Is ADHD A Real Psychiatric Disorder: This Will Blow Your Mind 

Introduction 

Attention deficit hyperactivity disorder (ADHD) in the adult population is a topic of great debate. There are many psychiatrists who say ADHD symptoms do not suddenly disappear as a person continues into adulthood. On the other hand, there are some psychiatrists who do not think ADHD is a real diagnosis. 

The term ADHD might be better thought of as attention deficit disorder (ADD). The concept of hyperactivity is more common in the child/adolescent patient population. It’s unclear if the hyperactivity is related to executive dysfunction which is the hallmark of ADHD. It may be that the hyperactivity is within the range of normal (agitation or activation) for a child, or signs of another mood disorder such as mania in bipolar illness (especially true in the adult population as bipolar diagnosis is commonly reserved for adult patients). 

We can make an argument that placing children in a traditional school setting where they are asked to sit and pay attention to uninteresting material for 7 hours is unnatural and directly against the way humans evolved to function. The human body and mind evolved to move and be active not to sit in classrooms. As a result, agitation, hyperactivity, and acting out can be the result of this unnatural state. 

The hallmark of ADHD is attentional impairment and executive dysfunction. Hyperactivity is not seen in adult populations with ADD. 

Attention As a Trait 

Attention can be thought of in the same manner as blood pressure. There is a mean blood pressure in the population but there will be individuals that fall outside the standard curve. Most people in the population will fall in the middle having a reasonable amount of attention and those with low attention levels do not necessarily have a disease although they may have consequences associated with reduced attentional activity. When someone is overly attentive it can be a symptom of disorders like obsessive compulsive disorder (OCD) or psychosis. Like blood pressure, having readings that are too high or too low can cause problems. It’s normal to have a certain amount of inattention, and we can think of attention as a spectrum with a range of normal levels. 

What are the Causes of Inattention 

-It could be a perfectly normal trait, as we explained some people have lower attention spans naturally as a personality trait 

-Mood disorders like depression and bipolar disorder have in inattention as a possible consequence of the change in mood 

-Psychotic disorders also have cognitive changes that may cause inattention (internal preoccupation) 

-Anxiety disorders 

-Neurocognitive disorders 

-We should avoid diagnosing ADD in the setting of one of these other conditions. 

Would you diagnosis ADD during a manic episode?

Prevalence of ADHD in the U.S. 

-The prevalence of ADHD in the U.S. ranges from 5.6% to 15.9% and there is great variability depending on the geographic region 

-For most biological diseases we should see similar prevalence rates across populations and geographic regions. For example, schizophrenia has a prevalence of about 1% worldwide. So why do we see significant differences across the U.S.? 

-We do not know much about the role socioeconomic factors, diet, exercise, and other social factors play in the development of ADHD. It’s possible that these are significant contributing factors resulting in the symptoms associated with ADHD. 

Is ADHD a neurodevelopmental issue? 

-One way of thinking about ADHD is as a neurodevelopmental problem that eventually improves over time. 

-In children with ADHD they seem to achieve peak cortical thickness later than children without ADHD, this has been confirmed on imaging studies. 

-The important part is eventually these children catch up with the normal controls. It’s more a delay in brain development and not a permanent state. 

-The ADHD children are about 2 years behind the normal controls and the area of greatest delay is the prefrontal cortex which is responsible for executive function. 

How Common is ADHD and Does it Last into Adulthood? 

Over the past decade ADHD in adult populations has gotten more attention. Some would say the prevalence in adults is 4% to 5% with equal rates being seen in men and women. 

The national comorbidity survey estimated 46% of children with ADHD have symptoms that persist into adulthood. Many of these individuals had comorbid anxiety disorders and we know anxiety can be a major cause of inattention and executive dysfunction. 

In other studies, similar findings were reported. What stands out to me in all these studies is the high rates of comorbid mood disorders including depression and bipolar disorder. It’s hard to make a diagnosis of adult ADHD in the presence of other conditions considering the significant overlap of symptoms and cognitive dysfunction associated with mood disorders. 

It’s possible that mood and anxiety disorder can account for most adult ADHD cases and a variation of a normal trait could explain the rest (individuals with low attention) 

Looking at medication response doesn’t help us much as amphetamines are helpful in everyone even those who do not have a psychiatric disorder (think college kids taking them for midterms) 

When you correct for comorbidities in Adult ADHD, only about half of the young adults meeting criteria for ADHD had ADHD only. Estimates from this showed that most children diagnosed with ADHD were no longer meeting criteria in adulthood (83% no longer had symptoms). Many of the newly diagnosed cases of ADHD were in individuals who did not have ADHD as children (87% did not have ADHD as children).  

This indicates that about 20% of children diagnosed with ADHD will have symptoms persist into adulthood, the other 80% will not 

In animal models, amphetamines have been shown to have some dangerous effects 

-Decrease response to reward stimuli 

-increased anxiety 

-decreased dopamine activity 

-decreased long-term survival of neuronal cell in the hippocampus (excitotoxicity) 

Risk of Substance Use With Stimulant Prescriptions

Most psychiatrists will tell you the risk of substance use disorder does not increase with stimulant medication treatment; in fact it’s reduced when ADHD is treated. However, a well-designed randomized controlled trial of delinquent behavior and emerging substance use in medication treated children found significantly higher rates of substance use in the stimulant treated individuals. The conclusion by Molina et al. was we need to re-evaluate the risk of substance use disorder as children age when they are prescribed stimulants. Now correlation does not equal causation, but this should give us some pause when blinding stating there is no risk for addiction with stimulant use (this claim is mostly based off observational data and not randomized controlled trial data). 

Guide To Viewing My Content

If you are new to the blog and my social media content, we should start with a brief introduction. 

My name is Dr. Garrett Rossi, I’m a medical doctor who specializes in adult psychiatry. I’m board certified by the American Board of Psychiatry and Neurology. I’ve practiced in multiple settings including inpatient, outpatient, partial care, assertive community treatment teams, and I provide ECT services.

I make mental health content on multiple social media platforms and each one has a specific style and type of content. 

Shrinks In Sneakers YouTube Click Here

This is where you can find the deep dives on mental health topics including medication reviews, psychiatric diagnosis, and various other topics. Videos can range anywhere from 5-20 minutes and time stamps are available in the descriptions for longer content. 

Shrinks In Sneakers Instagram Click Here:

This is where you can find shorter videos and posts on mental health topics. The focus on Instagram is more on mental health advocacy, and myths about psychiatry and mental illness. The content here is shorter but still has a lot of educational value. 

Shrinks In Sneakers LinkedIn:

This is where you can find more information about my professional activities. I have information about my advocacy work, professional memberships, publications, and is another good place to follow my work. I make frequent posts here as well. 

Shrinks In Sneakers Twitter

Here I’m not very active and haven’t spent much time but I do update blog posts and other relevant information here as well. 

If you have a question or want to get in touch with me, I am most active on YouTube, LinkedIn, and Instagram. 

We are building a community where empathy is a central part of the content. The goal is to make psychiatry more accessible, provide education, and reduce stigma associated with mental health treatment. 

Shrinks In Sneakers Reunite: Bound by Love for Psychiatry

I think everyone needs a person in their medical training that they bond with and lean on during this difficult period. 

Medical training has its ups and downs, the process is filled with highest highs and the lowest lows. There were moments that I loved training and there were moments where I hated training. 

I was lucky enough to find a great person to share these experiences with.  

We spent many hours discussing psychiatry, what excited us about the field and what worried us about the future. We discussed difficult cases and the drama of residency training. If I ever needed help or someone to cover a call shift last minute, I knew who I could count on.

I could trust this person to have my back and I would do the same no matter what. 

 I would encourage anyone who is going through this process to find someone who can help them grow as both a physician and a person. 

It’s always comforting knowing we can all get by with a little help from our friends. 

How to Manage Aggression with Psychopharmacology in an Inpatient Setting

I’m very careful about the content I consume and the resources I use to grow as a psychiatrist.

When I endorse something like The Psychiatry & Psychotherapy Podcast, you know it’s something I personally use and trust. 


I had the opportunity to work with Dr. Puder on a recent episode How to manage aggression with psychopharmacology in an inpatient setting. Unfortunately, I got caught up taking care of patients on my inpatient service on the day of the recording and did not get to talk with Dr. Puder and Dr. Cummings.

I would encourage you to listen to all the episodes, but my personal favorites are the ones with Dr. Cummings. He has a wealth of knowledge and I’ve learned some amazing clinical pearls that I apply in my daily practice. 

Check out the episode, you will not be disappointed

https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-145-how-to-manage-aggression-with-psychopharmacology-in-an-inpatient-setting

Why Labels Matter: A Personal Perspective

Introduction:

I’ve been writing a lot lately about the why words matter, and how the language we use can go on to influence our lives in many ways. In my clinical work with patients, I make an extra effort to explain the process of making a diagnosis. I also stress to my patients that diagnosis is a way of conceptualizing mental illness to help physicians design appropriate treatment plans. I want them to know that diagnosis is an imperfect process. When we label someone as “depressed or anxious,” we may not understand the lasting impact this can have on them. Many patients internalize and identify with being “depressed” sometimes to the detriment of their treatment. 

True Story:

I can share a personal perspective on the power of labels, because one particular label almost prevented me from becoming a physician. Imagine you are in fourth grade, and to that point you were already identified as “one of the least academically gifted” children in the class. At this point it was already clear there would be no gifted and talented classes for me. After another year of painful struggle academically, my parents requested I be tested by the child study team for a learning disability. At the time I did not know this was going to pretty much set the course for the rest of my academic career. Sure, enough, after what seemed like endless testing I was classified, given an individualized education plan (IEP), and placed in slower paced classes with fewer students. Now I had been officially labeled as having a learning disability. I had a real excuse to give up on any academic ambitions. 

Looking back on it, I’m not sure I even had a learning disability as much as the educational material and teaching was just so uninspiring. I continued through middle school, and high school and average student in below average classes, and I thought I was okay with that, after all I had a learning disability. I identified with this label which had a profound impact on my academics and ultimately set my medical career back five years. 

Famous Last Words:

The point of this is to help people who have been affected by labels. If you find yourself continually self-sabotaging, you may be allowing early labeling and the conditioning that comes with it to limit your potential. It’s important to accept your circumstances, and to try the treatments or interventions offered if you are not functioning well. However, we should not allow our life to be defined by these labels. Just because you have a learning disability or depression does not mean you cannot be successful. It took me many years to accept that I might actually be smart enough to go to medical school. I often think about how much further along I could have been if I did not identify with and internalize the idea of having a learning disability. Do not make the same mistake.

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