Clinical discretion, or, why you should put down the DSM.

[Trooper Keith]

How many of you remember reading a post like this one:

Originally Posted by Every new member

I just read the DSM and I think I meet 20 of the 18 criteria and I have done this since I was a child, I even have a hard time with homework and sometimes I hyperfocus on things that are stimulating and rewarding! I have ADHD rite guys? But no doctors are willing to diagnose me with it, so I need to find an ADHD specialist please help!

I'm going to start with a quote, and then explain why these two words mean you should probably never ever read the DSM ever: clinical discretion.

Originally Posted by DSM-IV-TR pg. xxxii

DSM-IV is a classification of mental disorders that was developed for use in clinical, educational, and research settings. The diagnostic categories, criteria, and textual descriptions are meant to be employed by individuals with appropriate clinical training and experience in diagnosis. It is important that DSM-IV not be applied mechanically by untrained individuals. The specific diagnostic criteria included in DSM-IV are meant to serve as guidelines to be informed by clinical judgment and are not meant to be used in a cookbook fashion.[Emphasis mine]

Clinical discretion and clinical judgment means you must have clinical training to employ this book. This is not because the APA thinks people are too stupid to understand it. This is because unless you have a background in psychology, you don't understand the language.

To make this ADHD specific:

Originally Posted by DSM-IV-TR pg. 92

six (or more) of the following symptoms of ________ have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level. [Emphasis mine]

These two bolded phrases are why you don't get it. Without at least an undergraduate, preferably a graduate level course in lifespan development, you probably don't understand what is "consistent with developmental level" let alone what is inconsistent with it. Without several college level courses in psychology, including social psych, behavioral psych, and abnormal psych, you don't know what is maladaptive or not.

Off the top of your head, do you know at what age children begin being able to work on goal directed behavior? Do you know when you can expect a child to be able to attend to one thing at a time? Do you know the circumstances that influence attention in adults? Do you know at what age and under what circumstances children and adults should be expected to organize their tasks? At what age do children gain the motor control to sit still? When can children be expected to stay in one place and not engage actively in exploring their environments? At what age should children be slowing down enough to engage in schoolwork? When is it okay for a child to talk excessively and when is it a problem? At what age do children have the necessary executive function to wait their turn and disrupt their natural Id-impulse for instant gratification?

If you can't answer all of those questions off the top of your head, you can't diagnose ADHD and you have no business reading the DSM-IV criteria for ADHD because you don't understand them. I came up with those questions reading down the list for symptoms of ADHD, they aren't arbitrary. If you don't know the answer to those questions you literally do not have enough information to use this book.

So next time you read about a disorder online and flip to it in the DSM and read the symptoms, don't think "I have this!" or "I do this!" Think, "do I have the requisite knowledge to know whether or not these symptoms impair me clinically or are inconsistent with my developmental level or situational circumstances?" This isn't an option, this is a requirement. Without adequate schooling, the DSM might as well be a book of voodoo, because it uses language and descriptions that aren't understood by laypeople.

Obviously you understand "often loses things necessary for tasks or activities." The question is whether you can judge if your losing things is significantly impairing your life (can't find the remote to change the channels is not significantly impairing) or whether you know how much you can be expected to understand this.

Before you decide your child has ADHD, you damn well have better completed your college level coursework in child development, because otherwise you're making a hasty and grave mistake.

Discuss.

[daveddd]

i feel this way about all these "diagnostic quizzes "

[Imnapl]

Several years ago, my teenage daughter went to a psychiatrist who spent many years training for an ADHD assessment. The doctor opened the DSM, read the list of symptoms of ADHD to my daughter and said, if you had ADHD, you would have outgrown it by now.

I guess he was at the bottom of the class, absent, or not paying attention during his graduate level lifespan development course and from my brief observations of the man, I only needed a first year psych course to understand that the middle aged "expert" in the room hadn't read anything new about ADHD since he was an undergrad.

[Fortune]

Originally Posted by daveddd

i feel this way about all these "diagnostic quizzes "

There's no such thing as a diagnostic quiz, and anyone who uses one to make a diagnosis is misusing it.

[βĩο₱Ħعℓĩᶏ]

I do think that many people actually have a good idea where they are compared to "normal," otherwise, many would never go to a psychologist or pdoc. However, your point is still just as valid.

[daveddd]

Originally Posted by Fortune

There's no such thing as a diagnostic quiz, and anyone who uses one to make a diagnosis is misusing it.

maybe not, but if you bring it in to the doctor , i bet he doesnt bother to do any differential dx

especially after you already have convinced yourself that this is your problem

[ginniebean]

I haven't seen posts like that except on rare . More often I see people who are in their late 30's and 40's (or higher) who can't get diagnosed.

[ginniebean]

Originally Posted by daveddd

maybe not, but if you bring it in to the doctor , i bet he doesnt bother to do any differential dx

especially after you already have convinced yourself that this is your problem

It's just not that easy! Most doctors don't want anything to do with adhd. They might refer you to a psychiatrist but generally not before trying to talk you out of it and then when you do see the psychiatrist he 'doesn't believe in it' because he refuses to read any of the research.

ADHD in adults is under -diagnosed.

If others have some reason to think that it's not, do share!

[Fortune]

Originally Posted by daveddd

maybe not, but if you bring it in to the doctor , i bet he doesnt bother to do any differential dx

especially after you already have convinced yourself that this is your problem

We went around on this before. I think you're oversimplifying things tremendously, and making a slippery slope argument. I doubt anyone's getting diagnosed because of internet quizzes unless there was already something actually there to begin with. Some conditions, also, many psychiatrists are more reluctant to diagnose than others no matter how many signs may be present. People come here talking about how ADHD was dismissed after they passed a simple screening test that is explicitly not diagnostic and not intended to be the only screening test.

Do you really think doctors are easily swayed and will diagnose you with whatever you say you have just because you're convinced of it? If this is true, then isn't the level of expertise Keith is talking about completely pointless and in fact non-existent? Or maybe the truth is more complex?

Short version: Internet quizzes aren't the problem. The people who diagnose themselves with them are. Not that they're always wrong, but that if you think you have something, you should have more than a quiz to go on. Most of them are toys. Some of them are screening tools. None of them will give you a definite "yes."

[daveddd]

Originally Posted by ginniebean

It's just not that easy! Most doctors don't want anything to do with adhd. They might refer you to a psychiatrist but generally not before trying to talk you out of it and then when you do see the psychiatrist he 'doesn't believe in it' because he refuses to read any of the research.

ADHD in adults is under -diagnosed.

If others have some reason to think that it's not, do share!

through my life i have been to approximately 15-20 psych doctors

every single one of them was more than open to adhd

older ones, younger ones, women, men all of them "believed " in it


what are you actually basing your theory of this massive amount of misdiagnosed/undiagnosed adhd on

[daveddd]

Originally Posted by Fortune

We went around on this before. I think you're oversimplifying things tremendously, and making a slippery slope argument. I doubt anyone's getting diagnosed because of internet quizzes unless there was already something actually there to begin with. Some conditions, also, many psychiatrists are more reluctant to diagnose than others no matter how many signs may be present. People come here talking about how ADHD was dismissed after they passed a simple screening test that is explicitly not diagnostic and not intended to be the only screening test.

Do you really think doctors are easily swayed and will diagnose you with whatever you say you have just because you're convinced of it? If this is true, then isn't the level of expertise Keith is talking about completely pointless and in fact non-existent? Or maybe the truth is more complex?

yes, i really believe this

before i was even able to tell my symptoms apart all i new was hyper and distracted , i was given an adhd and no further questions

[Mignon]

Originally Posted by daveddd

through my life i have been to approximately 15-20 psych doctors

every single one of them was more than open to adhd

older ones, younger ones, women, men all of them "believed " in it


what are you actually basing your theory of this massive amount of misdiagnosed/undiagnosed adhd on

You apparently are basing your opinion on your personal word amd anecdote, but require more of Ginniebean for the same.

[βĩο₱Ħعℓĩᶏ]

Originally Posted by Imnapl

Several years ago, my teenage daughter went to a psychiatrist who spent many years training for an ADHD assessment. The doctor opened the DSM, read the list of symptoms of ADHD to my daughter and said, if you had ADHD, you would have outgrown it by now.

I guess he was at the bottom of the class, absent, or not paying attention during his graduate level lifespan development course and from my brief observations of the man, I only needed a first year psych course to understand that the middle aged "expert" in the room hadn't read anything new about ADHD since he was an undergrad.

Are you insinuating regulating "experts?". Why I never...!!!

[daveddd]

Originally Posted by Fortune

We went around on this before. I think you're oversimplifying things tremendously, and making a slippery slope argument. I doubt anyone's getting diagnosed because of internet quizzes unless there was already something actually there to begin with. Some conditions, also, many psychiatrists are more reluctant to diagnose than others no matter how many signs may be present. People come here talking about how ADHD was dismissed after they passed a simple screening test that is explicitly not diagnostic and not intended to be the only screening test.

Do you really think doctors are easily swayed and will diagnose you with whatever you say you have just because you're convinced of it? If this is true, then isn't the level of expertise Keith is talking about completely pointless and in fact non-existent? Or maybe the truth is more complex?

Short version: Internet quizzes aren't the problem. The people who diagnose themselves with them are. Not that they're always wrong, but that if you think you have something, you should have more than a quiz to go on. Most of them are toys. Some of them are screening tools. None of them will give you a definite "yes."

i said i feel this way, you dont have to

there have been studies or reports or something on med students diagnosing themselves with every other disease they learned about

[daveddd]

Originally Posted by Mignon

You apparently are basing your opinion on your personal word amd anecdote, but require more of Ginniebean for the same.

i dont understand the part about ginniebean

and yes, its nothing more than an opinion