In a recent article in the BMJ the author wonders about the reasons beyond the rising trend diagnosing Attention Deficit Hyperactivity Disorder (ADHD). The article attempts to infer reasons for this. One possible reason was that the diagnostic criteria especially DSM may seem for some to be more inclusive than ICD-10. The speculation may explain the rise of the diagnosis where DSM is used officially or have an influence. In a rather constructive way, an alternative to rushing to diagnosis is offered and discussed in some details. The tentative deduction that the Diagnostic Statistical Manual (DSM) may be one of the causes of rising diagnosis, due to raising the cut-off of age, and widening the inclusion criteria, as opposed to International Classification of Diseases, 10th revision (ICD-10), captured my attention. On reading the ICD-10 diagnostic criteria for research (DCR) and DSM-5 diagnostic criteria, I found them quite similar in most aspects, even the phraseology that starts with 'Often' in many diagnostic criteria, they seem to differ a bit in age. In a way both classification, are attempting to describe the disorder, however, it sounds as if someone is trying to explain a person's behaviour to you, however, this is not a substitute to direct clinical learning, and observing the behaviour, as if the missing sentence is 'when you see the person, it will be clearer'. El-Islam agrees with the notion that DSM-5 seems to be a bit more inclusive than ICD-10. A colleague of mine who is a child psychiatrist and she is doing her MSc. thesis in ADHD told me, that DSM-5 seems to be a substantial improvement as compared to its predecessor. The criteria - to her - though apparently are more inclusive, they are more descriptive with many examples, and she infers that this will payback in the reliability of the diagnosis. She hopes gene research can yield in biological tests for implicated genes and neurotransmitters in ADHD e.g. DRD4, DAT, gene 5,6,11 etc. One child psychiatrist, regretted the fact that misdiagnosis and under-diagnoses, deprive the patient from one of the most effective treatments in psychiatry. It is hoped the nearest forthcoming diagnostic classification (ICD-11), will address the issue of the diagnosis from a different perspective, or else converge with DSM-5 to provide coherence and a generalised newer standard of practice. The grading of ADHD into mild, moderate, and severe seem to blur the border between disorder and non-disorder, however, this quasi-dimensional approach seems realistic, it does not translate yet directly in differences in treatment approaches as with the case of mild, moderate, severe, and severe depression with psychotic symptoms, or intellectual disability. The author states that one counter argument could be that child psychiatrists are better at diagnosing the disorder. I wonder if this is a reflection of a rising trend of a disorder. If ADHD is compared to catatonia, it is generally agreed that catatonia is less diagnosed now, may be the epidemiology of ADHD is not artefact, and that we may need to look beyond the diagnosis to learn for example from environmental factors. Another issue is that there seems to be significant epidemiological differences in the rates of diagnosis across cultures. This may give rise to whether ADHD can be classified as a culture-bound syndrome, or whether it is influenced by culture like anorexia nervosa, or it may be just because of the raising awareness to such disorders. Historically, it is difficult to attempt to pinpoint what would be the closest predecessor to ADHD. For schizophrenia and mania, older terms may have included insanity, for depression it was probably melancholia, there are other terms that still reside in contemporary culture e.g. hypochondriasis, hysteria, paranoia etc. Though, it would be too simplistic to believe that what is meant by these terms was exactly what ancient cultures meant by them, but, they are not too far. ADHD seems to lack such historical underpinning. Crichton described a disorder he refers to as 'mental restlessness'. Still who is most often credited with the first description of ADHD, in his 1902 address to the Royal College of Physicians. Still describes a number of patients with problems in self-regulation or, as he then termed it, 'moral control' (De Zeeuw et al, 2011). The costs and the risks related to over-diagnosis, ring a warning bell, to enhance scrutiny in the diagnosis, due to subsequent stigma, costs, and lowered societal expectations. They all seem to stem from the consequences of the methodology of diagnosis. The article touches in an important part in the psychiatric diagnosis, and classifications, which is the subjective nature of disorders. The enormous effort done in DSM-5 & ICD-10 reflect the best available evidence, but in order to eliminate the subjective nature of illness, a biological test seems to be the only definitive answer, to ADHD in particular and psychiatry in general. Given that ADHD is an illness and that it is a homogeneous thing; developments in gene studies would seem to hold the key to understanding our current status of diagnosis. The suggested approach for using psychosocial interventions and then administering treatment after making sure that it is a must, seems quite reasonable. El-Islam, agrees that in ADHD caution prior to giving treatment is a recommended course of action. Another consultant child psychiatrist mentioned that one hour might not be enough to reach a comfortable diagnosis of ADHD. It may take up to 90 minutes, to become confident in a clinical diagnosis, in addition to commonly used rating scales. Though on the other hand, families and carers may hypothetically raise the issue of time urgency due to scholastic pressure. In a discussion with Dr Hend Badawy, a colleague child psychiatrist; she stated the following with regards to her own experience, and her opinion about the article. The following is written with her consent. 'ADHD is a clinically based diagnosis that has three core symptoms, inattention, hyperactivity and impulsivity in - at least - two settings. The risk of over-diagnosis in ADHD is one of the potentially problematic, however, the risk of over-diagnosis is not confined to ADHD, it can be present in other psychiatric diagnoses, as they rely on subjective experience of the patient and doctor's interviewing skills. In ADHD in particular the risk of under-diagnosis is even more problematic. An undiagnosed child who has ADHD may suffer various complications as moral stigma of 'lack of conduct' due to impuslivity and hyperactivity, poor scholastic achievement, potential alienation, ostracization and even exclusion by peer due to perceived 'difference', consequent feelings of low self esteem and potential revengeful attitude on the side of the child. An end result, would be development of substance use disorders, or involvement in dissocial behaviours. The answer to the problem of over-diagnosis/under-diagnosis can be helped by an initial step of raising public awareness of people about ADHD, including campaigns to families, carers, teachers and general practitioners. These campaigns would help people identify children with possible ADHD. The only risk is that child psychiatrists may be met with children who their parents believe they might have the disorder while they do not. In a way, raising awareness can serve as a sensitive laboratory investigation. The next step is that the child psychiatrist should scrutinise children carefully. The risk of over-diagnosis can be limited via routine using of checklists, to make sure that the practice is standardised and that every child was diagnosed properly according to the diagnostic criteria. The use of proper scales as Strengths and Difficulties Questionnaire (SDQ) in its two forms (for parents SDQ-P and for teachers SDQ-T) which enables the assessor to learn about the behaviour of the child in two different settings. Conner's scale can help give better understanding of the magnitude of the problem. Though some people may voice criticism as they are mainly filled out by parents and teachers, they are the best tools available at hands. Training on diagnosis, regular auditing and restricting doctors to a standard practice of ensuring that the child and carer have been interviewed thoroughly can help minimise the risk of over-diagnosis. The issue does not stop by diagnosis, follow-up can give a clue whether the child is improving on the management plan or not. The effects and side effects of treatments as methylphenidate should be monitored regularly, including regular measurement height and weight, paying attention to nausea, poor appetite, and even the rare side effects which are usually missed. More restrictions and supervision on the medication may have an indirect effect on enhancing the diagnostic assessment. To summarise, the public advocacy does not increase the risk of over-diagnosis, as asking about suicidal ideas does not increase its risk. The awareness may help people learn more and empower them and will lead to more acceptance of the diagnosed child in the community. Even the potential risk of having more case loads for doctors to assess for ADHD may help give more exposure of cases, and reaching more meaningful epidemiological finding. From my experience, it is quite unlikely to have marked over-representation of children who the families suspect ADHD without sufficient evidence. ADHD remains a clinical diagnosis, and it is unlikely that it will be replaced by a biological marker or an imaging test in the near future. After all, even if there will be objective diagnostic tests, without clinical diagnostic interviewing their value will be doubtful. It is ironic that the two most effective treatments in psychiatry methylphenidate and Electroconvulsive Therapy (ECT) are the two most controversial treatments. May be because both were used prior to having a full understanding of their mechanism of action, may be because, on the outset both seem unusual, electricity through the head, and a stimulant for hyperactive children. Authored by E. Sidhom, H. Badawy DISCLAIMER The original post is on The BMJ doc2doc website at http://doc2doc.bmj.com/blogs/clinicalblog/#plckblogpage=BlogPost&plckpostid=Blog%3A15d27772-5908-4452-9411-8eef67833d66Post%3Acb6e5828-8280-4989-9128-d41789ed76ee BMJ Article: (http://www.bmj.com/content/347/bmj.f6172). Bibliography Badawy, H., personal communication, 2013 El-Islam, M.F., personal communication, 2013 Thomas R, Mitchell GK, B.L., Attention-deficit/hyperactivity disorder: are we helping or harming?, British Medical Journal, 2013, Vol. 5(347) De Zeeuw P., Mandl R.C.W., Hulshoff-Pol H.E., et al., Decreased frontostriatal microstructural organization in ADHD. Human Brain Mapping. DOI: 10.1002/hbm.21335, 2011) Diagnostic Statistical Manual 5, American Psychiatric Association, 2013 Diagnostic Statistical Manual-IV, American Psychiatric Association, 1994 International Classification of Diseases, World Health Organization, 1992
Dr Emad Sidhom
about 7 years ago
This field of medicine requires much more physiological and pathophysiological knowledge than most people give it credit for. Psychiatric illness DO have physical manifestations of symptoms; in fact those symptoms help form the main criteria for differential diagnoses. For example, key physical symptoms of depression, besides having a low mood for more than two weeks (yes, two weeks is all it takes to be classified as 'depressed'), include fatigue, change in appetite, unexplained aches/pains, changes in menstrual cycle if you're a female, altered bowel habits, abnormal sleep, etc. Aside from this, studies suggest that psychiatric illnesses put you at higher risk for physical conditions including heart disease, osteoarthritis, etc. (the list really does go on) Although some mental health conditions, like cognitive impairments, still do not have very effective treatment options; most psychiatric medications work very well, and are necessary for treating the patient. The stigma surrounding them by the public causes a huge problem for doctors. Many patients are reluctant to comply with medications because they are not as widely accepted as the ones for non-mental health conditions. A psychiatrist holds a huge responsibility for patient education. It can be tough to teach your patients about their medication, when many of them refuse to belief there is anything wrong with them (this is also because of stigma). Contrary to my previous beliefs, psychiatrists DO NOT sit around talking about feelings all day. The stereotypical image of someone lying down on a couch talking about their thoughts/feelings while the doctor holds up ink blots, is done more in 'cognitive behavioural therapy.' While this is a vital healthcare service, it's not really what a psychiatrist does. Taking a psychiatric history is just like taking a regular, structured medical history; except you have to ask further questions about their personal history (their relationships, professional life, significant life events, etc), forensic history, substance misuse history (if applicable), and childhood/developmental history. Taking a psychiatric history for a new patient usually takes at least an hour. The interesting thing about about treating a psychiatric patient is that the best guidelines you have for making them healthy is their personality before the symptoms started (this is called 'pre-morbid personality'). This can be difficult to establish, and can often be an ambiguous goal for a doctor to reach. Of course, there is structure/protocol for each illness, but each patient will be unique. This is a challenge because personalities constantly evolve, healthy or not, and the human mind is perpetual. On top of this, whether mental or physical, a serious illness usually significally impacts a person's personality. Most psychiatric conditions, while being very treatable, will affect the patient will struggle with for their whole life. This leaves the psychiatrist with a large portion of the responsibility for the patient's quality of life and well-being; this can be vey rewarding and challenging. The state of a person's mind is a perpetual thing, choosing the right medication is not enough. Before I had done this rotation, I was quite sure that this was a field I was not interested in. I still don't know if it is something I would pursue, but I'm definitely more open-minded to it now! PS: It has also taught me some valuable life lessons; most of the patients I met were just ordinary people who were pushed a little too far by the unfortunate combination/sequence of circumstances in their life. Even the ones who have committed crimes or were capable of doing awful things.. It could happen to anyone, and just because I have been lucky enough to not experience the things those people have, does not mean I am a better person for not behaving the same way as them.
almost 7 years ago
Risk and Outcomes of Substance Use Disorder among Anesthesiology Residents: A Matched Cohort Analysis
Anesthesiology. 2015 Oct;123(4):929-36. doi: 10.1097/ALN.0000000000000810. Research Support, N.I.H., Extramural; Research Support, Non-U.S. Gov't
over 5 years ago
Here's the information students need to know about how drugs work and how they can affect athletic performance. Through "real life" scenarios, students gain insights into the application of pharmacology in their clinical practice—from assisting an athlete who is taking a new medication to recognizing drug-related side effects when a negative reaction is occurring to handling instances of drug abuse. Beginning with an overview of pharmacokinetics and pharmacodynamics, the text presents prescription and over-the-counter medications in relation to the injuries or health conditions athletic trainers commonly encounter. Frequently abused substances such as amphetamines, herbals, and anabolic steroids are also addressed. Legal and ethical issues of drug use are presented, such as HIPAA–mandated privacy issues, drug testing, and which drugs are deemed as acceptable or banned according to NCAA and US Olympic standard.
almost 6 years ago
The epidemic of substance abuse continues to pose a significant challenge to clinicians nationwide. Although there is a tendency to simply associate drug abuse with poverty, the problem affects every social stratum gender and race; and pregnant women are no exception. Caring for pregnant, substance-using women and their infants presents complex legal and ethical issues. Debate is ongoing about whether criminal penalties should be imposed on women based solely on their use of alcohol and other drugs during pregnancy. Furthermore, controversies persist about the rights and wishes of pregnant women versus the interests of their fetuses. For health professionals, conflict arises when the pregnant woman chooses behaviors that have the potential to harm the developing fetus. The ethical dilemma arises from competing autonomy-based and beneficence-based obligations to the maternal-fetal dyad. This chapter explores the ethics-based conflicts in the delivery of health care to drug abusing pregnant women.
over 5 years ago
Brain dysfunction associated with heroin addiction is sustained even after at least 3 years of abstinence, according to the first brain imaging study to evaluate long-term outcomes of former addicts.
over 5 years ago
Indiana's prescription drug monitoring program has changed the way some pharmacists dispense controlled substances, results from a new survey show.
over 5 years ago
The number of children calling ChildLine about their parents' drinking and drug abuse has doubled in the past year.
almost 7 years ago
This review summarizes recent evidence related to the safety, efficacy, and metabolic outcomes of bariatric surgery to guide clinical decision making. Several short term randomized controlled trials have demonstrated the effectiveness of bariatric procedures for inducing weight loss and initial remission of type 2 diabetes. Observational studies have linked bariatric procedures with long term improvements in body weight, type 2 diabetes, survival, cardiovascular events, incident cancer, and quality of life. Perioperative mortality for the average patient is low but varies greatly across subgroups. The incidence of major complications after surgery also varies widely, and emerging data show that some procedures are associated with a greater risk of substance misuse disorders, suicide, and nutritional deficiencies. More research is needed to enable long term outcomes to be compared across various procedures and subpopulations, and to identify those most likely to benefit from surgical intervention. Given uncertainties about the balance between the risks and benefits of bariatric surgery in the long term, the decision to undergo surgery should be based on a high quality shared decision making process.
over 6 years ago
Stream Journal club: Chronic disease management for tobacco dependence by BMJ talk medicine from desktop or your mobile device
about 6 years ago
Opioid use and misuse for non-cancer pain is a challenge for emergency department physicians, the health care system and society. There are some disturbing trends reported by the Center for Disease Control (CDC) over the last few years. Between 1991 and 2010 prescriptions for opioid analgesics increased from 75.5 million to 209.5 million according to the National Institute of Drug Abuse (NIDA). This was followed by an increase in abuse and overdose. The CDC estimates that narcotic pain relievers now cause or contribute to nearly three out of four prescription drug overdoses and about 15,000 deaths per year.
almost 6 years ago
Childhood trauma isn’t something you just get over as you grow up. Pediatrician Nadine Burke Harris explains that the repeated stress of abuse, neglect and parents struggling with mental health or substance abuse issues has real, tangible effects on the development of the brain. This unfolds across a lifetime, to the point where those who’ve experienced high levels of trauma are at triple the risk for heart disease and lung cancer. An impassioned plea for pediatric medicine to confront the prevention and treatment of trauma, head-on.
almost 6 years ago