Alternative Diagnosis - The Personality Connundrum in Disruptive Behaviour and Impulsive People

ADHD is not a diagnosis of preference in France, where health professionals and parents alike are averse to the neurobiological train of thought which is currently so pervasive in the US and many other western countries.

There are of course various studies and on going research programmes which claim to show that ADHD is related to a disordered or paratypical brain activity, which may be related in turn to a misbalance in dopamine and seratonin acitivity and metabolism. The current umbrella theory is that ADHD is typified by a lack of  neural activity in terms of the cognitive and "central coretex narative"   to which the brain eventually sets off an internal, subconscious alarm and tries then to wake up or you could say, jump start the brain by creating over stimulation of the weaker neural processes. So on the one side we see typical 'glue brain' attention deficy periods, and then rushing of thoughts and disruptive behaviour. This is then bipolar in nature. Hence stimulant therapies such as Methylphenidate, are prescribed because they both match the notion of neuroligical aetilogy and because these drugs do work in a proportion of cases.

However, a disruptive pupil who does not pay attention is then given a social based diagnosis with no actual investigation as to the underlying neuro biological symptoms. The prescription drugs are shown to work in the studies, so why should we seek a more expensive route for differential diagnosis, involving both brain activity and a wider social and personality discussion with the family?  The drugs work of course to the threshold for acceptable efficacy that the FDA and other medical authorities stipulate. However that varies betweeen studies and treatments, as do the criteria for initial diagnosis and inclusion to the clinical trials, which may be far more stringent or preloaded than actual diagnostic practice at the primary health care front line.

In the clinical trials,  there are always two groups though which are then brushed under the carpet when the efficacy is over 40%. The first are non responders, and the second are those who withdraw or are withdrawn due to side effects. Here we touch on the elephant in the living room of chemical medicine: that we often do not fully know the aetiology of a disease at the molecular level, yet we follow a course of drug introduction which are shown to have positive effects on symptoms, bind receptors believed to be involved or are variants of earlier chemicals found to have more specific effect, less side effect, or even as in the famous cases of Viagra and One Alpha, that drugs being experimented upon in one disease area, had powerful indications in another seemingly unrelated one.  We can say with some confidence that up to a third of patients do not respond to  ADHD medicines, depending on the diagnosis and probably the genetics of that population. We can also say that a small proportion will experience side effects, often the 'amphetamine' like experiences of grinding teeth, more micturition and so on.

The 'cures' are to an extent a magic bullet, a key to the lock. But only if you care to see the lock as you have been told to look at it. The trouble is that the pyschological and social therapies or you could say, regimes, which could equally well be employed are more nebulous, outside France that is. They vary and perhaps demand a referal and further diagnosis. Also compliance and attendence may be far lower than for popping a pill before breakfast.

The French take a different stand point, where chemical intervention is the last resort it seems, and is prescribed in less than 0.5% of cases. They consider rather first, the social conditions and context for the child's "misbehaviour" and think more in terms of neuroticism, angst and post traumatic stress for the more severe cases presenting. Milder cases are often considered as just what they present as: misbehaviour - innapropriate talking, impulsiveness and other disruptiveness and a lack of concentration-  in school most often. Alternatively the child may be considered to be just bored, understimulated, with some topics at school.

Here we reach a crux of the cultural differences between several entire systems: medical, pharma business, political and cultural. In countries which show high prescription of ADHD medicine in children, there is most often also a political agenda to make schools less liberal in thinking, and more 'sqaure' in terms of producing better 'hard skills' for the jobs market down the line. The USA, the UK and even Norway under the latest government are all examples of this, where Ritalin (TM) in particular is prescribed first line by many physicians and psychiatrists. Creative subjects and time on them in school have been reduced, and "sqaure" subjects like maths and grammar are even introduced into creative education and physical activities. At the same time many western countries have relaxed direct to consumer market communication, and the borders are fully blurred by the free flow of informatuion on the internet. Physicians have the lock and key now to "arrest" this disruptive behaviour rather than 'wasting time on wooly and lengthy' psychological approaches as was mentioned to the author by a GP.

What alternative diagnoses could or should be aired ? Should we follow more closely the French approach, or would it burden the health care system without the same efficacy as "pill-pushing"?

GROUP EXPERIENCE

Our group of adult ADHD sufferers have evolved with most actually now dropping out of the prescription drug programme. Some feel well managed though, especially when using the slow release formulations of the stimulant therapies. Most though either did not tolerate, did not comply enough, or simply did not want to continue on prescribed medicines. Since our group is a little biases and 'self selecting' when it regards further therapy, we cannot say that they are representative what so ever, yet the routes they are exploring in and outside of the health care system are illuminating.

They take us on a laymans journey through their own lives, diagnosis, "first line" treatments they recieved and then why they chose to take the route away from medication, and even to reconsider if their diagnosis was correct in the first place. ( the cases will be expanded , come back to the blog for more later)

CASE A  in their own words

" Getting a diagnosis of ADHD as a man in my forties came as a surprise. In fact with some disbelief. How could I have come this far in life ? University and business school education??  Both the cognitive tests I took and the following discussions with a clinical psychologist and then consultant psychiatrist were almost like getting a diagnosis of cancer. A tumour of the personality. A metastasized, malignant burden on my psyche.

I wasn't by any means devastated, because I knew I was unhinged, which is why I sought help,  and I knew there was now a "cure" with proven clinical effect. Four years on I feel though that I have come full circle to actually reconsider my own diagnosis and the nature of the disease in context of wider personality traits and neuroses.

To kind of contradict this last statement, I actually do believe very firmly that I have neurological ADHD. I have classic symptoms of under stimulation followed by rushing thoughts. I responded well enough to the slow release Ritalin formulation, having had marked amphetamine like side effects and bad stomach from the normal preparation. I had great concentration when dosed up on normal tablets, and more even productivity at work, but found I was grinding my teeth, going to the toilet often, my stomach was getting crampy and I found it hard to sleep at night. I was also experiencing a marked 'down' in the early evening when I would often become drowsy or irritable. The slow release was very much more expensive for me, and came with some bowel disruption. Also I felt that the positive effects were wearing off after three months, while the peeing and the distrubed sleep continued.

During the consultations with first my district psychologist, then the clinical psychologist and then consultant at the hospital I had said over and over again that I thought there was a parallel emotional disturbance that I would like to address, related to some childhood trauma including berievement and some quite serious bullying. That was brushed aside and the route forward was management by Ritalin. After this I had only one short consultation with the consultant, really to see how I was tolerating the normal tablets and if I was benefiting. My plea for more support and investigation of the social and emotional elements I thought were important, were simply brushed aside. I changed the formulation through my GP to the tarmic release and realised that if I wanted some kind of ongoing psychological support, I was going to have to beg for it or come seeking a new diagnosis!

At a couple of points in the consultations I realised it may be going towards these stimulant, neuroactive chemical treatments and asked if there was alternatives. The medical profession went vague on me hear. When I raised the history of valium, that was considered not relevant because these new drugs were shown not to be habit forming. With less than five years of experience and a powerful pharma lobby, it is really too soon to tell IMHO.  No alternatives were suggested. It looked like they were only available via charity and self-help groups.

In the course of this I made some bad career decisions and after a lot of turmoil in the work place, caused largely by circumstances and not myself, I was unemployed two times with only a short period of work in the middle. It felt like a perfect storm for damming me for my own impulsiveness in moving jobs in the first place, and not having a more successful and stable career - this is where and why my ADHD is in the picture as a diagnosis and kind of journey through the whole rigermorole of pharma dominated diagnosis. So I was feeling disillusioned and back to worse than square one.

Luckily I took a nother journey of self discovery and self therapy.  Firstly I accepted an anger management course after the stress of losing my first short lived job having moved from a stable job, buibbled over to family life. This made me think about the impulsiveness of my behaviour in terms of making bad decisions and often becoming angry or withdrawn, or eratic. All features of the 'fight or flight' response.  The self management included firstly seeing your self as others see you when you fly into a rage or become irritable and snappy over a period of time. Also to stop, and back up and assess the situation.

Another fortuity was that my local council have a community psychiatric care centre, which began to offer an open course on Cognitive Based Therapy (CBT) for stress and berievement etc. This built upon my anger management in terms of self awareness and analysing my own feelings and responses before rushing to conclusions and potentially innappropriate and impulsive behaviour.

Not to go into details of a well documented therapy,  I had some real benefits from CBT and could address more of the emotional status issues I experienced. For example, I decided that my stress stomach and panic attacks in the middle of the night were coming from the acid reflux starting my body on the route to negativity, not that I had overly neurotic dreams or semi conscious anxiety. My body and brain wer interpreting my stomach complaint as being a sign of stress, and tyring to offer 'peri conscious' interpretations. As I learned in anger management, these biological routes do not get any better, rather they seem to get more 'hard wired' and become 'second nature'- the normal, the status of choice to act with.

Also I used the alternative resolution techniques to address not only my 4am panic feelings, but also elements of social angst, and how I interpret situations which have gone badly for me. Furthermore I could use the tackling techniques to put my current unemployment as an opportunity to heal and be with the family before the economy picks up and it is easier to get a job.

I haven't stopped there though. I have gone on to look at how my personality may be internally always in conflict. I recently uncovered articles which to some extent challenge the polar personality trait scales- I used to describe myself as an "inner directed extrovert" yet in fact, I am more of an introvert with a compulsion to seek social contact as some way of resolving the inner intimacy-imposed isolation dilema. ( I studied two years of psychology at University while majoring in molecular biology)

It is a big chicken and egg with this and perhaps circular- these personality traits and inner conflict may be in part or whole generated by a neurological condition. However perhaps the condition, being a bit slow in the mornings and having rushing creative thoughts, is the lesser of the evils, and is either masked or exacerbated by my neurosis. I consider that my CBT and Anger Management route has been more fruitful for me by a long margin than the improved concentration and slightly more even temperament on Ritalin.

To myself I am kin dof a puzzle wrapped in inexplicability and clouded by insecutiry and failures which are by in large on the job front, not my fault. As a little boy I was bashful and bumptious and kind of being sociable was something which I tried hard at, yet was completely inept at. I grew a kind of clowning personality, with a very brash side, but made new friends easily all my life.  I fitted well into academia and performed above average and also had a lot more curiosity and imaginative thinking than most peers, whcih got me noticed and ear marked as a future professional scientist. Yet I hated tedious lab work, I just had no patience and I wanted to experience other things in life than being a poor student and post doc through my 20s.

I sought some good degree of excitement in career and hobbies as a kind of way of addressing my inne5r drive to suceeed in something interesting. However I often fel ldown socially, failing to make key relatioinships on a professional level and falling into being the kind og rebel-without-a-cause employee. I struggled to meet 'the right girl' and got involved with some wrong types, wrong time-of-life, wrong situation. My impulsivity drove me to change girls and change jobs like a crazy guy. That was fine as a young bachelor, but evenutally a 'portfolio' career as I was told to use as a euphenism I guess, rubs thin as a middle aged man on the job market.

I do feel that I have made more progress in a year of CBT and reflectiveness, self awareness, self arrest and some meditation to boot, than I did in a year with Ritalin. Also where as for me at least, the drug tickled at the symptoms, the psychological approach takes me into how I tackle much wider aspects of life than just concentration failure. I also think CBT helps me as a parent, a friend to others and that when I do get back into work, it will help my performance and relationships and eventually help me become a better people manager. "

ADHD: The Teenage Over Diagnosis and Adult Under-Diagnosis ?

As I have blogged before we have personal experience with ADD/ADHD in both adults and children, and have reviewed much of the leading current literature and reviews of papers. In this qualitative review, we discuss a practical and critical approach to the disease, from a perspective of the over diagnosis amongst "youth"- the plague-and-the-pills, and from the point of view of adults who actually have life ling ADHD, but whose symptoms only are apparent during life crises or general under-achievement for example.

The enigma at the core of ADHD (over ADD alone) is that it is contradictory in nature: it goes between phases of AC and DC if  you like. The name given to the disorder was of course coined from the  description of the presenting-symptoms which are socially interpreted. The symptoms were defined externally, classically from how the school child could not concentrate and was then also overly active, when compared to the average child. "They can't listen and they just can't sit still".

The actual bipolar nature however was discovered somewhat later, when the attention deficiency  was uncovered as actually being the reverse of hyper-activity: the brain was chronically under stimulated in those afflicted with ADD and ADHD in its' 'true sense', when experiencing those phases of lack of focus, distractability and drowsiness.

Later on research in neurology and new psychological assessments confirmed this, and further demonstrated the link between the under stimulated higher thought processes, and the super-stimulation pathways present in ADHD, which then try to "kick start" the brain and actually lead to classically uncontrolled streaming thoughts, and in many cases a reduction in natural inhibition  leading to dangerous or socially crass behaviour.

So the circle was closed: the ADD was related to the ADHD and often children in particular were experiencing a bipolar disease, and living with the frustrations of a lack of concentration at both poles.

Differential Diagnosis as a Counter to the Over-Diagnosis of ADHD

There above then, you have the ætiology and diagnosis in a nutshell: however ADHD is amongst the most over diagnosed and correspondingly over-medicated area in teenage mental health. In some school classes it has been seen as the predominant chronic medical affliction.

On the other hand, in adults not previously diagnosed with ADHD as children, and  presenting potentially with symptoms for the first time, it is likely that ADHD is very often misdiagnosed as depression and bipolar-depressive disorder. The extent of this in adults, has not been established while over diagnosis in teenagers is a "hot potato" in health authorities.

 Resulting medication and psychological exercises or therapy then can lead to patients continuing with difficulties and also developing a focus-complex : in the teenager the incorrect (or patient lead ) diagnosis of disease can be offered as an excuse for attitudinal and behavioural problems which should be tackled with motivation and schooling methods; For adults, there can be a focus on reactive depression, or other longer term  negative events in life which in fact are not the source of the bipolar behaviour, rather it is an internal disease.

Economic and Societal Importance

Differential diagnosis for both ADHD and then the mono-polar Attention Deficiency Disorder is therefore important for public health authorities to assert within their structures so as to reduce the burden on mental health services and pharmacy budgeting in child health which is heavily subsidised with tax payers money. Also for private practitioners alike,  they should consider the potential for litigation stemming from aberrant and potentially damaging medication with "Ritalin" and related substances for patients who are actually not relevant or even should have a contra-indication for such stimulants.

The key questions for the medical delivery system are then :

a) does this teenager actually have a social-problem, which can and should be tackled with social, educational and parental means or is this an ætiology of ADHD likely to respond to drugs, diet and concentration regimes?

b) Does this adult presenting with situation reactive symptoms actually have an underlying ADHD which has a negative influence on their life and has contributed to the current malaise and indeed is a major factor in creating or exacerbating the negative situation or crises.

In the cases of a disease being misdiagnosed,  the a path for treating ADHD or treating a different condition is counter productive and even can be contra-indicated from the medical point of view and is a misuse of funds. A reactive depression may be a meta-symptom in adults for example, relating to a life event, but if sufficient patient history points to ADHD then a longer term investigation and treatment of the disease will be cost effective.

In the case where a "null" diagnosis- this patient has no sickness, just a social problem: then this is important to establish that the prevalence, especially amongst teenagers, is a system problem: that schools and social services have then a responsibility to modify methods and take remediation of those pupils with the worst attitude problems.

This is then a case for systems management outside the health profession. However as a gate keeper,  practitioners being there a sceptical police who alert the educational authorities that there is a social problem being presented as ADHD on a basis frequent enough to merit immediate intervention and longer term system re-evaluation. Schools then must find new ways of teaching which manage unruly students, including them and borderline students in general classes and excluding them from ordinary academic classes when their attitudes lead to disruptive behaviour and contaminate other pupils.

What Are the Alternative Diagnoses and to What Extent Are We Discussing a Societal Perceived Disease?

The crux of the matter in over-diagnosing teenagers as having ADHD is that there is on the one hand, a perceived nuisance and non conformity issue: in highly structured schooling or in societies (for example small towns) where people have often "modest " behaviour patterns, a higher level of activity, of physical and mental energy can be misinterpreted and indeed the individual can be  labelled as having the disease. In more normal classrooms, poor discipline and weak leadership can also result in an unruly class, with ring leaders using "ADHD" as a scapegoat.

The more intelligent child ;  the more communicative child ; the more physically active child ;  the poorer socialised child, the child who seeks social leadership by disruption : ADHD as a sickness has a social element but it is a disease, while the cultural interpretation of misbehaviour and hyperactivity is realistically the first step to differential diagnosis: IS THIS A SOCIAL PERCEPTION ISSUE and not a disease in this child ?

The very reverse can be true in adults: The adult is diagnosed as being socially inept, prone to moods, rebellious, "slow on the take up", and a poor learner: an "odd-ball" in many cases. So it is perhaps symptoms of depression actually are those which the patient presents with, or alternatively they are referred to psychological services by a family member or doctor. In the worst cases of course, they are referred by the courts or the prison authorities. It is these criminal cases perhaps which are taken most seriously as having a root in a disease, ADHD.

To summarise this little dilemma ; in the child a diagnosis of disease has more prevalence, where as in the adult, the social circumstances and personality issues are often the misdiagnosis or "sub clinical" . This is kind of a para-thesis : the "fundamental attribution error" in a new context, where unruly or ADD behaviour in children is over diagnosed as being an inherent neurological disease, where as in adults the social history and personality defect become the focus.

Differential Diagnoses Proposed:

1) Is this a social-judgemental problem or actually a disease in the child? Is the social referral of an adult the reverse, actually possibly ADHD?

2) If this is a hyperactivity disorder, is there a bipolar nature with "down" times somewhat cyclical?

a) Does the "down time" come after prolonged periods of hyperactivity and reduced sleep?
- seek also information on hypo-mania and other super-stimulated disorders. Including brain damage and neurological hyperactivity as a post traumatic event chronic reaction. - Test also for substances of abuse in the amphetamine like area.

b) Does the "down time" come at particular times of day or on a fairly predictable cyclical pattern ?
- this can be seen in many ADHD cases, but also it could be related to diet- for example lactose intolerance/lactose to opiate metabolism, diabetes or early stage blood sugar homeostatic problems, poor diet, irregular eating times;  Also insomnia/parasomnia and narcolepsia are also areas to uncover.

c) Misdiagnosis: Stress, PTSS, Depression in adults:  is the adult in particular, seemingly themselves the cause of the stress or depression? Has their behaviour actually created the situation which is the source ? Should a similarly qualified or experienced person cope with the sources of stress or depression better ? Has the patient actually a longer history of ADHD like symptoms ?

d) is the ADD person being misdiagnosed with depression ? In fact is the bipolar nature of a patient suppressed by social circumstances and personality and infact they have both the AD and the HD sides ?

e) Is the patient self diagnosing? A whole topic in itself:

Initial Diagnosis as Ammunition for Googling, and the Internet for Self-Fulfilling-Illness ?

The actual diagnosis of ADHD is of course for the vast majority, outside neurological research institutes. Diagnosis at the GP, psychologist or psychiatrist is based on a consultation by in large, with in some cases a bank of traditional concentration, attention, short-term memory and "boredom" fatigue tests.

The Danger in using pateint-provided-history alone is that of course, a teenager may be inventing their ADHD to gain attention (Munchhausen?), to find an excuse for lack of discipline and effort in class when they could change-their-ways consciously, or in the worst cases, effecting the procurement of Ritalin for resale as a substance of abuse? Furthermore an initial discussion can plant keywords literally for later Googling in the patient's own time, and they can return with a construct matching their issues to ADHD ( or the reverse, following a lead word from the first consultation into a misdiagnosis).

Using a Bank of Neuro-Psychological Tests and Questionnaires to Assist in Differential Diagnosis of ADHD:

The bank of simple and well proven, normalised tests for attention deficiency is actually a route to which some adults are delivered as presenting with life long ADHD. Often administered by specialist neuro-psychologists, the patient may have had a referral for a provisional diagnosis of post-traumatic-stress, or potentially brain damage or several other routes to this little circus of elementary and well established motor-cognitive, memory and motivation  tests.

These tests then are sometimes concluding that ADHD is a probable ætiology from a different route to the neuro- psychologist's desk.  However it is our contention that such a bank of tests be conducted on all teenagers who present with socially-diagnosed ADHD. 

One of the key's to their applicability in teenagers is that some of the tests use a subterfuge, and also they set goals which a teenager may either like to meet  (or fully reject, demonstrating a larger social problem). The subterfuge is in the test appearing to be a trial or puzzle, an aptitude test, when actually measuring things like attention span, short term memory or motivation for tasks.

Some studies with control non ADHD subjects in single blind studies where the ADHD is clearly established in the patient group, have not shown effectiveness, while on the other hand other studies have shown that the reverse is the case, and adult specific studies suggest that tests can establish a differential diagnosis where symptoms are non specific, resulting from social crises or other "bi-products" of the ADHD afflicted person.

The bank of tests is then usually administered by a neuro-psychologist and this is important because they may be able to identify other motor-cognitive diseases by the demeanour and physical approach the patient takes to the tests, and in considering the results.

Sometimes a more directed ADHD questionnaire is 'administered' to help explore the patient's social behaviour and perceptions around attentiveness, concentration, thought and day-dreaming etc. Alternatively a wider questionnaire which may be used as a means to open discussion or to exclude other illnesses is administered by the psychiatrist. These stages could be partly moved to the GP surgery or even school nursing station for administration such that a degree of triage is conducted at lower cost to establishment and at lower risk of contaminating the patient with the self-gratification that escalation to consultant psychiatry service entails.

Also adults who present with situational reactive depressions and stress related disorders, should be questioned on their earlier life and patterns of problematic interactions, lack of assertiveness, social ineptness etc to establish if there is cause to follow a route of finding ADHD as the "carrier signal" to which other disruptions are amplified: such as depression and stress at work, and a lack of assertiveness and sound- judgement in situations which leads to negative consequences or even chaotic, downwards spiral in risk taking, revenge, and other over-reaction or inability to handle circumstances.

Neurological tests then should be chosen from a bank of tests which are all culturally normalised for the nation or region. Physicians and psychologists may like to actually normalise these tests to a local area or indeed to a school authority such that average responses are mapped and a mean deviation threshold for diagnostically valuable results is established in the special context. This can be done on a relatively small sample size, chosen from a definable and finite sub-population eg 15 year old school pupils in a county.  Also a further blind trial can be conducted where those with clear ADHD diagnosis are fed into 'healthy' candidate studies. 

Failures in these tests may be attributed to a lack of normalisation perhaps, but also to using them only selectively: the "consultation" and overall assessment is taken in a context of a fairly intense series of
tests, where the net result is also indicative of ADHD by virtue of attention span flagging, and the same measure being analysed by disparate techniques.

Conclusion: ADHD - Cut to the Quick , Sift out the Fakers.

To repeat what we conclude above, our contention is that ADHD is over-diagnosed in children (esp. adolescents)  and under-diagnosed in adults by patient provided histories or subjective reports from from private or public social bodies around the afflicted.

 Many medical authorities require by statute that patients be referred to a psychiatrist prior to medication, and this should be standard practice once the first steps to establish that a "rigorously skeptical" differential diagnosis is under way. This is to prevent that on the one hand, the teenage patient has not been given a bias in language towards ADHD, and on the other, that an adult is not being misdiagnosed when ADHD is actually the "vector of their misfortunes" .

In the case of the teenager we want to avoid the case where after initial consultation,  they self diagnose by Googling the topic and misrepresent their symptoms or misreport the wider symptoms which may point to another disease or actually have just a "social problem". In the adult presenting with stress, or a strong reactive depression, or series of life crises for example then