Loading summary
Transcript16 lines
- [00:01]
A
There's a missing page in dsm and today you'll learn how it can help us distinguish between adult ADHD and other better validated causes of cognitive problems.
- [00:17]
B
Welcome to the Carlat Psychiatry Podcast, Keeping psychiatry honest since 2003.
- [00:22]
A
I'm Chris Aiken, the editor in chief of the Carlat Psychiatry Report.
- [00:26]
B
And I'm Kelly Newsom, a psychiatric NP and a dedicated reader of every issue. Last week we looked at the research on adult onset ADHD and we ended up agreeing with the dsm. ADHD is a neurodevelopmental disorder, so the symptoms should trace back to childhood. In rare cases they don't show up until the teenage years, possibly because a high IQ or a supportive parent covered for the child. But onset in middle age is unheard of. Nearly every case of adult onset ADHD in the literature turned out to be better explained by other causes. But try telling that to a 35 year old man who walks in with new cognitive problems that he's convinced are due to adhd. Today we look at what better explained by other causes means in practice. But first, a preview of the quiz. You can earn CME credit through the link in the show notes which population is less likely to recover fully from the cognitive effects of cannabis use? A ADHD b Anxiety disorders c People who start using late in life d People who start using as teens.
- [01:53]
A
Every disorder in the DSM carries this line. Don't diagnose it if the symptoms are better explained by something else. It is the most boring part of the criteria, but it also carries the most weight, and its origin story traces back to the 1960s and a brand new technology, the video cassette recorder.
- [02:14]
B
This was a time when psychoanalysts ruled psychiatry. To them, diagnosis was just the surface. They were more interested in the unconscious origins of the symptoms, and so psychiatric diagnosis was pretty lax. If patients had mild symptoms, they got diagnosed with anxiety neurosis, and if they were more severe, they usually got a schizophrenia diagnosis. Nobody paid much attention to this until an NIMH researcher, Morten Kramer, noticed the diagnosis in the us where were way out of sync with those in the UK, sometimes by a factor of 10. Kremer purchased video recorders and recorded structured interviews of hospitalized patients, both British and American. He then had British and American doctors watch the tapes and come up with a diagnosis. The difference was striking. The Brits, using strict Kraepelinian thinking, diagnosed manic depression, where the Americans, using a looser Freudian framework, diagnosed schizophrenia.
- [03:14]
A
The study was a major embarrassment for American psychiatry, but for a group of Psychiatrists working in the Midwest. It created an opening. In the 1950s, Washington University in St. Louis, Missouri, started recruiting psychiatrists who wanted to align psychiatric diagnoses with the medical model. They were renegades in their time. They didn't fit in with the psychoanalytic schools that dominated in the northeast. And in 1974, two years after that videotaped study came out, these psychiatrists published a new textbook that aimed to take a just the facts approach to psychiatry, avoiding all speculation. It was called Psychiatric Diagnosis by Eli Robbins and Samuel Guzet. Robbins and Guzet concluded that only 12 psychiatric syndromes qualified as valid disorders. Their standard for validity came from the medical model. Reliable symptoms that separate one disorder from another, a predictable course of the illness over time, and a link to biological markers like lab values, treatment response, and a known pathophysiologic or genetic basis. Here's the 12 diagnoses that met the bar for them. If you memorize one list in psychiatry, this is schizophrenia. Bipolar disorder, Major depressive disorder. Back then, those were lumped together as manic depression, ocd, panic disorder and specific phobias. Anorexia and bulimia, conversion disorder and somatization. Antisocial personality disorder. This is the personality disorder with the most biological basis, particularly on EEGs and frontal lobe changes in genetics, substance use disorders, dementia delirium, and of course, psychiatric disorders due to a medical cause.
- [05:26]
B
The book is still updated today, and in 50 years, the authors have added only two diagnoses to that core list, both with provisional status. 13 PTSD and 14 borderline personality disorder. I know it sounds like we're a long way off from adult adhd, but this was the backstory to DSM iii and knowing it will help your diagnostics. While this Washington school was refining the diagnostic criteria, Robert Spritzer was working at Columbia to get one diagnosis removed from the DSM entirely. Homosexuality. Those neo Kraepelinians weren't just bothered by loose Freudian diagnostics. They worried that psychiatric diagnosis would be abused. Used to label people who didn't fit into society or actively oppose the government unless they were grounded in science. Homosexuality was one example of diagnostic abuse. In the Soviet Union, political dissidents were diagnosed with sluggish schizophrenia. And in the US they diagnosed 1960s youth with protest psychosis.
- [06:33]
A
What is your diagnosis of what's going on inside the Democratic Party? The problem with the Democratic Party is that they've got Trump Derangement syndrome. That was Secretary of State Robert F. Kennedy, Jr. But if you've read any book on Donald Trump's, supposed mental illness or heard MAGA referred to as a cult. You'll know that the misuse of psychiatry is not exclusive to any one side of the political spectrum. Back to 1974, Robert Spitzer successfully expunged homosexuality from the DSM using the medical logic of the Washington School. The APA was so impressed with his feat that they handed over the entire DSM to Spitzer. To update, Spitzer front loaded the DSM committee with psychiatrists from the Washington School and they drafted a brief list of validated psychiatric disorders called the Research Diagnostic Criteria. But the APA committee was not going to accept such a short list. The DSM is a billing manual as well as a diagnostic one, and psychiatrists have to bill for whatever walks through their door, valid disorder or not. Spitzer achieved this compromise by moving the goalposts from validity to reliability. As long as everyone could agree on whether a patient met the criteria, the diagnosis was reliable and suitable for this new dsm. Validity, Spitzer hoped would come later as we investigated these new syndromes with brain imaging, genetics and treatment studies. The irony is, 50 years later, his colleagues have only added two disorders to that valid list.
- [08:24]
B
Psychiatry isn't the only field guilty of this diagnostic fluff. Here's a few from the ICD V97 33 XD sucked into jet engine subsequent encounter R46 one bizarre personal appearance. There's also other contact with Cal walked into lamppost problems in relationship with in laws.
- [08:50]
A
Patients do present with all of those problems, but that doesn't mean that they are valid medical disorders. When Spitzer released DSM 3, the original valid dozen was expanded to 265 disorders and today the manual has more than 300. That's all fine and in fairness many of these 300 are subtypes of the valid dozen. But what is missing in the manual is a clear statement about which are real and which are not. I suspect that if they did include that kind of list, insurers would hold it up and say we're only going to pay for these 12.
- [09:31]
B
We call that the missing page in DSM instead of a clear list. It's buried in that boring part of the criteria that says you should not diagnose it if the symptoms are better explained by a more valid diagnosis. ADHD was not on the original list of valid diagnoses, but a case could be made for including childhood ADHD in genetic studies. It is highly heritable 75%. It has a characteristic treatment response and neuroimaging findings and reliable follow up data. But Others argue that most patients with ADHD have comorbidities, and it's not clear that ADHD separates cleanly from other disorders, particularly among adults. Next week, we'll look at how to separate it. One cause of ADHD symptoms is cannabis use. And today's study looks at how long it takes the brain to recover from that. It's a systematic review by Valerio Ricci and colleagues in the American Journal of Addictions that pulls together 26 studies involving over 2,800 participants.
- [10:42]
A
Before we get into this study, let's address a controversy. It is not clear that cannabis causes adhd, and it could be the other way around. People with ADHD are more likely to use cannabis, but we can say they are not using it to treat their symptoms, at least not objectively. Cannabis was tested as a treatment for ADHD in a randomized placebo controlled trial, and it did not work. In one trial, cannabis actually made the cognitive symptoms worse, while the patients thought it was making their cognition better. Think about that. Multiple randomized placebo controlled trials find that acute THC or cannabis impairs working memory, attention, executive function and verbal learning, all in a dose dependent manner. So we do know that cannabis worsens cognition in the short term. What's missing are randomized controlled trials of the long term effects. Now, today's update looked at the other side. What happens when cannabis is removed? Does cognition get better? Most of the studies here were cross sectional or longitudinal, but three of them were randomized trials. The studies tracked people with neuroimaging cognitive testing and biomarkers, comparing cannabis users to controls or to four more users across abstinence periods. Those periods of abstinence lasted from 72 hours all the way to 8 years.
- [12:20]
B
Verbal memory recovers fast after quitting. Teens and young adults showed gains within a week and those held up through four weeks. Working memory took a little longer, two to three weeks to improve. Attention and executive function lagged behind. One study found them still impaired at 3 weeks. Chronic heavy use downregulates CB1 receptors, and these return to normal about a month after quitting.
- [12:47]
A
So cognition generally improves in a couple weeks. But the benefits of quitting were not the same across the lifespan. Adults who quit showed no lasting impairments, but teens who started using cannabis when they were younger didn't fare as well after quitting. One of the studies that confirmed this lasting problem with teen cannabis use was the famous New Zealand cohort. Ironically, the same study we mentioned recently that found adult onset adhd. Hmm, maybe some of these were the same subjects.
- [13:24]
B
Another factor that predicted poor recovery was heavy use, more than five joints a week. The bottom line? Cannabis can mimic adhd, and those problems usually improve within a few weeks after stopping. But the patient's subjective experience tells a different story. They may think it is helping, so try this in practice. Have them test their cognition objectively, like with the free ThinkIt app that's T H I N C I T or another computerized cognitive test. Then test again four and eight weeks after quitting. Do you with patients who don't know they have an illness? It's called anastagnosia, and in the August issue of the Carlat Report, we interview Xavier Amador, who developed a therapeutic way to engage them in treatment. Also in the issue pharmacotherapy and Autism. Start your subscription with the Promo code podcast for $30 off. And thank you for helping us stay free of industry. Sam.