False Positives
/The diagnosis of ADHD in clinics and hospitals in the USA rose by 60% in just two years, from 2020 to 2022. How is that possible? One proposed reason is that it wasn’t sufficiently recognised, so the increase can be attributed to greater diagnostic accuracy. Wider awareness would have had a particularly marked effect amongst marginalised groups, where it might have been even less recognised. However, a different view, and one gaining traction, is that there isn’t a disorder to be diagnosed – that it isn’t so much a disorder as a difference being promoted as a disorder.
ADHD depends for legitimacy as a disorder on the Diagnostic and Statistical Manual of Mental Disorders (DSM), currently in its 5th revision. The manual has been widely criticised precisely because it is predicated on disorders – it confers a stamp of approval on clusters of behaviours by medicalising them. As a prominent critic has pointed out, in contrast to conventional medical definitions the diagnoses described by the DSM ‘are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure’ (Thomas Insel, Director, NIMH).
ADHD is bracketed with a variety of behaviours generically labelled ‘neurodivergent’, which in principle offers an opportunity to represent these behaviours as a distribution rather than a diagnostic category. However, neurodivergence has in its turn been placed firmly in the category of a neurological disorder. The claim that 15% of the UK population is neurodivergent means that more than one in seven people are neurologically disordered, but while many adults so ‘diagnosed’ are relieved to have an explanation for their different behaviour, how divergent are they, and divergent from whom? How different from those whose behaviour falls between 15% and 50% of the population? It would simply be a matter of degree, not a step-changed category.
There is no doubt that in circumstances such as a class full of schoolchildren, even a single inattentive, over-active and impulsive one can be extremely disruptive, but consider this in a different context: these are also characteristic behaviours of extraverts. Should we consider extraversion a disorder? The extraversion-introversion continuum is best explained as a function of a neuroscience model titled stimulus intensity modulation, which argues that extraverts have relatively lower levels of resting (or basal) cortical arousal compared to introverts. Extraverts’ stimulus-seeking behaviour is intended to raise basal arousal to optimal levels, and the model has been validated using objective physiological evidence such as responsiveness to anaesthetic induction.
Applying the model to ADHD, it helps to make sense of the positive effects of methylphenidate as a pharmacological treatment: the drug acts as a stimulant, which paradoxically reduces overt disruptive behaviour. Perhaps the real reason for an over-diagnosis of ADHD is a consequence of including those whose behaviour tends towards the extraverted end of a normal distribution. However, extraversion doesn’t comprise an impairment. Indeed, in many social circumstances it might even be an advantage, so deciding whether or not someone is suffering from ADHD might best be clarified by considering the degree to which it impairs their everyday lives. Though impairment is an imprecise and subjective judgement rather than offering an objective laboratory measure, it might allow a clearer focus of resources on those in genuine need.
Imprecise definitions are not unique to the field of ADHD, and there are clear parallels in psychological perspectives on stress. For example, the incidence of post-traumatic stress disorder (PTSD) following exposure to trauma has been quoted as up to 60%, but how is the diagnosis arrived at? Is it the frequency with which symptoms such as flashbacks occur, or their intensity? How many symptoms are required to determine the disorder? Do predisposing factors play a role, and how do they interact with exposure? As noted in an earlier blog (‘Righting Wrongs’), much of the research in psychology fails to meet conventional scientific criteria, and in fact, more carefully controlled studies indicate that the incidence of PTSD is more likely between three and five percent.
As we acknowledged in an earlier blog (‘Carried Over the Threshold’), this is not in any way to minimise the suffering of the victims of PTSD, any more than an attempt to dismiss the social and behavioural difficulties that people thought to be neurodivergent might experience. Rather, it is questioning the vague and imprecise way in which they are defined and measured, which inevitably leads to unreliable conclusions. The threshold referred to in the earlier blog is the notional point at which what we call everyday stress is transformed into PTSD. Approached this way, PTSD lies towards the end of a distribution, and the degree of rumination about emotional upsets across the distribution offers a helpful metric.
In the Challenge of Change programme, rumination – churning over what-ifs and if-onlys – is how stress is defined, and it forms a core characteristic across the whole distribution, irrespective of the threshold. Once the threshold is crossed, behaviours including rumination intensify and significantly impair sufferers’ functioning, and PTSD is best treated with intensive one-on-one counselling and appropriate drug therapies. By contrast, the Challenge of Change training provides an integrated series of steps aimed at modifying ruminative behaviour in response to everyday pressures, and the training begins by changing the language that’s used: instead of drawing a misleading distinction between so-called ‘good’ and ‘bad’ stress, we distinguish between pressure and stress.
Pressure is simply a demand to perform. The intensity of the pressure will fluctuate, but since change is the one constant in life, we’re continuously subjected to pressure: there is almost always something to be done! An important first step is to avoid describing this natural pressure that arises in everyday life as stress. Walk into any corporate office and you’ll hear exasperated proclamations about how stressed people are. Most likely, all that’s happened is that pressure has increased. In the absence of rumination it remains pressure, but proclaim stress often enough and it becomes a self-fulfilling prophecy.
* Note: Victoria has been accredited in both the CoC Resilience and Dream Team training programmes, and in view of her expertise and experience in the field of ADHD she was invited to collaborate on this blog.