Questions Over the Large Scale Accuracy of Psychiatric Diagnosis

Limitations of Diagnostic Criteria and Assessment Instruments for Mental Disorders, DA Regier, et al, Archives of General Psychiatry, vol. 55 (1998), pp. 109 - 115 (+ commentary which follows pp. 119-120).

This article critically reviews the results of two large psychiatric epidemiological studies and finds major discrepancies between them. The reviewers conclude that assessment and DSM-IV diagnoses remain quite problematic especially for lower grade disorders (like dysthmia or Attention Deficit). Very high rate prevalent rates call into question whether these diagnostic cases represent true disease or aspects of normal coping behavior. Furthermore, Robert Spitzer, the acknowledged father of the modern DSM in his commentary states "our current diagnostic criteria are limited" as guides to the need for treatment. To confuse making a mental disorder diagnosis with demonstrating treatment need, however, would be a serious mistake. Yet this is precisely how researchers justify current rates of national stimulant medication use by invoking prevalence rates of 3 to 20% (depending on what study is cited).

Reviewed 12/12/98

Do All Children with Conduct Disorder also have ADD?

"Clinical Efficacy of Methylphenidate in Conduct Disorder With and Without Attention Deficit Hyperactivity Disorder," Rachel G. Klein, et al, Archives of General Psychiatry, vol.54 (December 1997), pp. 1073-1080.

In this study the researchers (generally strongly identified as advocating medication interventions for ADHD) find that Ritalin has a short-term positive effect on children and adolescents with Conduct Disorder.

Conduct Disorder (CD) is the descriptive diagnosis for troubled, bad, acting-out teenagers who violate the law and often use alcohol or drugs. It is on a continuum between Oppositional Defiant Disorder most commonly diagnosed in preadolescent children and Anti-Social Personality Disorder (ASPD), the label attached to most adults who regularly engage in criminal behavior.

The researchers acknowledge that their original goal was to try and distinguish between the diagnostic categories of CD and ADHD. Sir Michael Rutter, perhaps the preeminent child psychiatric epidemiologist in the world, has for the last twenty years questioned the validity of the ADHD diagnosis as it has been represented since 1980 in America. [Neither he nor I dispute the notion that there exist very active, distractible, impulsive children that ADHD exists] He questions ADHDís diagnostic utility - by calling someone ADHD does it add to our understanding of the disease process, its prognosis, treatment and its difference from other diseases. He has said all along the current description of ADHD does not.

So the researchers set out to see if they could distinguish ADHD from CD by giving both groups Ritalin with the belief that only those with ADHD would respond (this is called diagnosis via pharmacological dissection). To their surprise, the researchers could not round up enough adolescents who only had CD without any ADHD. In other words, virtually all the teens who met criteria for CD also met criteria for ADHD. So they wound up giving Ritalin to the CD comorbid with ADHD group and lo and behold some of their CD symptoms improved (makes sense - Ritalin decreases impulsive acts). Thus CD becomes another indication for using Ritalin in children.

The diagnostic ambiguity/utility question was lost or dropped in the article. Is there any value is saying ADHD is comorbid with CD when all CD children are also ADHD? How do these different labels guide different treatment? Also there are important legal implications. ADHD, which is presented as a neurological disability, increasingly is invoked as a legal defense or mitigating factor in sentencing with the notion that the acts perpetrated were not entirely under the person's control due to this neurological condition. Since criminal activity essentially defines CD and Anti-Social Personality Disorder, then potentially all offenders would be viewed as having ADHD (which is likely given the broad scope of the ADHD diagnosis). Thus, if all CD and ASPD are also ADHD, then invoking the ADHD diagnosis as a defense could be rendered meaningless if we are to hold people responsible for their behavior. Russell Barkley raises these very questions in ADHD and the Nature of Self Control as I do in the last chapter of Running on Ritalin.

Reviewed 8/15/1998

Consensus Conference Chaos

Report from the National Institutes of Health Consensus Conference on the Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder, Bethesda, MD, November 16-18, 1998. I attended the three day event including the press conference at the end.

Thirty one presenting experts gave it their best shot to 12 impartial scientists specifically not involved in the field of ADHD. In what had elements at times of an out of control town meeting, the jury decided that America has a major public health crisis of a disorder that no one can clearly define or determine who exactly has it. Furthermore, while the jury concluded that Ritalin is probably safe and works to improve childrenís behavior and performance in the short term (14 months), the diagnostic threshold at which the benefits of Ritalin outweigh its risks is also undetermined.

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