In this modern world, sometimes it seems that everyone has “something,” and many of these conditions are relatively “new” and their incidence is increasing. Leading diagnoses from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), include ADHD, autism, depression, and anxiety. Conditions that have become more common in recent years that have no primary entry in DSM-5 include asthma, pre-diabetes/diabetes, hypertension, hypercholesterolemia, cancer, and POTS (Postural Orthostatic Tachycardia Syndrome). People very often present with a suite of these unrelated conditions.
This means that (1) we are less mentally and physically healthy than or parents and grandparents and (2) that doctors are probably much better now at recognizing medical problems and identifying people who need treatment. Or it could be (3) that individual differences in personality and physiology have become firm diagnoses and that normal differences are being pathologized. My first thought that the third possibility is also correct crystallized shortly after I began to leave the world of basic research and began tutoring medical students and became a member of the Admissions Committee that chose them. One of the attributes considered at that time was whether an applicant is an introvert or an extrovert. I was the new person on the committee but I asked why that mattered. I pointed out that a medical student can be an introvert or an extrovert, but s/he will learn to be direct and straightforward with patients and meet them where they are, eventually as a good physician. “Extrovert” and “introvert” were deleted from the “Attributes” section of the evaluation form in the next cycle. This discussion led me directly to Shyness: How Normal Behavior Became a Sickness by Christopher Lane. [1] Shyness is a perfectly normal human behavior.
Dr. Suzanne O’Sullivan has covered this from a broader perspective as a neurologist in her intriguing book, The Age of Diagnosis: How Our Obsession with Medical Labels is Making Us Sicker, which was published in March 2025. She begins without equivocation:
Importantly, overmedicalization and overdiagnosis are not just things that the medical community are doing to the unsuspecting public. The pathologising of distress and the messy truth of life through biology, is a scientific and a social trend. If we do indeed have an overdiagnosis crisis, how is society’s expectation of success and perfection playing into that? We are encouraged to believe anything we want should be possible for us, but that cannot always be true. I hear that medical diagnosis has become something that is used to reframe our perceived failings. An unrealistic expectation of an unachievable level of physical and psychological might be turning us into patients and robbing us of control over our own destiny. (italics in original)
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In writing this book I explore how modern medicine is redrawing boundaries between sickness and health and what impact it is having on our lives. I have grown very concerned that we are turning increasing numbers of healthy people into patients with insufficient gains and unmeasured harms. Diagnosis is seen as the key that opens the door to so much that we long for – an explanation, the potential for recovery, support, a tribe of fellow sufferers – but there are darker things behind that door too that are not always given proper consideration.
“Patient” is derived from the Latin “pati,” which means “to suffer.” Unfortunately, in many cases the capacity of modern medicine to diagnose has not led to a consequent ability to cure, “meaning people are living with a diagnosis for longer, but not necessarily living longer as a result…(for example, with) the fate of an early diagnosis of dementia that cannot be changed.”
Following up on this directly, Dr. O’Sullivan’s first topic is Huntingtin’s Disease (HD). HD is an autosomal dominant condition, which means that one copy of the mutant huntingtin protein means the person will get HD, with only “when” being unknowable [2]. The question is whether the diagnosis of inevitable disease is always indicated. Since a carrier has a 50% chance of passing the disease to his or her children, this is obviously an important thing to know. But if no children are anticipated should we expect a person who has a parent with HD to want to find out? Good question. And it turns out that of those at risk due to having a parent with HD, about 90% who consult a genetic counselor eventually decline the test for the mutant gene, with a “common reason not to test is the realization that knowledge cannot be unlearned.” Although research on HD continues, there seems to be no light at the end of that tunnel. Yet.
Lyme Disease (LD) and Long Covid come next. Both are very real diseases, and Dr. O’Sullivan covers their history very well. The agent Lyme disease is the bacterium Borrelia burgdorfii, which is transmitted by the deer tick. LD was recognized only in the mid-1970s through the work of Polly Murray, who had been battling the disease with her family and neighbors in and around Lyme, Connecticut, since the 1950s. The larger question of Lyme disease is whether something called chronic Lyme disease (CLD) is real. Given that Polly Murray suffered from the disease for nearly twenty years before it was formally recognized, this answer must be yes. And biology has at least one answer.
Borrelia burgdorfii is a spirochete, as is the bacterium that causes syphilis (Treponema pallidum). Spirochetes are insidious pathogens, and they can be refractory to antibiotics. They cause multi-system disease. Is there a subculture (patients and physicians) that is fixated on CLD, in which case CLD may also be a psychosomatic disease? [3] Dr. O’Sullivan makes a good case. But this does not mean Lyme disease is not a real disease caused by an identifiable pathogen. The term “Long Covid” was introduced on Twitter in May 2020 during the first months of the pandemic. A case is made that Long Covid is a psychosomatic disease. While this is also convincing, it should be remembered that SARS-CoV-2 is also an insidious pathogen that causes serious, long-lasting multifactorial disease, despite an associated vocal subculture similar to that associated with CLD.
The French neurologist and anthropologist Paul Broca traced breast cancer through four generations of his wife’s family after she was diagnosed at a young age. It has been largely forgotten that he was the first physician to recognize that breast cancer can run in families (the pedigree in this pdf download is worth a look) This was long before the rediscovery of Mendelian genetics in 1900, so a mechanism was not available. We now understand the molecular basis of familial breast cancer (along with many others) after the discovery of mutations in BRCA1 and BRCA2 that predispose women carrying these mutations to develop breast and ovarian cancer. This has led to pre-diagnosis that often leads to prophylactic surgery for good and sufficient reason. This has undoubtedly saved many women from a certain future, but predictive diagnoses are just only that. Early estimates of likelihood of BRCA-related breast cancer were too high, and statistics apply to large numbers, not individuals. However, genetic counselors are now able to provide better information. Still, a recent metanalysis asked if overall mortality improved with screening:
The study included over 2 million people who have been screened for a range of cancers including prostate, breast, and bowel. In the case of large bowel cancer, screening extended total lifespan by one hundred and ten days, but for all other cancers there was no evidence that finding early cancers on screening allowed people to live longer.
But again, statistics do not apply to individuals. Thus, we all must make our best choice given current knowledge. With these frank biological diseases, it would seem that the error should be on the side of action. But contrary to popular belief, the correct choice cannot always be known in advance. Sometimes that choice should be watchful waiting (e.g., prostate cancer) and sometimes other choices are indicated. In her experience, Dr. O’Sullivan observed that “women who had risk-reduction surgery all complained that their surgeons didn’t seem to appreciate the gravity of what they were going through.” This regrettable but not surprising. It is probably caused by the overriding need to do something.
Autism has a long history in the DSM. The signal fact that autism diagnoses have increased over the past twenty or thirty years is difficult to explain as anything other than expanded and more sophisticated definitions and better recognition of what is in reality a very broad spectrum of disorders. Contrary to current American policy-based science, which is the modern form of Lysenkoism, there is no single “cause” of autism. Vaccines have nothing to do with the condition. The stories of the patients in The Age of Diagnosis are riveting, worth the read for themselves. They range from the 24-year-old Poppy, to the nonverbal Elijah, who at 20 years old has the mental age of a 4-year-old. Regarding Poppy, who has received little support from the National Health Service in the UK and is therefore unimpressed with NHS messaging on autism. From Dr. O’Sullivan:
‘You’re not happy with the NHS message on autism?
‘Too much misinformation.’
‘For example?’
‘The function label for starters. If you call someone high functioning it’s like you’re saying they’re not disabled enough. And don’t call me a person with autism. That sounds like I am carrying autism around in a bag. I’m autistic…That’s how my brain works. It’s part of who I am. It’s not something that can be put down like a bag.’
Whether or not the increase in diagnoses of autism is “true” may be debatable. What is not debatable is that people “on the so-called spectrum” are just people, some with greater challenges than others, with Elijah at the most challenged end of the spectrum. As his mother put it to a busload when she was attempting to get him under control, “all the other passengers were staring at me…So I turned around and said, ‘This is what autism looks like, not what you saw on the telly last night.’” Every person, not patient, with autism must be met where he or she is, if suffering is to be lessened.
ADHD is a tale unto itself. It is most assuredly real but it also has a history. It began with DSM-2 in 1968 as “hyperkinetic reaction in children (usually boys), described as a single line as distractibility and restlessness that went away in adolescence.” In my elementary school in the 1960s, this would have been described by every one of my teachers as “boys being boys,” which is why we had two recess periods per day in good weather. In DSM-3 (1980) the term attention deficit disorder (ADD) was introduced. Hyperactivity was added in DSM-4 (1994) and the condition became ADHD. DSM-5 describes ADHD “as a pattern of inattention or hyperactivity that interferes with social functioning or development. The diagnosis requires that the difficulties be present before the age of twelve, that they are present in lots of settings, that they reduce the quality of social, academic, or occupational functioning.” Mild, moderate, and severe ADHD seem to be in the mind of the patient and the eyes of the diagnostician.
A few crucial observations about ADHD from Dr. O’Sullivan:
The youngest children in a class have repeatedly been shown to be more likely to get an ADHD diagnosis that older children, which suggests that for some, immaturity may be being conflated with a neurodevelopmental problem. There are also substantial differences in diagnostic rates with within single countries that are not easily explained by differences in culture or access to healthcare. In Norway, where…healthcare…is readily available to all, diagnostic rates vary between 1% to more than 8% in different regions…14% of children in Mississippi…have ADHD, but only 5% in California. This suggests that some practitioners are making substantially more diagnoses than others.
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The frank truth of it is that despite decades of work, no biomedical research project has succeeded in finding any brain abnormality common to people with ADHD. There are no biomarkers that allow behaviours exhibited by people with ADHD to be distinguished from other disorders or even from normal human experience.
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Stimulants (e.g., Adderall and Ritalin) are first-line treatment for adults (who only recently have been diagnosable with ADHD), while in children they are reserved until educational and behavioural support have failed (debatable). Among the working group advisers for the development of ADHD in the DSM-5, 78% disclosed links to drug companies as a potential conflict of interest (actual, not potential). Pharmaceutical funding is also common in educational, professional, and consumer websites providing information on ADHD. Drug companies also provide funding to patient advocacy groups and ADHD charities. (Where have we seen this before?)
There is little evidence that these drugs work as intended in adults. But what about children diagnosed with ADHD? ADHD can be viewed as an example of neurodiversity and that “our moods, concentration levels, social skills, creativity, all our personality traits lie on a continuum, affording us different strengths and weaknesses. There is no right or wrong way to behave or feel and all ways of being should be embraced.” Yes, but that is not how people in general look at this. Neurodivergent implies its counterpoint, neurotypical, which describes a person “who is said to organise their thoughts and behave in a ‘typical’ way.” Thus, people who are labeled neurodivergent can be and are often made to suffer in society, as in the case of Poppy. This is not a trivial concomitant of the diagnosis and must be considered.
One of the more remarkable attributes of what could be called the ADHD Industrial Complex is the matter of accommodations, in which students with ADHD get extra time on exams, frequently in separate, quieter rooms, although the hundreds of exam rooms in my history have been very quiet (I did once have a friend reach back during an exam and grab my shaking foot that was distracting her, though; she had a point, as we and the proctor laughed about it later). However, studies have shown that in populations diagnosed with ADHD, students receiving accommodations do not perform better than students who do not have accommodations. And this seems to describe the situation with diagnosis creep of conditions such as ADHD and test anxiety (yes, students can get special treatment because they get nervous before exams). From Dr. O’Sullivan:
A big problem with these sorts of accommodations is that they promise better school or work performance but don’t deliver. They risk creating the expectation that extra support is essential. If a student believes that they need support to do well, they may continue to think they need it going forward in life when actually they could have done just the same without it. They will eventually meet a situation in which no special accommodations are available and when that happens a history of assuming they require extra help could set them up for failure.
Yes, they will. In my current work this happens regularly. And a distressing fraction of students who have been diagnosed with ADHD and cognate disorders continue to believe that their diagnosis is an excuse for not doing this or that, being on time, and completing their tasks in a responsible, workmanlike fashion. But the world at large does not work that way.
It should also be noted that ADHD, as well as most other ostensible neurodevelopmental disorders used to have a “recovery identity (and in) the 1960s and 70s, the DSM described it as condition that went away in adolescence.” No longer:
…ADHD is slowly being incorporated in the identities of many young people. Some support groups discourage the attempt to overcome ADHD traits. People are told to unmask and to share their ADHD selves with others. But learning to control our moods, behaviour and impulses is part of growing up, whether one has ADHD or not. We all become more socially competent, gain focus and are better able to cope through practice. Encouraging young people to do otherwise may be well-intentioned but is potentially setting them up for non-recovery. The rise of…ADHD presentations in adults may also undermine a young person’s expectation that their difficulties will disappear in time. A growing population of adults have incorporated ADHD into their self-concept. When a medical problem is part of a person’s identity, it becomes inescapable.
Finally, these words of wisdom for our scientistic, rather than scientific, overly confident era that must have a biological explanation for every disorder:
As it always happens when diagnostic inclusivity draws in milder cases, the negative impact of medicalisation… is inevitably ignored. Medicalisation through biological theories and treatment with chemicals can also all too easily sideline essential social change. There is lots of evidence pointing to life circumstances as major risk factors for mental health problems. Adverse events in early life, family history of mental health problems, negative family environment, bullying, racism, social isolation and inequality are all risk factors for mental health problems. They are also possible to change so maybe that is where our attention should be focussed.
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(But) a consultation that ends with a prescription is a relatively easy one for a doctor. It manages their own anxiety and makes them feel useful. It is also easier for the patient…But chemical treatments come with side effects, like drowsiness, agitation, insomnia and sexual dysfunction…And while explanations that rely on internal biology might offer relief, they also risk robbing people of control over their own futures and distracting from the need for social change.
The book concludes by stating that “we need to adjust our expectation of constant good health because it’s turning us into an ageist society.” Yes, we do. As we must also resist creeping genetic determinism and its attendant semi-domesticated eugenics, along with the MAHA silliness from “longevity doctors,” some who believe that we should even work harder on abolishing death. These are not serious people but their influence does serious damage.
The Age of Diagnosis is a deeply unsettling book in the good way. It challenges our preconceptions of what health is and our default preferences – medicalization – for dealing with the uncertainties of life. This book will at times undoubtedly elicit discomfort in everyone who reads it. This is something we all should subject ourselves to on a regular basis, especially in our strange world.
Notes
[1] More recently Jonathan Haidt published The Anxious Generation, which we discussed here in 2024. Both Lane and Haidt have their detractors, but each also takes a broader view that is seldom seen. I was particularly interested in Shyness because as a child I could be bashful to the point of desired invisibility. Few believe me now, but this is true and it was painful mentally and physically and still haunts me on occasion when I am speaking in public. But like many, I grew out of it as I grew up and realized that I was not abnormal, just different. It remains perilous to break Horowitz’s First Law (Joel Horowitz was my brilliant freshman sociology teacher): You must never generalize about you own necessarily limited experience. But I don’t think mine is all that unusual. In any case, the “Yes, we have a pill for that” strategy has not worked.
[2] HD tends arrive earlier in subsequent generations because of genetic anticipation. When the mutant huntingtin gene is replicated, the defect (an abnormal amplification of a long sequence of the amino acid glutamine) gets longer and this leads to earlier symptoms.
[3] Psychosomatic illness is real to the patient, with objective, measurable symptoms. Psychosomatic does not mean imaginary, but the psychosocial component is real.
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The big question in this interesting essay is, What is diagnosis and how is it culture-bound?
I recall reading some micro-histories of Italy by Carlo Ginzburg and Piero Camporesi and others. During the 1500s and 1600s, in smaller towns and in agricultural areas, the symptoms and diagnoses were quite unlike postmodern USA: People took to their beds. There were weird, lingering paralyses. The evil eye was a real possibility. I just finished Alessandro Barbero’s biography of San Francesco di Assisi, a saint who had a remarkable cure rate.
ADHD seems similarly culture bound. As mentioned, it started off as a Problem with Boys. (Although it doesn’t seem to have been invented by nuns, who always suspected that boys are a problem.) Yet when we talk about “attention,” what are we even talking about? The inability of most kids (and even most of us adults) to sit through hours of lecture? Whenever I have be near an Excel spread sheet or a Google Doc, oddly~!, I develop ADHD, too.
I hesitate, but this topic has come up on the site recently: Treatment of “body dysphoria,” which is a brand-new disease. My contention is that gender theory’s general worthlessness is that it led to pathologizing a condition that might not have to be treated as a disease. Recall that in the 1960s and 1970s, gayfolk wanted to get homosexuality out of the DSM.
Further, it may seem as if there is a tendency now to diagnose too many syndromes — but let’s recall a hundred or so years ago in the US of A, say, 1910, when many people lived with chronic pain and with conditions that couldn’t be treated effectively.
So what is a diagnosis?
On the other hand, my advice is always to diagnose oneself. It’s a way of forcing the doctor to focus. Anecdotally, one of my nieces had had various problems, endocrine and immunological. She diagnosed herself as having a tumor on the pituitary gland and had to browbeat the doctors a tad to get the correct tests done. She was correct — after years of “mysterious” symptoms.
Thank you DJG, Reality Czar
“Anecdotally, one of my nieces… diagnosed herself as having a tumor on the pituitary gland and had to browbeat the doctors a tad to get the correct tests done. She was correct — after years of “mysterious” symptoms.”
I had to self-diagnose and insist on being tested appropriately to finally confirm that I was infected via tick-bite with human infectious borrelia. I was brutally (and I do mean brutally) classified as a somatiform patient by the first ‘expert’ in infectious diseases that I consulted. And even after testing positive it was hard to get treatment because I do not live in a place where “Lyme” disease is considered to be endemic. The stigma of proper diagnosis borne by patient and health care provider in these circumstances is real. But the disease is also real.
As for “Lyme” Disease itself, it would more properly be called human infectious borelliosis. As evidenced by the usage of the term in the quoted work in this post, the overly restrictive application of Koch’s Postulate (one microbe, one disease) leads to underdiagnosis. While it is often stated that only Borrelia burgdorferi cause “Lyme” Disease in North America, there are multiple species of borrelia that cause Lyme-like disease. We now have strong evidence of more than half a dozen borrelia species, and probably at least a dozen, that cause similar symptoms and damage to the human body if not treated.
Borrelia myamotoi and Borrelia mayonii are just two examples that are well acknowledged in the medical literature that cause human infectious borelliosis in North America. It is still the case that the standard tests for “Lyme” Disease are not designed to catch other closely related species that cause human infectious borreliosis. This is another one of the causes of underdiagnosis. These and other related species need to be tested for separately from B. burgdorferi in order to be detected. Are they “Lyme” Disease? Strictly speaking, according to a restrictive application of Koch’s Postulate, the answer is no. Do patients who are infected with them have Lyme-like symptoms? Yes. Does the standard “Lyme” disease test used in North America identify all patients infected with all species of human infectious borrelia? No.
Another cause of underdiagnosis is the faulty method of “diagnosis by geography” that persists. Many diagnoses are missed because of an insistence that the infected human does not live in an area ‘endemic’ to the ticks that carry “Lyme” Disease. It has now been shown that many migratory birds carry ticks infected with borrelia across long ranges, and that they shed ticks along their migratory paths that will soon be hungry for another blood meal. Many species of migratory birds are also competent hosts for at least short term infection by borrelia. Some less common species of human infectious borrelia exist primarily in enzootic cycles that are not well-studied, particularly in biodiverse locations of the rural Southern United States and in South America.
Borrelia infect a wide variety of mammals, not just the White-footed Mice of New England. To name just a few, horses, raccoons, rabbits, minks, rats, canines, felines, and many species of mice, among others are proven competent hosts for human infectious borrelia. Antibodies to B. burgdorferi have even been detected in Black bears in North America. Some reptiles can also support infection by borrelia that infect humans.
Substantial numbers of humans who are infected with one tick-borne disease are simultaneously infected with at least one additonal disease. Estimates in some locations are as high as %50 of patients who are treated for human infectious borreliosis are also infected with at least one other disease, including babesiosis, ehrlichiosis, spotted fever, or a variety of tick-borne viruses. Some patients have been recorded as having been infected by three or more diseases simultaneously. If a patient is not treated for all the diseases they have, a variety of symptoms may persist after treatment for any one of them. (“Hickum’s Dictum” : A patient is entitled to have precisely the number of diseases they have, no fewer and no more.)
Yet another cause of underdiagnosis is the mistaken idea that tick bites of less than twenty-four hours attachment time do not result in infection with “Lyme” disease. Willy Burgdorfer, the discoverer of, and for whom the “Lyme” disease spirochete is named, is on record stating that approximately %10 of the wild-caught ticks he dissected had borrelia in the salivary glands, and could transmit the disease much more quickly than the standard 24-48 hours attachment time required for ‘normal’ transmission of the disease via regurgitation of the tick’s stomach contents into the host’s bloodstream.
Dr. Kim Lewis of Northeastern University, who is famous for discovering persistence in reponse to antibiotics in the bacteria that cause tuberculosis, has also studied borrelia and found that they too are capable of a similar type of persistence. Persistence is not classical antibiotic resistance, it is a different phenomenon: a small percentage of bacteria present during infection can slow down or nearly completely shut down reproduction and other life processes in response to the presence of adverse conditions like antibiotics. They do this in order to survive for longer periods of time. When adverse conditions are removed, the persistent bacteria in tuberculosis and other diseases can recover and begin reproducing again. This persistence is thought to be at least one of the reasons that tuberculosis may require long-term treatment in some patients, even when the bacteria are not classically antibiotic resistant forms.
Among humans, there seem to me to be at least five distinct patient groups effected by human infectious borelliosis. One, short term patients, who are diagnosed early and treated properly and quickly. Two, persistent cases that are often diagnosed late, after infectious borrelia have disseminated throughout the body (this happened to me, which is why I have had to become knowledgeable about the disease.) Three, patients who are diagnosed and treated and who likely have cleared the bacteria, but who develop autoimmune dysfunction due to the intensity, variety, and nature of the numerous human immune system evasion techniques employed by human infectious borellia. And four, patients who are permanently damaged by human infectious borrelia who may have been treated and who may have cleared the bacteria, but who are permanently damaged and are clinging to the diagnosis because of trauma inflicted on them by underdiagnosis in the first instance. Fifth, the rare case of completely somatiform disease.
Rather than quickly diagnosing patients with persistent symptoms of “Lyme” disease as having somatiform disorder, health care professionals need to be aware of all the possible factors that can cause persistence of symptoms. Many health care providers are not aware of all the developments in the science concerning tick-borne illnesses and human infectious borreliosis that have occurred in the past twenty years.
‘The study included over 2 million people who have been screened for a range of cancers including prostate, breast, and bowel. In the case of large bowel cancer, screening extended total lifespan by one hundred and ten days, but for all other cancers there was no evidence that finding early cancers on screening allowed people to live longer.’
I do not know about the US but here in Oz genetic screening can be a two-edged sword. Common sense says that this should be done across the board but decades ago laws were created that if you did have genetic screening done, then by law you had to disclose the results to any insurance corporation that you were with. Any negative finds would have you marked down as having a pre-existing condition for which the insurance was not liable.
I was talking with dna testing related to family trees with some people and said i wouldn’t risk it. I’m in the UK so don’t need health insurance yet, but it is coming and there have been enough reports of medical companies buying access to ancestory websites that it isn’t worth it. Regardless of if they can legally use that information or not, they will use it.
Bit of a tangent but – in pop psychology there are endless books and podcasts and advice columns about “setting boundaries” and precious few about learning to back up and make darn sure something is your business before barging in with you opinion.
So being unhappy when you constantly have to deal with ogres is a diagnosis. Being an orge, not so much.
(Exception would be an old tale about an emperor and crafty tailors.)
I broadly agree with the post’s stance from my own experience, if that is not a dangerous generalisation, but I disagree about the value of accommodations and diagnoses provided they do not become and excuse.
Son #1 and son #2 are both being assessed for their various quirks.
#1 was suspected of ADHD but to our surprise lit up the autism assessment like a Christmas tree. The ADHD behaviour is (just) sub-threshold (but apparently the psychology instruments for diagnosing the combination of ADHD-autism are not well validated so it’s something to keep under review).
The two traits seem to balance out in #1: he has his moments of temper and fixation but he’s just moved schools of his own choice to about the hardest academic secondary school in the country and his teachers have nothing but praise for how he has fitted in and he has signed up for the school play, takes the lead in class discussions etc.
#2 is having a tougher time of it. He’s developed anxiety at primary school, initially the social side and latterly around the lessons, which has turned into school refusal. We’re just starting down the assessment route but it looks like autism and ADHD with a side order of sensory processing involvement.
I’m a sceptic of the neurodiversity industry and of the “trauma” industry but #2 is genuinely traumatised by the current mismatch in society’s expectations of his behaviour and his ability to meet them. I am sure it will get better because expectations plateau for adults unless you choose unusual vocations of saintliness or diligence or self-control (vicars. auditors, bomb disposal experts etc.). But if accommodations can help while his brain catches up and develops coping strategies, I am all for them.
As an example, he went to sit the tests for two local grammar schools. Both offered him accommodations (extra time so time pressure didn’t cause him a meltdown, quiet room on his own so other people’s noise, pen clicking etc didn’t distract him, take a fidget toy in). However one school decided without telling us that he didn’t actually merit these and did not tell us, so we dropped him off early and he paced himself with extra time and was horrified to have to stop with only 2/3rds of the tests done and then have to wait ages stewing miserably until we collected him at the extra-time end time. :-(
The other school could not have been more different. We arrived late and they came and greeted him, calmed him down and held up the exam start for him in his own room.
Did it make a difference to outcome? Not on the test score, he passed both. But on one day he was a wreck and needed rebuilding all weekend and the other day he bounced out happy and confident as Larry. So the accommodations do matter, when considering the patient as a whole.
(And ironically #2 wants to go to the first, unaccommodating school, not the second! Which has only one special educational needs advisor, not five…. Kids!)
I believe it is now common practice to perform massive “pre-emptive” analytics and this explains part of what you say. Particularly after 60 yo when every person turns to be a dying sick thing even if the process takes up to 40 years or more in a few cases. Now I have a thing at home to take a sample from faeces and check if there is “hidden blood”. Possible cause: colorectal cancer. This is being delivered to anyone asking for it and Mrs. Ignacio’s companion always considers positively any extra analysis “to be sure”. I am more in the WTF camp. Hypercholesterolaemia. It’s Incidence skyrockets with age. But, what if a New Study Shows People with Higher Cholesterol Live Longer than People with Lower Cholesterol ? As I said, WTF!
Thank you KLG!
Cholesterol is the old man’s friend, Ignacio! Low cholesterol is a reliable marker of early mortality in the elderly. This has been known for at least one decade, more like two.
Body mass is similarly important. You want to go into old age slightly plump, like a good chicken….
And as Italians allegedly say – I have searched in vain for attribution – why live like an invalid to die healthy?
KLG,
Interesting piece. I’d love a follow up to this focused specifically on iatrogenesis and adverse effects of medicine.
I used to have a co-worker who would repeatedly shake his foot endlessly. If somebody sat down, extended and flexed his ankle ten times, I likely would not even notice. But in a 30 minute meeting, this co-worker would do that motion a thousand times. Apparently, I was the only person annoyed by this. The abstracts for the search term “restless leg syndrome” on PubMed don’t seem to apply to what this co-worker was doing.
Why are stimulants used to treat hyperactivity and deficit of attention? It seems to me stimulants move people in the wrong direction. I imagine treatment should slow people down with depressants, or chill them out with THC or whatever.
The paradox is considered confirmatory.
Like with most drugs for mental health disorders, it’s unclear exactly how it works (just as it’s unclear how the conditions develop).
That said, one theory about ADHD is that it’s related to having less activity in circuits using dopamine, especially in the pathways of your brain that deal with seeking out rewards (motivation).
To borrow Maslow’s Hierarchy of needs a bit: if you’re cold, horny/hungry you’re much less inclined to pore over a spreadsheet. One way to view that is your brain telling you that, right now, warming up, having sex/eating will be a much better idea than earning a sense of personal satisfaction/potential, future, financial reward.
How you feel that need is generally as a kind of misery and is related to decreased dopaminergic activity (it is a ‘happy hormome’). In addition, the hypothalamus kicks in, secreting chemicals to help you know what’s causing your misery (hypothermia, horniness, starvation) so that you can, ideally, direct yourself to correct it.
Essentially, you feel good when something, like having your needs satisfied, triggers an increased release of dopamine, and you feel stressed when your dopamine drops low, which motivates you to return to feeling satisfied.
That’s one very simplified way of looking at it, based on our current knowledge. Suffice it to say, the likelihood of doing less immediately rewarding things rather than ‘giving in to life’s pleasures’ is made easier by being generally more satiated at the outset (having relatively normal dopaminergic activity in your reward circuit).
With ADHD, though, it might be that it’s a lot more diffcult for persons to naturally get to, and maintain, that level of ‘satieity’. As we’ve heard, short bursts of exciting news, like on social media, can keep persons hooked by constantly stimulating them. That is, in essence, what persons with ADHD naturally try to create for themselves, to keep their ‘satiety’ even a little bit normal.
Regular activtities (eating, socializing, learning a skill) aren’t usually enough to boost dopamine output above a level of ‘mildly irritated’ for them, so they end up being easily distracted, quitting early and bouncing around in conversations and in life, trying to keep an amount of stimulation that’s not possible to maintain.
Additionally, since they aren’t hungry/tired/horny, the hypothalamus can’t tell what to go after. All it’s learned is that all roads, (save drugs, essentially), lead to boredom – the state of wanting something ‘stimulating’ yet not feeling stimulated by anything you try, or feel up to try, doing.
Another quirk is that physical activity itself, is stimulating, which is possibly why the two hyperactive sets of persons (they’ve split them into 3 groups now: innatentive only, hyperactive only and both) can’t sit still. Even leg shaking at your desk can help you focus, not to mention pacing.
Basically – the theory is that persons with ADHD are lacking in natural stimulation. Therefore, when you give them stimulants, they’re able to stop needing to chase their impulses. The new ‘normalized’ dopamine basically gives them the mental capacity they were lacking to do less rewarding activities (anything that requires patience/denying yourself immediate gratification, really). They’re actually more effective for hyperactivity symptoms, than for innatentiveness, though, (in persons with ADHD, persons without ADHD taking stimulants have a more ‘normal’ response), but they do help both.
I hope that this, simplified and theoretical, explanation helps a little to explain how ADHD works. Each person is different and none of the phamacological/biological, psychological or social treatments, is a surefire fix, but for the persons experiencing it, even some help is better than none.
I don’t think this difficulty will ever be satisfactory resolved. The “person with X” circumlocution came about in response to people objecting to “Xistic,” claiming it reduced the whole person to a single, unpersonlike trait. So pick your favorite, and someone will object to it.
Plus, the circumlocution has moved on to “person experiencing X,” perhaps in response to the quoted objection.
My Grandfather on my father’s side was whip-smart, but could not hold down a job. He would stumble from job to job, will gamble away everything he earned, and hit his wife and kids in a fit of anger. He would spend days away from home, wandering around somewhere. Sometimes he will be great company, at other times he will lash out or sulk away in a corner. His moods will swing like a a windsock in a storm. He ended everything with the help of a rope when he was 80. The man was completely healthy otherwise. It was like a punch in the gut.
My father was again smart, but had similar problems, just slightly less severe than my grandad. He at least could hold down a job, but earned a lot less than his similarly educated peers. He tries to spend his pension money on this or that useless shiny thing, but I caught on to this after the first dozen times. I convinced him to let me take charge of the money. I make sure that at any point in time, there is only just enough cash at home to pay the bills and buy essentials plus some emergency cash. Even if he gets an impulse to spend, he can’t spend a lot. If he wants to get more cash, he can always walk down to the bank and take it. But that extra step slows down the impulsive spending.
I am having the same problems. I finally got an ADHD diagnosis few years ago. My experience matched more than 90% of the symptoms listed in DSM-V. I am not medicated. I go to therapy and occupational health counseling. I am developing habits to cope with my brains constantly pulling me in multiple directions. I went through severe depression and anxiety in my young adult phase. I struggled with shame and guilt because I blamed myself for not being “as good as the others”. I am finally finding a reason to feel hope. I am able to hold down a job and live in some semblance of peace.
I sometimes think if my Grandpa would have suffered less if the awareness and support had been available in his day. I wonder what would have happened to me if I was in his position.
Using the fact of the diagnosis rate going up and presenting it plainly as people misusing or over diagnosing is a dangerous overgeneralization. This is a topic that should be handled with nuance and care.
The American Medical Association owns CPT codes, the alphanumeric representation of various procedures (and earns residuals on their use in billing). ICD codes represent diagnoses. Insurance will only pay for office visits and medications if they meet the arbitrary requirement of matching an appropriate diagnosis for that medication or procedure.
Long story short, doctors can’t bill an office visit or get prescription coverage without using an approvable diagnosis code. Lots of diagnoses are made just to get the insurance company to cover the service.