So we're introducing my co-hosts again. He was desperately missed in the last one. Thank you. Co-host, can you please tell us your name?
I'm Dr. Fu, Eric Fu. I'm a clinical and forensic psychiatrist. I'm not going to say where I work because I'm a paranoid person, but we're here to talk about something that is a little bit of a hot topic, right?
And that hot topic is your identity.
I don't think so. No, we're going to be talking about ADHD, right? That's why I was informed, unless you surprised me with some other topic.
People were upset that there's just a random person talking. Can you just say a little bit about your psychiatrist? Is that correct?
Yes, I'm a general clinical psychiatrist, outpatient, and also forensic. The forensic is primarily criminal, but I also do civil cases. We're not going to get into what that practice looks like. You can read all about that on various places. I also teach at a variety of different institutions. I'm not going to give any specifics. Is that enough, do you think?
That's more than enough. And psychoanalytic stuff?
Oh, yeah. Good point. A lot of my teaching does focus on psychoanalytic theory and technique and psychotherapy, but that's not actually the majority of my practice. Probably how I would describe my attitude or my philosophy towards it is integration of psychotherapy into general psychiatric practice and even forensic psychiatry would be my main area.
Dr. Fu, I thought Freud was proven wrong.
This is supposed to be an ADHD episode.
I want to get you fired up.
I just love it. If you want to put that in an episode, we're going to do one quick note, and it's that don't believe the hype, okay? Well, first of all, psychoanalysis, as written by many philosophers, is non-falsifiable and therefore not a science, so therefore cannot be proven wrong. That's kind of a joke, but also true. More importantly, I would say that in 2024, what we consider to be mainstream, commonly accepted scientific and non-scientific views...
What we consider in 2024 to be mainstream scientific and non-scientific views of the mind... A lot of it comes from Freud. And the stuff that we accept, we don't know it's Freud. And the stuff that we don't accept, that's what we think is Freud. So I think he's a little mistreated when it comes to that. Anyway, moving on to ADHD.
No, no, I'm not going to move itself. I find it funny how rudimentary people's understanding of what science is is if something's either right or something's either science and it's correct or it's wrong.
Well, that's an interesting point. I totally agree. But I think it's because there is actually a culture of science. And you probably, maybe you've heard, there is the concept of the... purpose of a system is what it does. I believe this is an element of systems theory. The purpose of a system is what it actually does. And so when people believe that there is quote science and there's non-science in such a simple way, I think it's because it's actually sold that way, right?
That science as a product wants a legitimacy and that to support that legitimacy, you have to present it that way. Honestly, I think we should cut all this out because it's really making, I think, me come across as a, you know, a hack or a crazy person to deny science. I'm not a science denier. Okay. I believe in science. Let's move on.
No, we got Dr. Fu is a science denier. Oh, no. No, I think it's showing that you have an actual understanding of the scientific process.
I mean, basically, any complicated process is going to have a lot of nuance, right? And when you're any industry, the deeper you get into it, if you've done research, if you've worked with researchers, you just know that there's a lot more shades of gray. So anyway, back to ADHD. I think it's really necessary, especially today, when we talk about ADHD... to be very very careful okay so this is what i'm going to say i'm going to keep it brief adhd i believe is a real clinical entity that describes a real neurodevelopmental disorder that can be found from an early age in individuals okay there are evidence-based treatments for this and it is appropriate to treat in most children who have been responsibly diagnosed with adhd okay so that's the preface but what we're going to try to do just like the science comment i think is that we're gonna we're gonna try to bring some shades of gray to that you sound like you have a gun to your head i feel like i do let me explain why um Okay, this is going to be very social media focused, but I don't know if you've noticed this, but I post on social media, in anonymized fashion naturally, about a lot of different topics in mental health.
Okay, and you can post about psychosis, or you can post about even an eating disorder or anything. And no one takes notice. If there's a post about certain topics, and ADHD is one of them, it will take the attention of social media. It's a popular topic. People feel strongly about it. They want to think about it. They want to have or they don't want to have it.
And so it will just attract a greater audience than you're used to. So that's, I guess we want an audience here, but that's why if you're going to talk about certain diagnoses, you kind of have a social media gun to your head.
Yeah. And now what's what's your understanding as to why there is this attraction to ADHD? Why is social media and a psychiatric diagnosis such good partners?
Well, you know, I guess this kind of jumps right into it. But are you familiar with culture-bound or culturally informed disorders and illnesses? I'm sure you are. Of course. We should talk about it.
We have to learn, like, funny ones in med school. Like, one of them where somewhere in Asia, people think their penises retract into their body.
That's right. I wish we both knew that off the top of our heads so that we could... pretend we're more experts than we are, but I think our excuse is that... Is it Kuru? I think Kuru is when you... That's a neuro... I believe that's a neurological disorder when you eat someone's brain, isn't it? Let's see. Shrinking penis panic, if you Google that.
Koro.
Koro.
Yeah. Koro. Okay.
You can see where... K-O-R-O. Kuru, I think, is...
Kuru is the cannibal disease.
It's a prion disease, yeah. That's when you eat other people's brains. Not to be confused with Koro. Yeah, my excuse is, of course, that since the DSM-5, they kind of stopped naming the cultural illnesses, the culture-bound illnesses or disorders. They used to have a fun set of named ones when it was DSM-4. So we haven't done that for a while. But why am I mentioning this? Let's talk about a...
Have you heard of neurasthenia?
Yeah.
Tell me your associations with that.
Help prime me. I'm blanking a little bit.
Yeah. Neurasthenia... was named under a different name, under a Mandarin name, as a more culture-bound syndrome or disorder in Asia. You can find a lot of literature on this already and also still today. And I kind of just came across this because a relative of a relative, I found out years back, was diagnosed with it. like by a psychiatrist. And I was like, neurasthenia? The last time I heard about that was when I was reading Freud, literally.
It's his classic paper on anxiety neurosis, basically generalized anxiety disorder today. So it's still popular in Asia. And the short version is that it kind of conceptualizes depressive and anxiety symptoms, as we would understand it, as a problem of the body or the nerves, that your nerves are having a problem, just like kind of the nervous illness concept that used to be more popular on the West.
And that's why neurasthenia comes from the West, but now it's retained in Asia. So it's a preferred diagnosis, and there's an argument that there's other diagnoses that we'd make, like major depressive disorder or an anxiety disorder or a trauma disorder.
It's similar to chronic fatigue syndrome, right?
I think the original westernized version was closer to that, but I think that... The way it's diagnosed in Asia, it begins to capture things that we diagnose under other chapters of the DSM or call other things. But it's used popularly because it's more preferable. It feels more comfortable to have it. It's familiar, too, to the general public. Rather than being told that you have a mental illness of some kind, you're told that you have something neurobiological.
And so that brings me to ADHD. Though ADHD I do think is real and has a basis, I do think that today we're at a stage where it's become the preferred diagnosis for many people or subcultures in the West, in the United States particularly, right? That people would rather be told that they have ADHD rather believe that than that they have something else something may be a little bit more scary or uncomfortable and i'm sympathetic to that right nobody wants to believe that they have or you know are suffering from something that's a little bit more stigmatizing or scary but that it may be inaccurate is what i'm getting at
So what would you say are the implications of having ADHD versus maybe the more accurate diagnosis? What are the implications of having ADHD that you don't think that are different from the implications of a different disorder?
Well, that's a good question. I would say that I suppose there's two things to separate out here. The first is that socially, I think that the perception of ADHD is one where people are unable to do things that other people can do, and it's not their fault. Which is, by the way, an inaccurate portrayal of ADHD itself. True ADHD is not just responsive to medication. It is treatable through medication.
Psychotherapy, skills, changes in your life, changes in what you do. I mean, before we had prescription stimulants, people still had this condition. They would cope somehow. They would change their lives or they would adjust in some fashion. This is true of most psychiatric problems, except for the very serious ones, right? In terms of why it's important that we think about this difference is that I think that we really need to be particular about diagnosis in order for people to know what they're working with and how to get out of it.
It's not how to get out of it, how to get better. And if you ignore all the facets that are beyond ADHD, inattention, executive functioning problems, you may ignore necessary treatments. And by the way, a lot of these times the conditions are comorbid, right? Some level of ADHD traits or even disorder are interacting with anxiety, depression, stress, something.
Yeah, to go back to one thing you said is that people with ADHD, or maybe one of the implications or the belief systems is that these people literally don't have the ability to do XYZ. And I do see on the social media, there's a lot of behind it is a lot of rage of people saying like, My mom said, why don't you just keep a calendar? And there was just an anger behind it as if this person – it would be the same anger as if someone expected a cancer patient to go run a – just go pick yourself up and go exercise.
There was a – I don't know. Other comments I see are things like, I literally do not synthesize the dopamine chemical. Or I literally do not have the actual ability to focus. A lot of, as you're pointing out, just like these beliefs that because they have ADHD, therefore their brains are synthesizing different chemicals. Their neurocircuitry is inherently different. Mm-hmm.
Yeah, well, that's just the thing, right? I think where we really should be going as people, as individuals, as a society is a synthesis of those two points, right? It is, let's stipulate that someone has ADHD, okay? It is a neurobiological problem. It is a neurodevelopmental disorder. And you should also keep a calendar. Right. The problem is, of course, in that little interaction, it's not about the calendar and it's not about the neurodevelopmental problem.
It's about the relationship between the parent and the child. Right. That there's an accusation rather than a effort to help, for example, probably reflecting other frustrations or dysfunctions or tensions in that relationship. But, yeah, it's this all or nothing thinking that seems to happen. You either fall into a category. It's the problem, again, with the categorical way of thinking diagnosis. You fall into some category, and that category either makes you responsible or irresponsible.
Not irresponsible. Either responsible or not responsible, right, if you're in a certain category or another. When really we should be thinking, well, one category might make you more or less able to be responsible, but nonetheless, we have to do what we have to do.
Yeah. Yeah. And I mentioned this in the in the solo podcast talking about, you know, in terms of what I think of the healthy way to have the disorder is the difference between like an internal locus control and an external locus of control, where if someone has an external locus of control, they believe that their diagnosis is uh gonna give them you know if if the example i had to give is if you miss your partner's birthday and your partner comes up to you and says like it's really hurt like do you say i'm so sorry i'm like i really messed up i screwed up or do you say how can how can you blame me like uh i have a disorder and you like my disorder is what caused me to to miss that thing um the the The former is taking responsibility.
It's recognizing that there's 10 things that have to go wrong to make that mistake. And maybe the disorder is a part of it, but it is not the entire thing.
Yeah. And I want to acknowledge it's a difficult way to approach life if you're going to be taking responsibility for everything. And there are people where they take too much responsibility almost all the time, or that to take responsibility feels so awful that they can't do it, right? So it's nuanced. It's difficult. It's a rough thing to go through to feel like It's your fault. At the same time, I would say that if there isn't some degree of self-reflection and consideration about what can I do, even if it's a little bit, in order to change things, it is, as you say, putting the locus of control entirely outside of yourself.
And I don't think that's good for people long term. I also don't think it's good for people to be overly simplistic in explaining themselves in only one fashion. Let's say neurobiological. Everyone is so much more complicated than that. The world and our relationships with people are so much more complicated. I think everyone's doing themselves a disservice if they ever think that the reason why they did or didn't do one thing is one particular condition.
Yeah, you're just a little... You mentioned the point of people can think they're too responsible for things. I remember when people are depressed with psychosis, a lot of times you see delusions of guilt manifesting as delusions that they did some terribly horrible act. And I might have to do some searching, but I... I think there's a thing where, like, when 9-11 happened, a bunch of poor, unfortunate, depressed people with psychosis called in and were like, I did 9-11.
Yeah, yeah. Well, you know, there's this fundamental feeling of guilt, right? Yeah.
Yeah, that's an example of taking on too much fault for...
Well, that's the thing, right? Those are severe cases where it doesn't even correspond to reality a little bit, right? But the minor cases are there, right? I think people either look at the disavowal of guilt as kind of anti-socially saying, I'm not responsible for anything. um when there's also often i think it's that it's not that they're unwilling to accept responsibility it's that it's so difficult to because they punish themselves so much when they are responsible right if you could say i'm at fault for xyz situation and you feel a little bad and then you're on it and you make a little change then it's a lot easier to say that was my fault right But if saying that was my fault means that you have to torture yourself for it, say that you're an awful person and genuinely feel that and that people hate you and that this will plague you and it will come revisit you 10 years later.
Some people do that. Then I'm very sympathetic that people might not. want to do that. But of course, the solution isn't then to externalize blame or control. The solution is to come to a healthier pattern of relating to our own actions, thoughts, and behaviors.
What would you say is a reason that people would develop a belief that if it's my fault, then this is – I thought this was supposed to be an ADHD podcast.
We're getting back to psychodynamics. It's not a – I don't think we – the jury's out. The jury's out, but I think the most plausible thing is that people take on patterns of thinking and relating to themselves and other people from their parents who took it from their parents. Some people call this inherited generational trauma. I think it's better just to call it we learn how to be and be with other people from our childhoods, and so did our parents.
Yeah, I like how things almost come full circle where, you know, like originally development was kind of the crucial lens that people viewed things. And then, you know, we slowly moved from psychoanalytics to a more biological understanding. And now we're coming full circle with like epigenetics is the big thing, which is... literally just like staying within the biology framework, but then saying like, Oh, we can look at your biology to see developmental things.
Like it, it's like, we can't retreat and say like, both things are true. We now have to develop biological frameworks for understanding things that we've understood for the last, you know, a hundred years.
I mean, that's, it's a very human thing, you know, in psychoanalysis, they'll call it splitting, uh, in CBT, they'll call it black and white thinking, uh, Right. And I think integration is actually relatively challenging for human beings. You know, it's a lot easier to think in all or nothing or black or white. And it takes practice to accept that two opposing things can be true at the same time.
But, you know, if we want to move forward, that's what we have to do. We have to integrate.
You love integrating.
Oh, yeah. That's my main thing. You know, do a little DBT. Nothing wrong with that.
um all right where uh now you mentioned adhd is real i think you use those that
direct quote right which of course implies the possibility that's not real right think about that so so there are people who are adhd truthers right they don't think it's real um i guess the short version of this is that It's kind of a broader problem with all of psychiatric diagnosis in that we don't have strict biomarkers. There are people who Act like there are clear biomarkers, objective signs that you can say this person definitely has this or this person definitely doesn't.
But that in the end, we're really just looking at presentations, life courses, and kind of types of people. I'm saying, well, this type really is more like this kind of thing that I've thought about. Or this type is more like another thing. And with ADHD, the argument that it may not be fully quote-unquote real would be that the criteria for its diagnosis has been, in some people's view, certainly maybe in mine, quite loosened, almost aggressively so, over the last few decades since it first was conceptualized.
Yeah. And another thing I want to point out that may be partially relevant. You know, before I started med school, I thought that, you know, pharmaceutical company, this pharmaceutical influence, I had a very childish view that like, you know, they're paying doctors to prescribe medications. And when you're on the other side, you can see it's more complicated than that. It's not as simple as big pharma is good or bad.
It's not as simple as big pharma is lining the pockets of doctors. What you see is vectors point in a certain direction that lead to certain results. And I think an example of certain vectors leading towards more diagnoses of ADHD and more prescription of stimulants. It's actually doctors aren't directly paid for prescribing stimulants. Like it's not like you prescribe Adderall and you get paid, but there is a financial incentive to diagnose ADHD.
And there's a financial incentive to have a relatively loose diagnosis of ADHD. So, you know, primary care doctors, for example, if you have an ADHD patient, that's a patient that's going to come monthly and they're not going to miss their appointments because their medications are inherently rewarding. They like their medications. They help with their lives. This is a patient who's going to come monthly. The checkups are going to be relatively easy.
Hey, how you doing? I'm doing good. Blood pressure is the same. Great. Here's your prescription. Go. And That's an easy patient where you get – so the incentive is actually to have those patients. Now, on the flip side, the incentive to have the more complicated patients, the patients in psychiatry who really need help, patients with complex comorbidities, patients who are suffering, they're difficult. They're a lot of work.
And financially, you're disincentivized to take those patients.
Yeah. I'm a big free market believer, but this is one of those situations where the free market does incentivize a certain style of practice, as you say. Patients that have means, have money, are free to change doctors when they want. If they don't like how you are approaching a case, they can just change the doctor. It reminds me of that recent post from the malpractice website i can't remember the name do you got do you remember the name hold on no no no um it's actually worth getting the reference right because they're pretty well known website let's see um med mail reviewer that recent post from the expert witness newsletter uh Yeah, that's it.
The recent post from the Expert Witness newsletter actually comes to mind here in the case number 231 of the Adderall suicide. At least a brief glance at that made it seem like it was a case where someone maybe wasn't getting... what they felt they needed from one doctor and then move to another one. And this happens. How fast would it be for me to say, all the symptoms that you're complaining about today in our 30-minute talk correspond to inattention and ADHD and you're denying any other significant depression, bipolar, psychosis, or anxiety.
Therefore, I'm going to give you a medication today. Versus, have you ever tried to do a structured or semi-structured clinical interview for all the criteria of adhd in an
adult uh not as thoroughly as going through everything but i've uh siphoned down like the the diva is the right the diva common one how long do you think it
actually takes to do the diva
Yeah, if you were to go step by step, it'd be like four hours.
Yeah, exactly. That's like, depending on the length of your visit, at least like several months, right? So why would a patient sit through that when they're very confident that they have ADHD already, or maybe not so confident, but they want some relief, when they could go cerebral, right? So it's just not feasible, right? It's a diagnosis where the criteria was initially designed to be observed by other people, right?
Observed by parents and teachers, not something reported by a person about themselves. Imagine if we applied this process to the diagnosis of intellectual disability. Let's pretend a bunch of people suddenly want to be diagnosed with intellectual disability of onset as adults. It's a ludicrous statement, but let's pull up the criteria. Imagine if we made a diagnosis based on the equivalent of the... Hold on. Let me pull up some stuff.
Do you remember... Oh, yeah. Here we go. OK, starting again. Imagine if we made diagnoses of intellectual disability the same way some clinics will process adult ADHD. For example, the adult ADHD self-report scale. Do you or do you not have the criteria? They just show you the criteria. They even fill in a gray box which criteria you're supposed to have. Let's say someone comes in. Do you have any deficits in your reasoning, problem solving, planning, abstract thinking?
Oh, I certainly do, doctor. Do you have any deficits in your adaptive functioning, like personal independence, social responsibility? Oh, yeah, absolutely. Oh, I guess you have an intellectual disability. You know, it's almost the same thing. These are both neurodevelopmental disorders, right? It would be ludicrous to you to have an intellectual disability, but we basically do something like that a lot of the time as a society when it comes to ADHD.
That's a very nice analogy. Thank you. let's keep talking about juicy stuff. Sorry. That was great. I want to talk a little bit about treatment. Okay. Now I know Dr. Fu is a huge proponent of stimulants. He actually, we were talking earlier. He said he wants to fortify all childhood cereal with amphetamines.
You know, I kind of feel like some child psychiatrists actually might feel that way. Um, and some people certainly feel very good about that. Uh, I really try to avoid most substances that have any addictive potential or withdrawal. And the reason isn't because... It isn't just because of the possible harm or rare side effects. And let me tell you, yes, I am biased by exposure to bad outcomes from stimulants based on my work.
You know, you look at criminal cases where people basically decompensated because of bad ADHD diagnosis and they ended up ruining their lives or the lives of somebody else. You know, malpractice cases. It's... It's not good when it happens. It is rare. You can't argue with the numbers there. You know, I actually think the greater danger in prescribing medications, particularly those with any kinds of euphoria or reinforcing effects like tolerance or withdrawal, the greater danger is to give people the wrong impression of what a treatment is.
And this is what I tell people. A treatment is different than a drug, not because of the substance that it actually is or its properties. The difference is that when you take a drug, it gives you an effect, and when you don't have that drug, the effect goes away. And the treatment, even if it gives me an effect or not that you can feel or notice, a treatment is something that you take in a specific way that leads you towards treatment change, that makes your life better and different than what it was before in a way that you want without giving you hopefully too much in terms of problems or side effects.
So I'm worried that in this world where Doctor visits are just getting shorter and shorter, and people are beginning to think of themselves as a container that holds a diagnosis that you have to feed a certain medication. I think it's an overly simplistic way to... go about your life and in your treatment, especially, and it kind of loses sight of what makes treatment treatment. And what makes treatment treatment is a really a deeper understanding, emotional and intellectual, of what you can be doing differently in your life and why.
So how do you think these medications should be a part of treatment and how would you sell them? Where do you think amphetamines or stimulants fit in and when are they appropriate and when do you think it is something that's, how do you pitch it?
Well, let's look at how stimulants were traditionally used. And I don't mean traditionally in the 70s as diet pills. I mean for children, right? Why do we give children with ADHD stimulants? It's because we presumably detected a clear difference in their ability to function compared to their peers and that there's a night and day benefit when they're given the stimulant without much side effects and that this allows them to engage with this whole process of school that everyone is compelled to be in from the ages of around six to 18.
It's letting them either keep up with or rise to their full potential because the stimulants for children occur alongside this learning trajectory, this developmental trajectory. This is not necessarily the case in all adults with ADHD or adults who are taking stimulants for other reasons. So what do I recommend? This is what I tell everybody, again, in terms of patients, that medications aren't going to solve all your problems.
Medications might solve some of your problems if you have more of a biological problem. But it's just one part of your treatment. It's something that makes it easier, ideally, for you to engage in the rest of your treatment, whether that's psychotherapy or lifestyle changes. And so, you know, coming back to that calendar idea, you might need that medication support. You might not. But whether or not you get it, hopefully it's leading you towards a change in how you conduct your life, what kind of things that you're doing, the way you're interacting with people.
I think one thing that's... Adult ADHD took off the framework of childhood ADHD. And from my understanding for childhood ADHD, it was initially conceptualized as a developmental issue and that these kids were behind in development. It wasn't saying that they were forever behind in development. It's, I mean, to do an analogy for height, if at 11 years old, some of the kids are six foot two and some of the kids are four foot 11.
And some of the kids, the kids that are four foot 11 when they're 12 years old, we're still expecting them to grow. We're not saying that they are, you know, small children. And for ADHD, it was conceptualized that they were just a few years behind the other kids and the stimulants were helping them to, to, to catch up to those kids. And that's why we saw a lot of, childhood ADHD, they would, quote unquote, grow out of it because they were behind in development and then eventually they would catch up in development and the stimulants were providing a boost before they caught up.
Would you say that's about?
I mean, that's one way of thinking about it. People are definitely going to dispute that. Very smart people and researchers are going to dispute that, right? There are people who think that it's some kind of a static, persistent neurodevelopmental disorder. My view is that it reflects relative weight of certain traits of how the mind processes information or acts, and that that's not necessarily itself a disorder. But, you know, there's some truth to what you're saying, basically.
If we look at the DSM-2, when they called it the hyperkinetic reaction of childhood or adolescence, they called it something that's more stable, internalized, and resistant to treatment than a transient situational disturbance, which would be like a stressor or adjustment disorder, right? but not so resistant to treatment as compared to psychosis, neurosis, and personality disorders. So yeah, so there's an idea that this was something that you could develop out of, right?
And it's not implausible if you actually look at the good research, in my opinion, on what happens. Most people stop meeting criteria for ADHD when they reach adulthood compared to when they were children. That's what most people have. their trajectory. Doesn't mean that they don't have any ADHD traits anymore. It just means that it's not quite so severe that they would necessarily reach the level of a psychiatric diagnosis, right?
Now, that also tells us, though, that people who continue to have some degree of ADHD problems in adulthood, there's probably one of two major things happening, right? They might just be on the more severe end of having actual ADHD. That can certainly happen, right? And then in cases like that, as long as you're not seeing significant side effects or problems from stimulants, that's a good treatment, right?
But what I tend to see most frequently is not that. What I tend to see most frequently is that people who are presenting, especially later in their lives with apparent ADHD, that is inattention problems, executive functioning problems, is that Something has happened in their lives, in their minds, or in both that is now interacting with their baseline ADHD traits. that they're having some kind of a new problem with anxiety, with depression, with stress, with their relationships, with their personality, which is not an indictment.
A personality is just what we learn to be like with ourselves and others. And things are getting hard for another reason. And a stimulant can make you feel better. It can sort of mitigate the effects of that interaction between your neurobiology and your situation, but it's not the full answer.
I moved... I changed the topic a little bit and didn't get to reflect on what you had said, your previous comment. What was the previous comment? I forget, but I then gave the analogy of height that wasn't that good, and then... It wasn't bad. Yeah. Um... I can move the conversation again, but was there anything else you wanted to say on that? Because that was good, and I kind of had a brain fart, so I lost some of it.
A little sleep deprived? You were saying... Yes, I am, actually. Sorry.
You were saying a little methylphenidate. It's a little safer than Adderall, you know? Yeah, what was it? They showed that something was, I can't remember. One or the other, there's a larger study or at least a review that shows that either methylphenidate or amphetamines are better in adults versus children. Can't remember which is which.
Yeah, it was methylphenidates were better in children and amphetamines are better in adults in regards to symptoms. Better. Yeah, exactly. It makes it seem like it's that clear cut. And I feel like as psychiatrists, we cling to those little factoids because we want to feel like we know something. And so it's like, oh, that's a thing to know. And it's obviously just infinitely more complex than that.
There's not one that's better than the other.
Well, it is an interesting question, right? Why might that happen? Why might you see that methylphenidate is better in children and adults are better on Adderall? Let's do a hot take. How about that? Maybe in childhood populations... you are more likely to capture true ADHD, and you're also more likely to capture premorbid bipolar and depressive disorders. And both populations would both respond well and also have least harm from a medication like methylphenidate, which there's at least some preliminary evidence showing is more suitable for use in bipolar disorders, though personally, I never give stimulants to bipolar disorder patients.
In adults, It may be a completely different presentation simply because of the loss of a large chunk of the ADHD population in childhood. Right. Many people go on. They don't need the treatment anymore or they at least don't meet criteria. They stop the treatment. And then you suddenly get a new set of people presenting for ADHD, for diagnosis of ADHD as adults who basically have some other problem going on.
Maybe rather than true ADHD, which could be, as I mentioned, all those different categories before, that could be a problem. Maybe what those people respond best to is the little euphoric boost of Adderall. Who knows?
Yeah, I like that theory that we know that amphetamines are just a little bit more rewarding, have higher abuse potential. And a lot of those conditions that you that you were naming that, you know, people are They know they have a problem and they cling to ADHD, but there might be something different underlying. A big part of that is dysphoria. A big part of the depression, a big part of the personality factors you're saying is a chronic underlying dysphoria.
Yeah. And it might not even be a full-on personality problem, right? It might be that maybe your job isn't very good. Maybe this is not a fun job for almost anyone except for very particular people. Maybe things aren't going so well in your family or in your relationship. And maybe the stimulant helps you feel like that's not such a problem. for at least the first couple of hours when it's at a high level.
But like I mentioned before, that's not treatment, right? That's a drug effect. We want to be looking for the treatment effect. And those can be very difficult to tease out when you have a medication class that can be and is used as a drug. This, of course, applies to benzodiazepines too.
Now, so you mentioned mood disorders, anxiety disorders, personality components. What are what are big ones that you think present as people clinging to the ADHD diagnosis? What do you see as one of the more common, you know, like I don't have, when you say mood, anxiety, personality, that's a, those are such vague categories. I don't have a picture in my head. Do you have like particular phenotypes that you're thinking of here?
By the way, I'm going to pick on you saying clinging, right? It's so judgmental. You're being so mean. I do think it's reflecting a reality in that everywhere, primary care doctors, psychiatrists, everyone I know is getting so burnt out by people presenting for adult ADHD evaluations. By the way, I'm not blaming the patients. I think patients are being sold a false bill of goods. It's like the only explainer for their mental distress or their problems of attention that anyone ever talks about anymore.
So of course, they're going to come in and say, I think of ADHD. They haven't been told about any other possibilities. But just as an aside, patients, I would recommend you try to come into your visits just talking about what your problems are. Don't come in with a diagnosis in mind. The process of diagnosis is so complex and fuzzy. Just say, this is the problem that I've been having.
What do you think? Then you can share what you think, too, and then you can see if it matches up. Anyway, the question that you had was... What was the question?
I was saying that the categories you gave, mood, anxiety, personality components, it's too vague. What are the most common presentations?
Yeah, yeah. I got to tell you, I don't think there is a most common presentation. It's always a little something different. But probably the biggest thing I see is that It's some kind of mood and anxiety problem, sometimes diagnosable as a major depression, a bipolar, or a primary anxiety disorder, but often just a fuzzy mix, right? Maladaptive, self-punitive, or anxious response to not doing so well. in a new work or school setting compared to before.
And there are so many things that can contribute to that, right? College is this huge change for people. You know, you're separated from family. You might have to learn all these new habits and ways of socializing and getting social support thousands of miles away from your family. You might begin to realize that the way your family was interacting before maybe wasn't the most healthy. Right. You might start experimenting with drugs and alcohol.
And that's a pretty universal college experience, I would say, for most people. It's overall some big change. And I would say one of the biggest problems is expectations. So I'm not going to give you one diagnosis that comes up. I'm just going to describe a few basic ones. I'll tell you another thing can even be obsessive compulsive traits. OK, even if it doesn't meet full OCD criteria, you've got some students who are reading and rereading each paragraph of the assigned chapter three or four times because they're anxious about missing the point or doing poorly in their course.
Right. There's so many different things that can make it hard to function at work or school and trying to reach the diagnosis first instead of talking through what the problems are, it's going to miss the picture.
And what a disservice having a diagnosis can do to someone. I think, you know, you talk about kind of being in college or new environments. A big part of having symptoms of inattention or symptoms of impulsivity is communicating information to you that you're in an environment that doesn't fit you. And if you just get slapped on an ADHD diagnosis and given medications to help you stay in that environment, you're not using the information.
Like to me, I think there's, you know, as we start pathologizing more and more and we're giving diagnoses, one of the big things we're missing is that our bodies are communicating information to us with these symptoms. Yeah. symptoms like dysphoria, symptoms like depression, symptoms like anxiety, symptoms like inattentiveness. These, for the most part, are trying to communicate something that the way we're living is not in accordance with our biology.
And theoretically, these diagnoses are supposed to be when these symptoms are occurring in to such a degree that it's affecting our function or occurring, you know, incorrectly in response to the environment. But for the most people, these are our body communicating to us, you know, the life plan that you're using right now is not something that's in accordance with what I want it to be.
Yeah, it could be, right? I think we should all be open to that there could be deeper meaning behind symptoms. Now, sometimes symptoms really are just a medical process, right? But often, even if there isn't a direct link, we can wonder about the possibility of more meaning. And if you get a little extra meaning out of that, I don't see what the harm is. But yeah, right?
It could be that sitting for eight hours a day And running through a spreadsheet is not the job for you. Maybe there are some people who are good for that. Maybe your job needs something a little more active, right? Or that has a lot more different tasks that you can attend to in short bursts rather than sustained bursts. I believe, I don't know for sure, I'm not a sociologist, that the cohort of people who are going to college today is just substantially bigger than and different, therefore, than what we had 30 or 40 years ago.
So it could be that the classroom and learning habits of the past just don't really correspond so much to how a lot of people can be in life. I would just say, if we can recognize, going back to what we talked about in terms of culture-bound disorders and let's say culturally preferred disorders, If we can recognize what's preferred or culture-bound in other cultures, then I think the intelligent question to ask ourselves is, what's our culture-bound syndrome as Americans, right?
Or as the West? What do we think is legitimate and real that other people would look at and go like, that's a little wacky, right? We're all living in a culture. So where do we have blind spots? My theory is currently it's ADHD. Not that it doesn't exist, but that we prefer to use that to explain so many other forms of distress and dysfunction from other sources.
And so just keep that in mind. You're more complicated than you think you are. And you deserve to get that complexity into your life.
I'm glad you brought up the culture-bound things because in a lot of lectures for the people who are pro-ADHD, there's almost like a... We believe it's the same percentage in every country everywhere. And to me, that just inherently doesn't make any sense. Countries have such different ways of living. How could...
Yeah.
How could the same percentage of people get diagnosed when, you know, as you're kind of saying, we know that the diagnosis is an interaction with a person in a society and that there's no that doesn't mean that it's not real. It doesn't mean it's it's made up, but it's inherent in how we diagnose is that the symptoms come as a result of a stimulus in an environment.
Yeah, but let's take that statement as generously as we can, right? Let's say they're saying that there is some underlying biological core that they think is at the same rate at every culture. Even if we agree with that, this is a bone I have to pick with anyone who says that something is over and underdiagnosed. How would you know? How would you know what it's supposed to be?
We don't have biomarkers. Again, we have no biomarkers. We have no idea whether we're over or under diagnosing anything at any time. We can only kind of guess at it. So, you know, rather than trying to find a diagnosis, I think what's more important is let's find a treatment plan. Let's find what's going to help you out. And that's one of the other issues, by the way, that I think contributes to the popularity of diagnosis, one diagnosis over another in cultures, is researchers.
They're well-meaning, but if you have a career... you're gonna act in a way to help your career, right? You're not gonna act in a way to diminish your career. You're not gonna turn around and start saying, actually, my 20 to 30 years of research work is flawed in this way, and really we should be recognizing this chunk of people as having this other diagnosis who's researched by my rival.
That's not gonna happen, right? You're gonna lean into it, and you will do so unconsciously, I expect. How can you go against your entire life's work? That would be so difficult. Now, there is something I wanted to also add that maybe we can insult, not insult, insert earlier into the talk. I don't know if most lay people ever considered a possibility that their development or their upbringing or basically their personality can be contributing to their executive dysfunction.
But I'll note that even in the DSM-5, I'm going to read from it directly. In adolescents and adults, it may be difficult to distinguish ADHD from borderline, narcissistic, and other personality disorders. Some personality disorders tend to share the features of disorganization, social intrusiveness, emotional dysregulation, and cognitive dysregulation. It may take extended clinical observation, informant interview, or detailed history to distinguish impulsive, socially intrusive, or inappropriate behavior from narcissistic, aggressive, or domineering behavior to make this differential diagnosis.
But of course, this also reaches some other problems I have with how the DSM is written. I think the DSM writes its personality disorders in a way that makes it extremely difficult to communicate to patients because it's as if each diagnostic category has been written by someone quite mad at a patient. OK, it's like it's like you use the language that's the most cruel and unforgiving as possible to describe these patients.
I could take almost any personality disorder diagnosis criteria from the DSM and put it in a different fashion to make it a little kinder and more understanding that people are having these problems without deciding to have these problems.
Yeah, that's where Nancy McWilliams' work really completely changes how you view it. Because as you mentioned, the DSM personality disorder criteria, a lot of it is describing an incredibly difficult... No one's going to read that and go, yeah, that looks like me. And Nancy McWilliams by... A few people do. Minority. A few people do. Yeah. Yeah. Personality disorder people. The Nancy Williams framing, it's like these are, I mean, these are, there are personality styles that we all have and that it's not, you know, with narcissistic personalities, we're all on that dimension.
We all have narcissistic traits. We all have narcissistic defenses. Yeah. it's so much more helpful to think of it as, you know, there's not disordered personalities and working personalities. It's kind of as we're talking with all diagnoses.
Yeah, but there is disordered personalities.
No, sorry, sorry, sorry, sorry. What do we mean by that, though? It's not too neat categories.
It's not too neat categories, but then I want to emphasize that for people who have a personality disorder diagnosis, it's because something happened to them. Something happened to them bad enough that what would have just been a style of personality or personality traits has become a real problem for them and yes i think if we're going to be honest there's probably something biological at work something innate but it's how that biology that innate quality of our character interacted with our life our parenting and our developmental experiences that produces a personality disorder it's not chosen it's near it's basically i i like to think that most personality disorders are a mixture of neurodevelopmental and trauma disorders.
Yeah. Um, and, and, you know, it's, it's funny that now we're seeing, uh, you know, that the focus from personality disorders go to a focus on, on trauma-based reactions as if they're describing totally different things. And, and we see the language, you know, it's either like personality disorders, there's an implication that it's like, it's this, you know, that this person is the problem. And then with trauma-based disorders, it's like this person's having a natural reaction to the terrible things that happened to them as if they're two separate things.
Um, yeah. And it's kind of going along that that biological line I was saying, we're like we're coming full circle now. You know, we're coming full circle where we're the only way we can acknowledge personality components and acknowledge biological things is now by framing it in trauma and almost like rehashing things that we've understood with regards to personality for a long time.
Now, by the way, for the podcast, do you prefer I refer to you as Dr. Malzberg? We should probably stick with Greg.
Greg's fine. What do you think we should do? For some reason, I like Greg and Dr. Fu. It makes it feel like there's a feeling there.
No, I don't like that. It's too much hierarchy. It's subtle. No, it's not. You're going to call me Dr. Fu. I'm going to call you Dr. Malzberg. Well, let's see. So, Dr. Malzberg, having read and talked now in preparation. I refuse. Having now read and discussed about ADHD at length, is there anything that you think has changed about your approach or attitude towards it? No. Not at all?
Oh, boy. Well, that's a little inflexible.
No, I'm just making a joke. After our conversation, is there things... I learned a ton from you. I'm very bad at, in the moment, assessing my understanding and my emotional state. So if you ever ask me things in the moment, I'll just never be able to answer them.
Well, that's not very helpful. We're supposed to be wrapping things up for the nice people who are listening to the podcast.
I apologize, nice people. I can't do it. I can't do it.
You know, I'll say that across my time period, I went from being very credulous about ADHD. Anyone who came in talking about it would have it to becoming overly skeptical. And now I think I hope I've reached some degree of integration. But it's just a fuzzy area. In the end, we make a diagnosis to give a good prognosis and a treatment plan. And I just want to make sure that everybody out there, patients and clinicians alike, are preserving the complexity in their inner lives when they work with each other.
Yeah, actually, now that you mentioned that, now I can have something I... Before, when I was doing a little bit of research for the previous podcast, I went into it expecting me to talk about how I think, you know, to bring a lot of question to it that, you know, I don't know. And as I learned more and more, I found, as I better understood it, I appreciated the complexity.
I appreciated... The people who are struggling from it and how helpful the diagnosis was and how helpful treatment was and how it turned their lives around. And then the flip side of people responding to the over-diagnosis. And I think understanding that both things are taking place. There are, without a doubt, people who are benefiting so much from the diagnosis and treatment. And then there are also a problem of financial incentives that have made it so that there's problems with this diagnosis and people are being over-diagnosed.
Not over-diagnosed because we don't actually know, as you said before. But you get what I'm saying. All these things are true. Yeah.
And by the way, if you're a bit of a wonk, and especially if you're a clinician, I would recommend not to read this as a model for truth, but just as a way to see how maybe in the alternate universe we would have thought about these issues. There is a concept called the primary disorder of vigilance from Dr. Warren Weinberg. He passed away, I think, over a decade ago at this point.
But he was a child neurologist and child psychiatrist who basically put forward that there was a more constrained and specific form of what he would call primary disorder vigilance and that other things that we would probably call ADHD today could be explained by other causes. So worth a read if you want to look into the literature there.
Yeah, I really like that paper that you sent me. One last point I wanted to make. I apologize, just popped in my head. One thing that really helped me to better understand ADHD, and this isn't even from my reading, and this is from a talk with a colleague, that ADHD isn't just a difficulty with executive functioning or anything. It's also the resulting self-beliefs and personality that can come from from that process.
So to me, when I feel like this is a clear kind of ADHD, one of the main things I see is you see a low self-esteem as a result of kind of being criticized their whole lives. A lot of people with ADHD, their whole lives when they were children, they weren't listening. They were told they weren't listening. They were told they were bad. They have tons of these little anecdotes that once they understand with the, with the diagnosis of ADHD, it actually helps them reframe their thinking.
You know, they have a lot of little quirks, um, you know, a lot of their whole lives, they lost a lot of things and, or they, they've developed these like very odd systems to compensate and that the diagnosis can actually help integrate all these things that feel like, Oh, I was a really, I was a really bad kid growing up. I didn't listen. Um, That can help be integrated into a more holistic understanding of why that was.
All these strange patterns of behavior that just feel like oddities from growing up now could be integrated as an understanding of like, oh, I was struggling as a kid with executive function. And these are some of the ways that it came out. That's right.
And I will say, though, let's take a story like that. It's very common to have those experiences if you have some neurodevelopmental disorder of any kind. At the same time, I would say that set of ways of relating to yourself and thinking and worrying about things, I wouldn't call it ADHD or autism disorder or something like that. It's basically a anxiety or interpersonal problem that comes from your other issues, right?
It's complex. And again, I'm trying to fight back against the idea that everything can be solved with a pill. or one treatment, right? There is a more complex way of having to go through your life and contend with yourself and other people that one diagnosis can't capture. Okay. Yeah. Well, we should probably finish up. Do you think we could try a, you know, social media focus review of like comments or posts or hot topic issues for our next one?
Of course. I think it'll be fun.
Do you want to make a call to the viewers?
Sure. You know, what we'll maybe try doing next time is go over things like reader comments or just hot topics or trending posts on social media. I think that'll be a ripe area for discussion.
Yeah. So if anyone has anything, any interesting questions or comments or things you want us to dive into, you know, we like fiery stuff.
Give us a like, subscribe, put it in the comments. Right. Post it. Social media. Excoriate me on.
We want attention. Whatever.
Whatever you want to do.
Dr. Food just wants to be famous. Oh, no.