Are We Over-Diagnosing ADHD Based on “Hyperactivity"?

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COMMENTARY

The diagnosis of attention-deficit/hyperactivity disorder (ADHD) continues to be the focus of controversy in psychiatric literature.¹ I would like to begin by critically examining the “H” in “hyperactivity,” as suggested by S. Nassir Ghaemi, MD. I concur with Dr Ghaemi that distractibility and “hyperactivity” are not part of the same psychological problem.²

Since 1991, when I started to observe the behaviors of children diagnosed with ADHD, I have noticed that “hyperactivity” is associated with either a mood disease or anxiety.I have hundreds of cases documented in 3 books,^3-5 and as of today, I have not found 1 case in which the increased activity, physical or psychological, is associated with a diagnosis of ADHD.

On the contrary, the reported “hyperactivity” has been a manifestation of obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), social anxiety, bipolar illness, autism, and a few other diseases.

On the other hand, as my mentor and friend Ronald W. Pies, MD, likes to say, “the body can have as many illnesses as it pleases.”⁶ The key difference between having several concurrent diseases and an unjustified diagnosis is that in the first scenario, every medical entity has symptoms of its own. The following vignette is an example of a frequently encountered diagnostic confusion.

Case Example

“Kevin” is a preadolescent Caucasian boy raised by his grandmother. From early childhood, he was exposed to physical neglect, and he also witnessed the assassination of his father, who was described as a violent person and addicted to street drugs. While in foster care, Kevin was sexually molested and again suffered emotional and physical neglect. He has severe anger issues, but his grandmother says he is very smart and can do his schoolwork, if he wants to.

Several psychiatrists and psychotherapists have diagnosed him with PTSD, bipolar disorder, autism, bulimia, and insomnia. Lastly, a school counselor had Kevin and his grandmother complete a Vanderbilt questionnaire and determined that Kevin has ADHD.

Discussion

It seems obvious that a person like Kevin would have impaired attention in the classroom, but the questionable habit of elevating symptoms to the status of a diagnostic category misled the school clinician to diagnose ADHD, leading to other serious consequences from giving psychostimulants to a child misdiagnosed with ADHD, but suffering from mood and/or anxiety disorders.

I should emphasize that Kay Redfield-Jamison, PhD, said once in an interview, “There are few things worse than putting a child with bipolar illness on stimulants.”⁷

And then, there is what I would call institutional fallacy. Here is 1 example: Six respected researchers from a prestigious university published their findings in an esteemed psychiatric journal.⁸ The writing is impeccable, and the conclusions appear to be sound, but when you read between the lines, something is not right.

In the first paragraph, they say, “For example, in a study of robust open-label dosing with lisdexamfetamine, 40% of adults with ADHD were considered to have unresolved and clinically significant impairment in essential elements of executive behavior. Therefore, there is a significant need for new ADHD interventions.”

Notice that the investigators assume that all the participants in the study quoted by them have ADHD. Furthermore, how can a drug weaker than lisdexamfetamine (Vyvanse) have a significant effect on an individual with an impaired attention span when conventional amphetamines failed to improve symptoms?

If you wonder why I question the accuracy of the diagnosis in that study,⁹ I must say that I do so in any ADHD publication, and I have an abundance of evidence to sustain my view (see references). However, the investigators of this second study are heavyweights in the field who I respect and admire.

Over several decades, I have encountered thousands of children (and adults with a childhood history) who were labeled conduct disorder and/or oppositional-defiant plus ADHD, when in fact they had OCD, social anxiety, PTSD, bipolar disorder, or even schizophrenia. It may be hard to believe, but I treated 2 children who for several years were receiving methylphenidate while having constant auditory hallucinations.

Not surprisingly, they were adopted by nice families, and the evaluating physicians assumed that the legal guardian in front of them was the child’s birth mother.

Another component of “institutional fallacy” is the pervasive belief that ADHD is a frequent comorbidity with other diagnoses. If we agree that ADHD is a diagnosis of exclusion, we then need to ask for the science behind the validity of those co-occurrent illnesses. As Dr Ghaemi and the late professor Hagop Akiskal, MD,¹⁰ stated multiple times, we should diagnose ADHD only when other explanations for an impaired attention span have been ruled out.

I propose that we reclaim science and discard false assumptions, including that sleep disruption, moodiness, aggressive or defiant behaviors, autistic obsessions, etc, are inherent components of the ADHD syndrome. Instead, we should be digging deeper to determine if non-ADHD disorders better explain these features.

Dr Mota-Castillo is a former chair of psychiatry at the Burrell College of Osteopathic Medicine in Las Cruces, New Mexico. He is currently practicing child psychiatry in Florida, Georgia, and California.

References

1. Hinshaw SP. Attention deficit hyperactivity disorder (ADHD): controversy, developmental mechanisms, and multiple levels of analysis. Annu Rev Clin Psychol. 2018;14:291-316.

2. Ghaemi SN. Clinical Psychopharmacology: Principles and Practice. Oxford University Press; 2019.

3. Mota-Castillo MR, Heath D, Pittington A. Protecting Your Children From Bad Medicine: How the ADHD Diagnosis Has Been Abused. Jawbone Publishing Corporation; 2007.

4. Mota-Castillo M. ADHD: A Real Disease, But a False Epidemic. Kindle Edition; 2019.

5. Mota-Castillo M, Pistone D. Are My Mood Swing Bipolar? All You Need to Know About Bipolar and PTSD. Kindle Edition; 2015.

6. Pies RW. Clinical Manual of Psychiatric Diagnosis and Treatment: A Biopsychosocial Approach. American Psychiatric Association Publishing; 1994.

7. Redfield-Jamison K. Interview. Monitor on Psychology. 2000;31:9.

8. Surman CBH, Walsh DM, Horick N, et al. Solriamfetol for attention-deficit/hyperactivity disorder in adults: a double-blind placebo-controlled pilot study. J Clin Psychiatry. 2023;84(6):23m14934.

9. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(4):716-723.

10. Dilsaver SC, Akiskal HS. Preschool-onset mania: incidence, phenomenology and family history. J Affect Disord. 2004;82 1:S35-43.