Psychiatric Annals

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Zombie Ideas About Adult Attention-Deficit/Hyperactivity Disorder

Andrew A. Nierenberg, MD

Adult attention-deficit/hyperactivity disorder (ADHD) presents a host of challenges for clinicians. Some don't believe it exists. Most don't routinely screen for it if they do believe it exists. Many fear the fundamental treatments for it because the stimulants can be abused by the people who receive treatment legitimately or treatment can be diverted from them to others who would use them inappropriately. Overtreatment of ADHD, rather than undertreatment, is considered a main public health problem. Finally, many others don't know what to make of the high frequency of comorbid conditions—are the symptoms of the ADHD syndrome due to ADHD or cognitive/attentional/emotional dysregulation aspects of the comorbid conditions (major depressive disorder, bipolar disorder, or anxiety disorders to name a few)? The lack of clinically useful biomarkers (as with all psychiatric disorders) adds to clinicians' confusion even further.

The Zombie Idea that Adult ADHD Does not Exist

Paul Krugman, the Nobel prize winning economist who writes for The New York Times, uses the term “zombie ideas” to describe an idea that has been repeatedly proven wrong over time but keeps coming back from the dead to haunt its opponents (such as supply side economics). The zombie adult ADHD idea is that it is not a diagnosis, symptom cluster, or entity that causes suffering and dysfunction. Instead, journalists and other nonclinicians who write books about the corrupt ADHD industrial complex (and therefore have a profound conflict of interest because they want to sell books and to be paid for speaking tours, but have no responsibility to care for people who suffer) claim that ADHD was made up by pharmaceutical companies to sell more ADHD medications. The zombie conspiracy theory (with no data to support it) is that the pharmaceutical companies teamed up with key opinion leader researchers to form a cabal to provide harmful medications to patients to make a profit. The larger zombie theme is that all doctors who collaborate with or consult to industry are corrupt and evil—as now enshrined in law in the Sunshine Act1 (see the “Dollars For Docs” section of ProPublica)2—which costs untold millions of dollars for regulatory compliance with zero proof that patients are better off as a result. In my view, The New York Times has been particularly egregious in perpetuating the zombie idea of corrupt academic researchers.3

The counter argument that adult ADHD exists is not an argument at all—it is based in data. Data about the epidemiology, heritability, phenomenology, neurobiology, and neuroimaging of adult ADHD4–7 as well as advances in understanding the neurobiology of attention and impulse control8 converge to show that adult ADHD is as legitimate as any medical syndrome. To continuously reiterate these arguments with data does get tiresome; it's a bit like the ongoing debate about which category of zombies is more dangerous—the slow ones or the fast ones—or whether the facts even exist.

The Zombie Idea that Stimulants Cause More Harm Than Good

Stimulants and dopaminergic agents approved by the US Food and Drug Administration for adult ADHD have among the largest effect sizes and safety record of any class of psychiatric medications.9 Rates of misuse and abuse are low and research shows that for many the appropriate use of stimulants prevents substance abuse and untreated ADHD increases the risk of substance abuse.10,11 Diversion continues to be a concern and does need to be addressed. Epidemiologic studies show that the worldwide public health problem is undertreatment and not overtreatment.12 Data slay the zombie ideas yet again.

The Zombie Idea That Comorbid Conditions Make ADHD Invalid

Adult ADHD has many comorbid psychiatric conditions. Conversely, many psychiatric disorders have reverse comorbid adult ADHD. According to the zombie argument, adult ADHD is merely a manifestation of the cognitive domain of these other diagnoses. It would be difficult to prove or disprove this argument. Nevertheless, whether a component or a separate but related diagnosis, we are still left with the practical problem of how to treat the attentional and impulsive dysregulations and with what? If the dopaminergic stimulants and nonstimulants work, then does it matter what you call “it”? Zombie ideas don't have to treat people who suffer, clinicians do. And I would contend that it is important what you call “it” because if you don't look for “it,” you won't see “it.” As the late former Major League Baseball player Yogi Berra said, “you can observe a lot by just watching.” In this spirit, it behooves us all to systematically screen for adult ADHD, take a careful longitudinal history to understand the clinical course and rule out other causes of attentional/impulsivity problems, and treat judiciously while tracking progress or lack thereof. Then and only then, can we defeat those pernicious slow and fast zombie ideas about adult ADHD.

References

  1. Health Policy Briefs. The Physician Payments Sunshine Act. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=127. Accessed May 16, 2017.
  2. ProPublica. Dollars for Docs: how industry dollars reach your doctors. https://www.propublica.org/series/dollars-for-docs. Accessed May 16, 2017.
  3. Schwarz A. The selling of attention deficti disorder. The New York Times. http://www.nytimes.com/2013/12/15/health/the-selling-of-attention-deficit-disorder.html?pagewanted=all&_r=0. Accessed May 16, 2017.
  4. Adler LA, Faraone SV, Spencer TJ, Berglund P, Alperin S, Kessler RC. The structure of adult ADHD. Int J Methods Psychiatr Res. 2017;26(1). doi:10.1002/mpr.1555 [CrossRef]. [Epub].
  5. Thagaard MS, Faraone SV, Sonuga-Barke EJ, Ostergaard SD. Empirical tests of natural selection-based evolutionary accounts of ADHD: a systematic review. Acta Neuropsychiatr. 2016;28(5):249–256. doi:10.1017/neu.2016.14 [CrossRef].
  6. Uchida M, Spencer TJ, Faraone SV, Biederman J. Adult outcome of ADHD: an overview of results from the MGH longitudinal family studies of pediatrically and psychiatrically referred youth with and without ADHD of both sexes. J Atten Disord. 2015; doi:10.1177/1087054715604360 [CrossRef]. [Epub ahead of print].
  7. Segenreich D, Paez MS, Regalla MA, et al. Multilevel analysis of ADHD, anxiety and depression symptoms aggregation in families. Eur Child Adolesc Psychiatry. 2015;24(5):525–536. doi:10.1007/s00787-014-0604-1 [CrossRef].
  8. Tomasi D, Volkow ND. Functional connectivity of substantia nigra and ventral tegmental area: maturation during adolescence and effects of ADHD. Cereb Cortex. 2014;24(4):935–944. doi:10.1093/cercor/bhs382 [CrossRef].
  9. Fredriksen M, Halmoy A, Faraone SV, Haavik J. Long-term efficacy and safety of treatment with stimulants and atomoxetine in adult ADHD: a review of controlled and naturalistic studies. Eur Neuropsychopharmacol. 2013;23(6):508–527. doi:10.1016/j.euroneuro.2012.07.016 [CrossRef].
  10. Wilens TE. Impact of ADHD and its treatment on substance abuse in adults. J Clin Psychiatry. 2004;65(Suppl 3):38–45.
  11. Wilens TE. A sobering fact: ADHD leads to substance abuse. J Am Acad Child Adolesc Psychiatry. 2011;50(1):6–8. doi:10.1016/j.jaac.2010.10.002 [CrossRef].
  12. Fayyad J, Sampson NA, Hwang I, et al. The descriptive epidemiology of DSM-IV Adult ADHD in the World Health Organization World Mental Health Surveys. Atten Defic Hyperact Disord. 2017;9(1):47–65. doi:10.1007/s12402-016-0208-3 [CrossRef].
Authors

Andrew A. Nierenberg, MD

Andrew A. Nierenberg, MD, is the Thomas P. Hackett, MD, Endowed Chair in Psychiatry, the Director, Bipolar Clinic and Research Program, and the Director, Training and Education, MGH Research Institute, Massachusetts General Hospital; and a Professor of Psychiatry, Harvard Medical School.

Address correspondence to Andrew A. Nierenberg, MD, via email: psyann@Healio.com.

10.3928/00485713-20170509-01

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