Why ADHD is a Strange and Often Misunderstood Diagnosis

By Douglas Berger, Psychiatrist Tokyo, Japan

ADHD or Attention Deficit Hyperactivity Disorder is a commonly diagnosed condition said to affect almost 10% of the population. However, this diagnosis is often frequently misunderstood for a number of reasons, not the least being that the medical community has tried to make a complicated problem fit neatly in the four letter ADHD acronym. At least this was better than the previous diagnostic congener for ADHD called “minimal brain dysfunction”, we can all imagine the problems associated with this kind of label. This short article will attempt to explain why ADHD is still such a misunderstood diagnosis.

Strangeness 1:

Persons with lots of attention problems often have a mess of hyperactivity associated with their inattention and vice-versa, but not necessarily. Sometimes inattention and hyperactivity are shared equally making for an egalitarian mess. The true diagnosis should really be “ADD and/or HD” under a diagnostic section titled, “Attention Deficit and Hyperactivity Disorders”, but this kind of diagnosis is not as compact as ADHD so that ADHD has held on to its troubled namesake.

Strangeness 2:

Now Strangeness 1 leads to some further problems. It’s common for hyperactive patients to clamor they are quite attentive to their surroundings, not messy, and get lots done so they can’t possibly have ADHD, and inattentive patients to clamor that they are not hyperactive so don’t have ADHD. Now the doctor needs to dig-in and explain that the ADHD acronym was made to give the disorder a sleek 4-letter look but it’s not so simple as 4 letters.

Strangeness 3:

While most psychiatric disorders cause trouble functioning, persons with ADHD may actually accomplish a lot of things- for better or worse. This can frequently lead these persons to deny they have a problem. Impatient and hyperactive persons can get a lot done (perhaps our newest head of state’s brash spatter of activity comes to mind), and scattered and inattentive persons can hyperfocus on specific tasks better than anyone else (perhaps Einstein’s messy hair and mess desk comes to mind).

Strangeness 4:

Young children with hyperactivity may have tantrums and run-around in class. Older children can be “class-clowns”, pull pranks, blurt things out, or be aggressive, but the running-around hyperactivity gets better over time. As an adult, these people can become argumentative, impatient, and frustrated easily. They may deny they have hyperactivity disorder, and indeed they are not hyperactive, their hyperactivity has transformed into impatience, and this is a problem with the diagnosis of “Adult ADHD” which now you see should really be called “ADD and/or HD with/or without Impatience”.

Some adults are hyperactive but do not show impatience or frustration. Hyperactivity is still hyperactivity, though hyperactive signs such as being fidgety, biting fingernails, tapping one’s pen on a desk frequently during meetings, etc. are not readily thought of as hyperactivity by the general lay person (no one sign alone makes a diagnosis). Impatience with slow persons, elevators, other cars on the road, waiters/waitresses, phone operators, etc. are common in everyone, but can clearly be seen to be part of a disorder when frequent and of some intensity out of proportion with what is logically necessary. It is almost like these persons have a mental “time-contraction” where waiting one second for them is the same as waiting a minute for a normal person.

Strangeness 5:

As alluded to in Strangeness 3, persons with ADHD can have hyperfocus and actually focus very well on a specific topic. The problem is that these persons over-focus or “zone-in” to some topic at the expense of relating to significant others (who may get irritated), and they may not be able to do a normal variety of activities. This can be exemplified by a scientist or academic who has an office full of paper piles, looks scruffy, is scattered and distracted in daily life, but is very knowledgeable about their particular area of expertise, or the teenager that spends hours just writing programing code and putting software up on the internet at the expense of normal social interaction, but lands a great job without even going to college.

Strangeness 6:

Hyperactivity often improves greatly from childhood to adulthood. Adults only rarely have tantrums, push in line, or show aggravation in public. Some do, however, and some show derivatives of hyperactivity they had in childhood: impatience, over-critical of others, irritated over small things, intolerant, road rage, air rage, pushing others, getting red with anger while arguing, etc. Inattention however tends to persist in adulthood; scattered objects in the home, disorganized papers, not following directions, etc. can all be seen in adults as well as in children. In fact, adults may have more trouble because the expectations are higher on them.

Strangeness 7:

What about the medication treatments for ADHD? Again it is not straight forward. First, having strong signs of ADHD does not mean the person will respond to ADHD medication (this is basically true for the medication treatment of any psychiatric disorder). Many persons give up because there is no response without realizing that a trial-and-error of drug doses and drug types, or combinations of types, is necessary in psychiatry. Some persons have side-effects, like headache, feeling too antsy, heart racing, insomnia, etc. Again this doesn’t mean that medications don’t work, it means the dose should be lowered or the drug type changed etc. Many patients make negative or giving-up conclusions about their medication treatment without looking at the treatment as a process that has to unfold.

Medications for ADHD can “clear the clouds” of attention deficit, decrease impatience and fidgetiness and increase focus. Persons can remember what they read and organize their life better. These medications can also cause normal persons to feel revved-up and engage in more activities than they usually do. Normal persons on these medications may also have increased focus and so that response to medications may not clearly confirm that the person had ADHD.

Strangeness 8:

With all the strangeness noted above we would think it couldn’t get worse. What is a better way to make professional fame and fortune than to create a new diagnosis and of course a treatment system for this diagnosis? The more non-specific the diagnosis the more potential clients one can have. “Sensory Integration Disorder” (SID) is one example of a diagnosis and treatment deriving from ADHD although it is not recognized by mainstream psychiatry. These persons (usually children) are said to have a sensitivity to various stimuli: noises, certain textures on the skin, and they may have distraction and focus problems and/or anxiety, hyperactivity, and oppositional behavior. This sounds like the designers decided to mush a few common symptoms of Autistic, Anxious, and ADHD children (“the three As”) in to one “super diagnosis” that deserves the special (and costly) treatment the designers created, naturally it’s called, “Sensory integration therapy (SIT)”.

The therapy is also non-specific and neither the therapy nor the treatment have been validated (there is no way to double-blind this kind, or any kind of behavioral or psychotherapeutic intervention). Brushing the skin, improving coordination, “desensitizing” the nervous system over years of frequent and expensive treatments are more strangeness. Considering there are none or very few adults with sensory symptoms like this, it is likely that just letting children grow up in a loving environment, giving them a good education, and focused treatment for a clear instance of one of the “three As” if needed, will result in adults with few of these problems. For a closer view of SID and the problems involved please see this link: http://www.quackwatch.org/01QuackeryRelatedTopics/sid.html

Disorders and Treatments

What about “standard” psychiatric disorders and their treatments? Some could argue that maybe they should be thrown out the window, however, this requires a nuanced approach. Some psychiatric diagnoses like depression, ADHD, and schizophrenia have a better validation than others such as personality disorders. See my article in LinkedIn on, “Are Diagnoses Real in Psychiatry” here for the full discussion: https://www.linkedin.com/pulse/diagnoses-real-psychiatry-douglas-berger-m-d-ph-d-?trk=pulse_spock-articles

For treatments, psychotherapy (including psychoanalysis, cognitive-behavioral therapy, mindfulness or meditation, etc.) may help persons function better in some ways. However, because psychotherapy research can not be studied in a double-blinded manner, there has never really been a validation of these modalities as being effective in any psychiatric disorder as bias due to hope and expectation in the subjective measurements of psychiatric conditions can not be eliminated (many studies have been done but none are single-blind (=patient blind), or patient and treater blind (=double blind) so that lay person and professions alike are frequently not aware of this huge problem. Masked raters only record the subjective report of the patient and is often mistakenly called single-blind (google “definition of single-blind”).

So while psychotherapy may be helpful for some symptoms in some persons, they are also over-sold as cures for a number of different psychiatric disorders. For medication, although outcome research can be double-blinded, blinding is not always effectively maintained (i.e., persons may sense they have a “drug” in them). For some persons medication treatment seems crucial, but there is also over-selling of medication to persons without a clear need. See my article on the problems in blinding outcome research published in f1000 here: https://f1000research.com/articles/4-638/v2

If your more confused now it is because diagnoses and treatments in psychiatry requires a nuanced understanding: confusing diagnostic terms that cause patients to deny that have the problem specified to them, over-selling and over-marketing of diagnoses and treatments, and unvalidated “me-too” for-profit treatments are springing up all the time. For example, running, juggling, meditation, and Tai Chi, are all valuable activities, but these activities can not be double blinded either so there is really no way to validate these kinds of activities as a treatment. Some of these have even been shown to help brain growth, but then again, most any activity that stimulates the brain will cause neuronal growth, also called “plasticity”. Perhaps you’ve noticed in the few seconds it takes to read these sentences that the only activities noted here amenable to making a profit for a therapist, meditation and to some extent Tai Chi, are actually the ones marketed by therapists. We don’t really need a therapist to run or juggle.

Of course psychiatric disorders do exist in the POPULATION even if the exact definitions and labels used to name these disorders have not really been validated. The problem is that it is harder to pin-down an exact label on an INDIVIDUAL with high accuracy. While the profession clearly needs to do more about educating the public about the problems in the validity of the current psychiatric disorder classification and in the outcome research of the treatment of these conditions, mental health professions fear letting the public and insurance companies know that we have so many uncertainties.

Douglas Berger, M.D., Ph.D.
 U.S. Board Certified Psychiatrist
 Tokyo, Japan

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