predominantly Inattentive type 314.00

ADHD-Combined and ADHD-Predominantly Hyperactive -Impulsive type 314.01 (for both)

ADHD Not Otherwise Specified (NOS) 314.9

ADHD NOS is for those "in between" or "borderline" cases where you believe ADHD to be present, but don't have the required number of symptoms ( 6 out of 9 for either ADHD-I,ADHD-C or ADHD-H-I types).

Lots of people still interchangably use "ADD" and "ADHD." I do it all the time when I'm talking to parents.However, I do make a point of telling them that "Today,everything is called ADHD, so when I' say ADHD -Predominantly Inattentive type, I'm referring to the old "ADD."

I even make that distinction in letters and reports.

Hope that helps
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Old 09-20-05, 08:25 PM
fixmeplease fixmeplease is offline
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I'm interested in how you (anyone can answer) define impairment when applied to AD/HD. What qualifies as impairment vs being merely an annoying habit or quirk? This seems very subjective to me.
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Old 09-20-05, 08:25 PM
Uminchu Uminchu is offline
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Quote:
Originally Posted by mctavish23
Hope that helps
Sure does!

But I think I'll keep calling it ADD until the name changes to "disinhibition disorder."
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Old 09-20-05, 09:17 PM
mctavish23 mctavish23 is offline
 

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"Impairments" are the "problems" that result from ADHD that others (without ADHD ) don't experience.

The impairments are considered "developmental delays" in the sense that same age /peers don't have those problems.

The journal article International Consensus 2002 has the most definitive definition of what constitutes a "disorder."

It's available at www.chadd.org or at Russell Barkley's website.

I hope that helps.I'll keep looking for more examples.
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Old 09-20-05, 09:19 PM
mctavish23 mctavish23 is offline
 

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Disinhibition is also at the top of my list as the next choice too.

Good insight.
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Old 09-20-05, 09:31 PM
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Quote:
Originally Posted by fixmeplease
I'm interested in how you (anyone can answer) define impairment when applied to AD/HD. What qualifies as impairment vs being merely an annoying habit or quirk? This seems very subjective to me.
I will quote the DSM itself in this regard:

"Attentional and behavioral manifestations usually appear in multiple contexts, including home, school, work, and social situations. To make the diagnosis, some impairment must be present in at least two settings (Criterion C). It is very unusual for an individual to display the same level of dysfucntion in all settings or within the same setting at all times. Symptoms typically worsen in situations that require sustained attention or mental effort or that lack intrinsic appeal or novelty (e.g., listening to classroom teachers, doing class assignments, listening to or reading lengthy materials, or working on monotonous, repetitive tasks.) Signs of the disorder may be minimal or absent when the person is receiving frequent rewards for appropriate behavior, is under close supervision, is in a novel setting, is engaged in especially interesting activities, or is in a one-to-one situations (e.g., in playgroups, classrooms, or work environments)."

That's how it talks about diagnosing impairment for this disorder. As far as the actual definition of what is impairment, we'd have to look someplace else. The generally accepted definition is exactly as it seems; functioning below the level at which a normal functioning peer is likely to function given no situational interference.
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