Traduttore, traditore
on ADHD diagnoses
Psychiatrist Hannah Spier, MD published a recent video on her Substack site commenting on the recent surge in Attention-Deficit/Hyperactivity Disorder (ADHD) diagnoses, particularly among adult women. In it, she criticizes the looseness of many of the criteria surrounding such diagnoses and hints at what might be the ulterior motives behind the desire to attain them. As Spier observers, many women seem to wear their ADHD diagnosis like a crown and regard it as a source of pride, as evidenced by the fact that they seem eager to announce it to anyone who will listen. Prima facie, it is somewhat unexpected that people would seem to be so proud of having ADHD because it is, by definition, a neurodevelopmental disorder. This, of course, entails both that it is a marker of impaired cognitive function and that it is out of one’s control anyway. It is, to say the least, surprising that a disorder characterized by these two things would be a particular source of pride. Obviously, this doesn’t imply that an ADHD diagnosis ought to be a mark of shame, but only that, as the word is traditionally conceived, if people are going to be proud of something, it ought to be their virtue, their efforts, their accomplishments and not purportedly genetic impairments. But I am ranging too far afield of the topic that I actually wish to explore.
Spier suggests that the apparent pride with which people seem to announce their diagnosis is actually a bad faith excuse to absolve themselves of accountability for their lives. Receiving the diagnosis of “neuro-divergent” shifts the center of agency to factors entirely outside of one’s control and consciousness to abstractions like “genetic heritability,” “neurochemical imbalances,” and “brain-wiring.” People are, it would seem, eager to absolve themselves of accountability for the difficulties they encounter in their own lives and an ADHD diagnosis promises to sweep in with a blank check of exculpation. Failure to achieve one’s goals? ADHD. Compulsive behavior? ADHD. Constant emotional friction and problems with internal regulation? ADHD. And so on.
But as Spier points out, the only one of these factors that is actually measurable, heritability, which is purportedly very high, actually tells the opposite story to the one that is often put forth the moment environmental factors are controlled. That is, a change in environment can, depending on the change, either drastically reduce or drastically exacerbate the symptoms of ADHD, which, it must be emphasized, are the only elements of ADHD there are. In other words, as Spier points out, the diagnosis is purely symptomological. Take away the symptoms of the disorder, and there is no disorder left.
Of course, not every feature of a person requires a measurable, repeatable, scientific (for lack of a better word) basis to be considered real. Personality traits, temperament, virtues and vices, and so on are all legitimate features of a person that do not require validation in a laboratory to be considered real. But we also do not pretend that such things are ratified by the scientific method the way people do with ADHD diagnosis. And this, I take it, is just Spier’s point: that there is a sort of composition fallacy or reverse-sorites confusion behind ADHD diagnosis when it is imagined that, by assembling a sufficient number of non-scientific judgements, we could suddenly arrive at a scientific one. This should be clear to anyone who peruses the so-called “Adult ADHD Self-Report Scale Symptom Checklist” in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, which is the primary assessment for the diagnosis of the condition. A survey of the questions:
How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
How often do you have difficulty getting things in order when you have to do a task that requires organization?
How often do you have problems remembering appointments or obligations?
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
Clearly, there is nothing really novel or unfamiliar to most people about encountering difficulties in relation to the situations alluded to in these questions. How should we interpret this fact? Spier’s view, to which I am largely sympathetic, is that it would be better to forgo the pretense of scientific judgments in relation to these situations and instead remain with what we can actually experience. She argues that any purported basis can just as easily be correlated with personality ratios in the so-called “five-factor model” (FFM) of personality like high trait Extroversion, Openness, and Neuroticism and low trait Conscientiousness. Traditionally, not being able to see a task through to the end is a very straightforward example of a vice: namely, a deficiency of perseverance. Of course, inconstancy like this was traditionally countered by discipline and resolution rather than amphetamine salts like Adderall or cocaine analogs like Ritalin. I’m going to return to this point in a moment.
First, however, I would like to summarize Spier’s video by saying that she raises many further questions surrounding the scientific basis of ADHD diagnosis including gerrymandered diagnostic criteria, the “mission creep” of these parameters over time (which, as she points out, follows a playbook also employed in expanding the criteria for autism and bipolar diagnoses, which conveniently carves out new market shares for pharmaceutical companies with each revision of the DSM), the utter absence of any consistent measurable or objective basis for diagnosis (which instead relies on self-report checklists like the one surveyed above). She ends her video promising future ones expanding on the different classifications of ADHD, reviewing the evolution of ADHD as a neuropsychiatric diagnosis, and exploring the manner by which various pharmaceutical companies may have contributed to this “scientific” process. Anyone with interest in this subject can find her video at the link at the beginning of this article and can subscribe to her Substack site for future articles and videos on this and similar subjects.
As I indicated, I am largely sympathetic to Spier’s critique of ADHD diagnosis, as well as her argument that the same critique extends to many other diagnoses in the field. But this opinion should not scandalize anyone at this point. Most people with a passing familiarity with the philosophy of science or metascience are familiar with the so-called “reproducibility crisis” that has cast aspersions on purportedly “settled-science” in virtually every field by the logic of the scientific method itself. Stanford School of Medicine Professor John Ioannides published what is perhaps the keynote of this critique in 2005, which his PLOS Medicine article titled “Why Most Published Research Findings Are False.” Since that time, further investigation into the subject has estimated that fewer than 40% of the high-profile studies in the field of psychology could be replicated, while in cancer biology the estimates drop as low as only 10%, implying up to 9 out of 10 scientific studies fail to meet one of the most elementary criteria of institutional science.
And yet I think all of these critiques, their legitimacy notwithstanding, ultimately look past the most important issue: namely, the increasing pressure to translate a behavioral pattern—or, as Spier proposes, an FFM personality profile—into the lexicon of psychiatry and pyschopathology. Of course, as she indicated, there are explanations for this pressure including industry incentive and, for lack of a better term, “science-envy” among ordinary people. In any case, we can comment on the phenomenon even in the absence of certainty about motivations. Framing something as a medical problem ensures that it will admit of only a medical solution which will consist in, naturally, some form of medication. Of course, if the same problems were framed in terms of personality and behavior, the prospective solutions would look very different. Above, I reproduced the first few questions in the official DSM self-report diagnostic checklist for ADHD, and considered the first question as an example. It’s clearly describing a specific behavioral problem. Why not then treat it as one rather than transposing it into the language of psychiatry? Again, it’s a rhetorical question because there is nothing mysterious about why people are so eager not to deal with it on its own terms.
But is there a reason to resist this temptation? From one perspective, the transposition from behavior to psychiatry is merely a translation between two different lexicons. The respective lexicons, of course, index to two paradigms that, howbeit “incommensurable,” could be equally valid nevertheless. Thomas Kuhn popularized this term by explaining that General Relativity is not an improvement on Newtonian mechanics. Instead, it substitutes one way of seeing with another.
By the same token, neither was the Copernican model of the solar system an improvement on the Ptolemaic one just as English was not an improvement on Ancient Greek. Kuhn elaborates:
The child who transfers the word ‘mama’ from all humans to all females and then to his mother is not just learning what ‘mama’ means or who his mother is. Simultaneously he is learning some of the differences between males and females as well as something about the ways in which all but one female will behave toward him. His reactions, expectations, and beliefs—indeed, much of his perceived world—change accordingly. By the same token, the Copernicans who denied its traditional title ‘planet’ to the sun were not only learning what ‘planet’ meant or what the sun was. Instead, they were changing the meaning of ‘planet’ so that it could continue to make useful distinctions in a world where all celestial bodies, not just the sun, were seen differently from the way they had been seen before.
Thus, in one sense, defining a behavioral problem as a neuropsychiatric disorder is value-neutral and it is merely another way of describing the same thing. But in another sense, it is not the same. Some tools will always be better for a given job than others. Charles V, Emperor of the Holy Roman Empire in the sixteenth century, purportedly quipped, “I speak Spanish to God, Italian to women, French to men, and German to my horse,” suggesting differential suitability among diverse languages to discuss diverse topics. You can hammer a nail with a socket wrench but that doesn’t mean you should, especially when the tool you need is more ready to hand than the one you may insist on using. Similarly, not every paradigm is best-suited to describe every phenomenon, and often one paradigm is not even capable of describing a phenomenon readily apparent in another without changing the subject. You could, of course, describe a smile as “a sustained, acetylcholine-mediated release of calcium from the sarcoplasmic reticulum of the zygomaticus muscle” but then, in transposing an experiential encounter into the language of anatomy and physiology, you would not be talking about a smile anymore. Hence, as it is said, “traduttore, traditore”: “to translate is to traduce.” A map can represent a territory but never substitute for it.
In the same way, if we insist on medicalizing self-evident features of a person instead of characterizing those features in the obvious language of behavior, personality, and virtue and vice, we might imagine that in doing so we are drilling down to the factual truth of the situation. In reality, we risk compelling ourselves by our mode of description to look past those facts under the illusion that a handful of abstractions in the DSM offer a more accurate characterization of a person than perceptions mediated through an actual experiential encounter.
Some readers may recognize this tension as a leitmotif in the history of ideas at least since the time of the Scientific Revolution. Goethe famously criticized Newtonian science for this sort of reductionism, comparing its adherents to “children who, having looked into a mirror, turn it around to see what is on the other side,”1 while the Newtonians shot back by accusing the Goetheans of pseudo-science and lack of rigor. Coleridge once speculated that everyone is either born a Platonist or and Aristotelian and perhaps the same dichotomy could be drawn between those who are temperamentally drawn to Goethean or to Newtonian science.1 The judgement is between experience and abstraction, between perception and cartography. Is truth a person or is truth an algorithm? A territory or a map? I don’t intend to elaborate on the subject further here but I have written more than a few essays on it here and it was a key element in my dissertation, for anyone with interest.
Every man is born an Aristotelian or a Platonist. I don’t think it is possible that any one born an Aristotelian can become a Platonist, and I am sure no born Platonist can ever change into an Aristotelian.
Samuel Taylor Coleridge, “Table Talk” (July 2,1830)
Normalcy has become a very narrow window of human spectrum. Have those who researched and defined what normalcy is fit themselves into that window?
Very inspiring and insightful, how you, the author take us on a journey to explore deeper about our modern times when it comes to ADHD.