I think it will be hard to expand psychiatry to that level while keeping it professional. The fundamental issue is that people ascribe personality flaws to others instinctually and also have strong feelings around being subjected to such treatment, in a way that they don’t have around sprained ankles. In everyday life it’s called badmouthing or trash-talking. It’s a part of human nature.
Doesn't that presume that human psychology (cognitive functioning) is uniform at a level that would obviate the need even for personalities and styles?
Our physiological system does have that uniformity across the population but our psychological system does not seem to. Isn't it then misguided to try characterizing small deviations when we don't even have a uniform "background" to subtract?
I think you’re overlooking the difference between diversity and changes to an individual.
Some people can’t get stranded ankles because they don’t have legs, so you don’t necessarily need a universal baseline across all of humanity when diagnosing conditions. Someone who is still within normal ranges but significantly doing worse than they where can quite reasonably seek treatment.
There isn't one because a sprained ankle is a binary diagnosis.
One of the biggest problems with psychiatry is that every diagnosis is a spectrum, and over time it's become more and more obvious that the boundaries for what is considered "neurotypical" are way too narrow.
Depression being a chemical imbalance was a complete lie to sell more medication, and how prolific this type of occurrence is within the industry is not hard to see.
At the very least, a plurality of phycological diagnoses are manifestations of physical behavior: diet, exercise, exposure to sunlight, etc
We're so overprescribed on medications to try to feel a certain way within far too narrow of a spectrum.
Why do you presume that there has to be an equivalent to a sprained ankle? Maybe the answer to your question is yes, only the catastrophic is worth addressing.
This is a very privileged view of the mind. I have ADHD (and autism). But I also have a quite high IQ, if one cares about such things. I'm pretty successful, professionally.
But it took until around 40yo to get the ADHD diagnosis and get a prescription for medication that has been life-altering. Was I suffering from catastrophic failures? Absolutely not: married, have kids, in the 1%, etc.
But have the meds had an incredibly positive influence on my life? Hell yes. I can do things that everyone else acted like was normal, but I straight up couldn't do it before. Housework is a prime example. It was like torture. Sitting around waiting for people to finish their sentences because they're "talking as slow as molasses" made for often unenjoyable social experiences.
But with the meds, this stuff is either tolerable or fun. My life is significantly better thanks to medical interventions. Instead of my wife blowing up because I didn't do something like mop the kitchen floor, I actually get it done (without meds I straight up cannot hold that kind of task in my mind if I'm not in the room looking at the mess; I will flit between ten other things in a different part of the house, then walk through the kitchen to get into my car to pick up the kids, see the kitchen, and think "ah, fuck me")
I'm happy that you're neurotypical and have a great life, but that's not true for a lot of us, and the idea that "only catastrophic mental issues should be dealt with by professionals" is you just telling on yourself and your ignorances.
I stopped using house work as example because people always answer "oh yeah, I also dislike housework". People just don't get it when this example is used. I switched to "not able to go outside for a walk even though I like being in nature" and "often not able to follow or participate in long talks with multiple persons".
There also is a good chance I don't have children because just being alive and by myself was super exhausting before I got diagnosed in my late 30. Having children was unthinkable until then.
But was it catastrophic? I don't know. I finished college except it took two times as long and got a job where I of course suffered pretty much the whole time.
But that was all very normal for me, just the way I was, at least that's what I used to believe.
They don't work for everybody though; I have ADHD and Ritalin/Focalin help just a little (and only if I take them to the point where I feel like pressed-meat in the mornings), while Adderall gives me hallucinations.
No, the drugs don't make doing chores fun or any of that.
For those with ADHD they turn on the prefrontal cortex which reduces or removes the feeling of utter torture and pain from doing chores.
It's sort of like taking a drug that takes away the fear and almost physical inability to to touch a hot stove most people have. Normally that'd be bad. Except here the hot stove is actually harmless and useful to touch.
there are many drugs that can do that but they have massive side effects ;)
Benzodiazepines, opioids, stimulants, opioid-like substances like carisoprodol (there is a reason why people call it Soma). these are the first that come to my mind. contrary to popular belief, downers often give you euphoria.
Why do you presume I'm neurotypical and undiagnosed with any psychiatric disorder? I'm formally diagnosed with severe OCD, depression, and ADHD. I was on SSRI, then SNRI and additionally methylphenidate for years. Eventually I got tired for feeling like a shell of a human being, and weaned off of the SNRI. It took a lot of effort to induce neuroplasticity and ease my OCD and depression, but I did it. Eventually, I weaned off the methylphenidate because I believed I could do it if I tried. Later in life, I also gained and eventually lost weight, which was a similar acceptance that "bad" things, like hunger, are ok and a symptom of something good, my body consuming fat. Then the same for sore muscles at the gym. Over time, I accepted discomfort and the fight or flight my brain was constantly trying to force onto me was a lie, and eventually my brain and nervous system caught up. My physical and mental health improved, my social life, my professional life, etc.
I bet if you knew your house would burn down if you didn't do "normal" things you would have done them no problem.
Stimulants make otherwise unenjoyable things enjoyable? Who would have thought? Do you think people that do "normal" things enjoy them? Is it necessary to enjoy everything all the time?
> Why do you presume I'm neurotypical and undiagnosed with any psychiatric disorder?
Because you talk like one, with no apparent empathy for the neurodiverse, except perhaps people with profound issues. "We shouldn't treat any problems except the catastrophically bad." Gross.
> I bet if you knew your house would burn down if you didn't do "normal" things you would have done them no problem.
This is not arguing in favor of your stance, but rather in favor of mine. You're essentially saying "ADHDers can't get shit done without being in dangerous situations, and THAT IS ACCEPTABLE." And yet you think this supports your idea that non-catastrophic disorders shouldn't be treated.
You are catastrophically incorrect and it's ironic that you would say I do not have empathy.
No I'm saying you lack the impulse control and self discipline to perform tasks unless the stakes are high. But you're not an animal, you can do something about that without medication. You can accept the discomfort and move through it just like you do when the stakes are actually high. Just like I do. The idea that everything in life should induce minimal discomfort or that "it's hard" is an excuse is a completely modern, first world problem, to speak of privilege.
Mindfulness and thinking about your thoughts are proven as effective or more effective than medication for a wide range of psychological disorders, including ADHD, or CBT if you want to formalize it.
Your story can be summarized as "I was bad at doing things that made me feel discomfort, but now I'm on stimulants and I don't feel discomfort anymore." What else did you try? What areas of life did you accept discomfort for the sake of long term growth? If there were any, what made them different?
The stimulants don't alleviate the discomfort.
I honestly question whether you have adhd or whether yours and mine are remotely the same.
Oftentimes it would be a great relief to do a specific thing...or it's something i actually want to get done and no matter how much i want to I struggle.
Getting sleep right helps a lot. Getting sunlight helps a lot. etc
But in the end a notable problematic aspect of it remains.
Yes they do, as the OP said and I myself experienced, they make previously torturous tasks doable with a significantly reduced levels of discomfort and a priori mental resistance.
> You can accept the discomfort and move through it just like you do when the stakes are actually high. Just like I do.
Have you ever considered that the things which you find doable or even trivial might be incomprehensibly more difficult for other people? You mentioned being diagnosed with ADHD higher up, but part of the diagnostic criteria for ADHD is quite literally about severity of the symptoms:
DSM-5: "There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning."
ICD-11: "Several symptoms of inattention/hyperactivity-impulsivity that are persistent, and sufficiently severe that they have a direct negative impact on academic, occupational, or social functioning"
Being capable of pushing through basic adult responsibilities, regardless of discomfort and difficulties (without burning yourself out!), and failing to do so to the degree that it severely negatively affects your life is the defining line between "order" and "disorder".
If you have a very demanding job then you might experience symptoms that are consistent with ADHD. That's why the diagnostic process is supposed to verify that there's a clear history of symptoms ranging back to your teenage years (or earlier) and that your symptoms aren't being caused by general life stressors.
> The idea that everything in life should induce minimal discomfort or that "it's hard" is an excuse is a completely modern, first world problem, to speak of privilege.
No, the idea is that people should receive help if we have a neurodevelopmental disorder that is severe enough to significantly impact our quality of life. Just like with any other medical condition.
> Mindfulness and thinking about your thoughts are proven as effective or more effective than medication for a wide range of psychological disorders, including ADHD, or CBT if you want to formalize it.
False:
> CBT is best used within a multi-modal treatment approach and as an adjunct to medication as current research does not fully support the efficacy of CBT as a sole treatment for adult ADHD [274,[316], [317], [318]]. Most controlled studies have been conducted in patients taking ADHD medication and demonstrate an additional significant treatment effect [313,[318], [319], [320], [321], [322]]. The largest controlled multi-center CBT-study to date has demonstrated that psychological interventions result in better outcomes when combined with MPH as compared to psychological interventions in unmedicated patients [228]. In a systematic review of 51 pharmacological and non-pharmacological interventions [316], the highest proportion of improved outcomes (83%) was for patients receiving combination treatment.
They were incomprehensibly difficult for me, so yes. My mind and body literally entered fight or flight at the thought of not doing a compulsion or forcing myself to focus on doing a task I didn't want to do.
"Quality" is an arbitrary definition that means nothing, that's one of the problems we're talking about in psychiatry. The OP clearly mentioned that there was minimal impact on academic, professional, or social functioning other than internal discomfort, for example, yet was prescribed anyway.
>False, regarding CBT
Wow it's almost like the replication crisis is a real thing and we have no idea what we're talking about. Look at these completely disparate results when examining a different population group.
> "Quality" is an arbitrary definition that means nothing, that's one of the problems we're talking about in psychiatry.
Why is that a problem? It's not completely objective but it's the best we have. That criteria is typically combined with more objective neuropsychological testing for a well rounded assessment.
> The OP clearly mentioned that there was minimal impact on academic, professional, or social functioning other than internal discomfort, for example, yet was prescribed anyway.
They didn't say that, they said that they weren't suffering "catastrophic failures", which is distinctly different from "minimal impact". They also said they had high intellectual abilities which is entirely consistent with the ICD-11 description:
> The degree of inattention and hyperactivity-impulsivity is outside the limits of normal variation expected for age and level of intellectual functioning
High-IQ can mask ADHD, but that doesn't mean they haven't been experiencing challenges associated with ADHD.
So you've clearly just restated what I said which is that it was principally a matter of discomfort, not clinical outcomes or justification, which is the defining characteristic for diagnosis in the DSM.
I didn't restate anything, I corrected you because you take every opportunity to downplay negative effects that these disorders have on people's lives, and you've done it again by simply labeling it "discomfort".
You find it problematic that the other person was diagnosed with ADHD simply because their life wasn't a total disaster but I'd like to remind you that it's an attention deficit/hyperactivity disorder and not a "Can't Hold Down a Job" or "Total Failure At Life" disorder and your desire to have it redefined it in those terms wouldn't help anyone.
I'm using the definition of the threshold necessary for a clinical diagnosis as defined in psychiatry, which is not merely "negative effects" or as I've repeatedly stated "discomfort".
It's something that persistently prevents someone from living a "normal" life, which is also defined far too narrowly.
You're absolutely insistent that virtually any amount of "negative effects" is sufficient for diagnosis and pharmacological intervention which is absolutely not the case.
Nobody is saying it's easy or the discomfort and difficulties aren't real.
> You're absolutely insistent that virtually any amount of "negative effects" is sufficient for diagnosis
There you go again, I'm doing nothing of the sort. They complained of severe difficulties and called some of them "torture".
You took that, minimized their complaints and accused me of wanting to medicate anyone suffering "virtually any amount of negative effects" which apparently includes the person who self-described it as torture.
This sounds to me like getting into "You say you're depressed? Come on, snap out of it!" territory. I guess I consider psychological disorders to be a disorder when you aren't able to "snap out of it" or "just do things that are unpleasant".
Like yes, I do things that are unpleasant - ADHD doesn't mean I live a life of ease, avoiding unpleasantness all day long.
>I bet if you knew your house would burn down if you didn't do "normal" things you would have done them no problem
Getting yourself to do things in a boring situation that you might only do in an exciting situation is a big challenge in ADHD management
If everything was a "house on fire" level emergency, many ADHDers would get more done but would eventually collapse from running around on adrenaline for days
The point is it's obviously a problem of perspective. Things are not important because they aren't considered important. If the stakes are higher they are elevated in importance and more demanding of attention.
To pretend that humans are hedonic beasts incapable of cognitive adaption is ridiculous. We do not operate purely on impulse save for pharmaceutical intervention. We can force ourselves to give things more or less importance regardless of the actual stakes.
Exciting and even emergency situations don't cure ADHD or allow people with ADHD to magically function "normally" (or even effectively enough to avoid serious harm to themselves/others). The amount of importance a person with ADHD attributes to a task doesn't tell you if they'll be able to complete it as well as they would if they were being treated with medication or even if they will be able to complete it at all.
People with ADHD cannot all just "force themselves" to function. Novelty, excitement and interest can help, some of the time, but the rest of the time it's disaster. Depending on severity, the result of not getting the treatment they need can often include things like an inability to keep a job, homelessness, prison sentences, and accidents/injury. Those kinds of outcomes are pretty damn important to avoid, extremely stressful (exciting) to experience or be in imminent danger of, and certainly more than enough to motivate people to do the best that they can, but some percentage of people will never be able to avoid those outcomes by trying to will themselves into "cognitive adaption".
Others may be able to stave off the absolute worst outcomes without medication, but only through exhaustive efforts that prevent them from accomplishing the things they want in life. Why should someone constantly and needlessly push themselves to their absolute limit just to accomplish what comes easily for most people? For what? Bragging rights about how they reshaped their brains by sheer force of will? If medication for a mental condition can make people's lives better they should be free to take it.
To whatever extent you've been able to function without medication, that's great. Don't assume that what worked for you is applicable to everyone else, or even to most other people.
You are forgetting what people did before psych meds were available. Almost everyone treated themselves with alcohol and tobacco. Coffee is up there, too. There is cognitive adaptation, not denying it, but only up to a point.
Tobacco didn't exist for most of the world until the 17th century and you're discounting the fact that life was objectively much worse by virtually every metric.
People were constantly bombarded with death, disease, things like starvation were near term risks, violence was everywhere, etc.
You're also overestimating the prevalence of alcoholism. Alcohol consumption was largely driven by safety and necessity, not abuse. Alcoholism was arguably more of a social stigma historically than it was today, certainly with harsher criminal penalties in many societies.
The situation you're describing is circular. Perspective taking and prioritization are executive functioning skills and executive functioning skills are precisely what are lacking in a person who has ADHD
If I knew my house would burn down if I forgot where my keys where it wouldn't do much more than turn me into a paranoid barely functional mess. Higher stakes do not automatically help. Although ironically part of being ADHD is functioning well in high stakes situations, it's not healthy to create high stakes situations in order to function (although some people do this).
This is one of the most personally compelling reasons why I agree with my ADHD diagnosis - I've known for a long time that I work better in a state of chaos than not. I actually often enjoy it. And others have commented on that about me as well.
Edit: by chaos I mean things breaking down, going wrong, catching fire, etc. I accomplish things easily once I've taken so long to get to them, that they're seriously urgent.
A person's treatment doesn't depend on what's "normal" it depends on the level of impairment/improvement. Why do you even care if somebody takes medication for a condition they have and it makes their lives easier? Why should anyone avoid a "quick fix" to a major problem because you think they should suffer more discomfort?
East Asians are "impaired" the least, and the presumption among Western scientists, particularly American scientists regarding Asian Americans, is that they are simply undiagnosed despite their out performance in nearly every metric of success.
I'm sure it must have nothing at all to do with cultural stigma. If that were true we'd see signs of mental struggles in their home countries. In the US I'm sure all the model minority bullshit people project on them doesn't cause them any extra pressure or anxiety right?
Asian Americans are so successful that they certainly must not have disproportionately higher rates of suicide right? That might be a sign of some "impairment" going unaddressed! Or maybe you see the rate at which they're killing themselves as yet another metric of success? Those scrappy East Asians are just so good at doing stuff!
Asian Americans and East Asians have lower suicide rates than Americans (over 60% lower), and especially American white males, you've fallen for a false trope, which is exactly what I expected when I posed the question. I knew that you would immediately appeal to this false trope because you're looking for an excuse.
They outperform by the metrics that matter for a clinical diagnosis and the West is so quick to jump to the conclusion that they're "under diagnosed", it's a uniquely Western and especially American conclusion.
That's a hell of a journey! Congratulations on the accomplishment and thank you for sharing.
Like many other biological systems, neurological wiring is multidimensional and not a natural fit into our arbitrary culturally defined abstractions, or even language. And the dimensions themselves are multifaceted expressions of multiple genes and environmental factors. I am happy to hear stories like yours, of people who can ultimately achieve "normal" functional parity without medication.
Have you considered if that would have been possible without the journey? Had you, on day 1, cancelled that first therapist appointment and decided to grit your teeth and "try" instead, could you have "accepted discomfort" on your own? Or is it possible that the methylphenidate created supportive conditions that improved your chances?
I ask because there is a body of well reproduced research demonstrating not only that ADHD patients have specific genetic and neurobiological differences from neurotypicals in areas associated with executive function, but that long term ADHD medication use can permanently bring the neurological differences into line with neurotypical controls. Something like 20% of medicated childhood ADHD patients can ultimately stop medication without losing points in functional testing or the associated brain structures. It's a lower percentage in adults and less well studied, but still exists. It's a big difference from the results of every non-chemical intervention we've studied, which have single digit efficacy percentages if they beat P at all.
I'm interested in your feelings about this because ADHD is by far the most-studied psychological disorder in the world, and ADHD medications as a group are not only equally well studied, but also the most successful and least harmful of any psychiatric drug. There are more safety and efficacy studies for ADHD medication than for ibuprofen.
So... if you feel your recovery was not helped by the neurogenetic compensations provided by methylphenidate, you should know that you are flying so far in the face of some of the best-validated medical science, that you imply invalidity of pharmaceutical or medical science as a whole.
... which is fine of course - it's your body and brain! But I bet it would help readers to know how you think this aligns with the science, or maybe what you think of medical science altogether. Questions like "Do you take ibuprofen?" And "Do you vaccinate?" Become relevant.
Yes I have and it was just as difficult post medication as it was pre. Ironically, while on the SNRI my ADHD was "worse" due to the sheer apathy I felt about literally everything, so I was prescribed to help me "focus" and be "motivated".
You're leaving out the part about being "well studied" paired with your conclusions is almost exclusively in American and Western European populations, things are significantly less clear in other populations and cultures.
You are overselling ADHD meds by quite a bit. There is plenty of data in literature that quite a bit of people will not respond positively to meds. So if they work for you that's great. But lightly shaming someone by implying they might be anti medicine is super uncool and as an ADHD person you really should know better. Lets not invalidate each other just because experiences are not exactly the same.
You have inadvertently outed yourself as not having a clue by your reply. It’s nothing personal but you just clearly don’t have a clue and/or don’t have skin in the game.
It’s fine. I don’t know anything about professional juggling because I have zero skin in that game.
Paging Dr. Brochacho: fMRI and brain networks have been around for a while!
Not sure if you noticed that your sources disagree with your thesis, with the limited exception that theres no convincing evidence that seratonin is the single causal factor for depression, which myth was heavily promoted by the relevant pharma companies.
Your articles also say that:
- depression medication does appear to be effective in some cases regardless, indicating some other neurochemical mechanism at work.
- the existence of a "neurochemical imbalance myth" underpinning psychology as a whole is, itself, a myth.
- the idea that this mythical myth about neurochemical imbalance has been debunked, is also a myth.
- that the psychological scientific consensus has, since the first peer-reviewed mention of the word "neurochemical" in the 60s, quite consistently been aligned with the 1978 synthesis statement by the then president of the APA:
> "Psychiatric disorders result from the complex interaction of physical, psycho-logical, and social factors and treatment may be directed toward any or all three of these areas."
Your second article is particularly clear in explaining all this.
"Furthermore, the SSRIs were accorded a rock-star status as effective antidepressants that they did not deserve. Most troubling from the standpoint of misleading the general public, pharmaceutical companies heavily promoted the “chemical imbalance” trope in their direct-to-consumer advertising."
There second article admits the overuse of the term while trying to defend psychiatry for never officially adopting it, but everyone who's been on them knows that's exactly what they were told about their effectiveness, so whether the trope originated with the pharmaceutical companies (my assertion) or not, they were still way over prescribed and there's no statistically significant evidence they actually work when controlling for confounders, as the first meta analysis clearly demonstrates.
Why does psychiatry need to have an ‘equivalent’ of a sprained ankle?
Most people recognise a sprained ankle, at least mild ones, as a self limiting illness. An issue with psychiatric diagnoses is that they are often not taken to be self limiting and often become a large part of a patients self image. While sometimes this can be helpful and help inform treatment it can also be harmful and I have seen this harm first hand in patients I see.
If there is no sprained ankle diagnostics and doctors just tell you to ignore not being well: just jump and run around as normal there is nothing seriously wrong.
And doctors only react when you can no longer use your legs for a year, otherwise they must be amputated.
Or would you rather have an earlier disgnostic with instructions to reduce extreme loads and try to take it easy. Let's check again in a week.
While there has been a level of diagnostic expansion that I don’t think is helpful, it’s also important to consider:
What’s the psychiatric equivalent of a sprained ankle?
Does something have to be catastrophic to warrant a diagnosis?