DSM5 in Distress

The DSM's impact on mental health practice and research

DSM5 Plans To Loosen Criteria For Adult ADD

Will this increase stimulant use for performance enhancement

DSM5 suggests two changes that would make it much easier for an adult to get a first time diagnosis of Attention Deficit Disorder: 1) reducing the number of symptoms required for adults from 6 to 3; and 2) relaxing the requirement that the onset of symptoms must have occurred before age 7 (by allowing the onset to be up to age 12).

The rationales for these changes are that: 1)two thirds of kids with ADD continue to have symptoms as adults; 2) the persisting symptoms often attenuate with age; and, 3) it is difficult for adults to recall onsets that occur very early in childhood. The work group hopes that the reduced symptom and onset requirements will increase the sensitivity of the diagnosis to pick up adults whose ADD has previously been missed.

As is usually the case, the experts have worried most about missed cases and have failed to consider the significant costs of loosening the diagnostic requirements. Whenever you increase the sensitivity of any diagnosis, in the same stroke you necessarily decrease its specificity. The lowered thresholds would misidentify adults with fairly mild attention problems as having ADD. Often, they will be given stimulant treatment that can have harmful side effects and complications. The widespread use of stimulant drugs also creates societal problems that must be factored into the risk benefit analysis.

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Even now, without the proposed DSM5 changes, adult ADD is a diagnosis that is too easy to get. Perceived difficulties with attention and concentration are extremely common in the general population and the symptoms that define ADD are mostly subjective- especially in adults who have usually outgrown the somewhat more objective defining items of hyperactivity and impulsivity. Thus, the first time diagnosis of ADD in adults is usually based on very fallible self perceptions of poor concentration and task accomplishment. Any lowering of requirements will capture many adults who feel the need to be sharper, but who really don't have serious enough attentional deficits to qualify for a mental disorder. The diagnosis will be especially common in perfectionistic students, in people who have demanding jobs, and in those who have to struggle to stay awake.like long haul truck drivers.

And there is another even more disturbing reason why adult ADD is so frequently overdiagnosed. ADD symptoms are very nonspecific - many other mental disorders also cause poor attention, low concentration, and difficulty sticking to an assignment. ADD is therefore often misdiagnosed in adults whose real problem is something else -eg substance abuse, bipolar disorder, depression, all the anxiety disorders, OCD, autistic disorders, psychotic disorders, and many others. No one should get a diagnosis or treatment for ADD until all of these have been considered carefully and ruled out as the primary cause of the attention problem.

The recent upsurge in the prescription of psychostimulants has in part resulted from heavy drug company marketting to primary care doctors and to potential patients. As a consequence, the differential diagnosis and treatment often occurs in a harried primary care environment with far less than a thorough and expert evaluation.

There are both individual and societal consequences of treatment once the misdiagnosis of ADD is made. Psychostimulants are among the most effective and the safest of medications in psychiatry when given under appropriate supervision for someone who is accurately diagnosed with ADD. But they can cause side effects in anyone and are especially harmful when taken by someone with another diagnosis that has been misidentified as ADD (especially substance use or bipolar disorder).

Then there are the societal concerns. A large secondary market for stimulant drugs has developed. It has been reported that thirty percent of college students use stimulants. Often, the pills were originally prescribed to treat presumptive ADD in one person and then are either sold or given away to someone else who uses them for performance enhancement. If DSM5 makes it a cinch for adults to qualify for an ADD diagnosis, it will indirectly be contributing to the abuse of stimulant drugs and to their illegal sale.

Can the watered down criteria for adult ADD be defended? I don't think so. I have heard three arguments meant to allay the above concerns, but none is very powerful.

The best argument is that patients who can be helped are missed using the current criteria. But even this doesn't hold much water. Patients at the boundary can already be diagnosed under the current DSM rules of the game. Whenever the circumstances clearly cry out for an adult ADD diagnosis, clinicians are entitled and encouraged to use their own judgment and not slavishly require the specific number of recommended items. The risk benefit trade off must balance the small risk of current underdiagnosis against the large individual and societal problems that will be caused by over diagnosis using the lowered suggested requirements.

The second argument seems to me to be totally indefensible. It goes something like- "Why worry so much about the overprescription of stimulants since these are relatively safe medications that are helpful in promoting improved cognitive functioning even in those who do not have clearcut ADD. If stimulants are general performance enhancers, their widespread use is not really that big a problem."

There are two obvious problems with this argument. First off, there is the important clinical issue that cannot be ignored- some individuals do indeed have psychiatric or medical complications from stimulant use. They need to be protected from its inappropriate and unnecessary prescription.

Then there is a larger public policy and societal issue. Increasing the use of stimulants beyond a quite narrowly defined psychiatric indication constitutes a kind of uncontrolled public health experiment. Who should decide whether this is a good idea? I maintain that the wider distribution of stimulants is simply too important a public health issue to be decided as an undiscussed and unintended consequence of changes made by a small group of DSM5 experts. These experts are necessarily focused on their own narrow diagnostic question and were not chosen for any expertise in public health. If stimulants are to become more widely available, this should result from an open public policy debate, not be the unintended back door result of loosening the DSM5 criteria for adult ADD.

It would be interesting to have a public policy discussion about the pluses and minuses of allowing stimulant use for performance enhancement in normals who want improved cognitive and physical functioning. But, let us not in the meantime lower the criteria for adult ADD in a way that indirectly promotes their "medical" use in those who do not really have a mental disorder.

The third argument is a clever variant of the performance enhancement issue. It calls attention to the role of an increasingly demanding society in exposing previously subclinical ADD symptoms and goes like this-"As societal performance standards are ratcheted up and external stimulation becomes non stop and blaring, it is not surprising that previously well adapted individuals with subclinical ADD may reach a clinically significant level of impairment that now qualifies as a mental disorder and requires treatment."

My point back is that the difficulties people have in meeting society's expectations should not all be labeled as mental disorders. Thirty percent of college students cannot suddenly have developed ADD. When steroid use was finally controlled by testing, there was a sudden explosion of ADD among Major League Baseball players - this was probably triggered more by a desire for improved batting averages than any of the traditional reasons for treating ADD. If we, as a society, want to help people enhance performance to meet (perhaps excessive) demands, this should be an open policy decision-not one cloaked under medical auspices, done by medical prescription, and enhanced by drug company marketting.

What should be done for DSM5? The criteria for first time diagnosed ADD in adults should be more, not less, rigorous than for kids (who are much easier to diagnose accurately because they have a more classic presentation). In evaluating any given adult for ADD, be sure that all the many psychiatric causes of inattention are first ruled out and that the adult problems are a continuation of ADD symptoms that started in early childhood. Any late onset of attentional problems is caused by something else, not ADD.

Should DSM5 decide to go ahead with its unwise plan to lower requirements, the majority of newly diagnosed ADD cases in adults will probably not be true ADD. Rather, the ranks of the misidentified will include: 1) many people with one of the other psychiatric diagnoses that cause inattention; and, 2) those who are seeking performance enhancement to reduce the normal inattentiveness of everyday life.

 

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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