People are unique, individual, and infinitely complex. In the interest of maximizing efficiencies, our world and medical community focuses on commonalities to evaluate, label, and treat patients. This approach raises some key questions: Can something so complex be labeled? Is the diagnosis and treatment of ADHD a science or is it an art? Let’s explore this system a bit deeper to understand how we get a diagnosis before answering these questions.
To make a medical diagnosis, doctors collect information from a patient’s medical history, a medical examination, and medical testing. Laboratory tests can be especially useful when diagnosing medical conditions that are well understood and whose etiology or manner of causation are clearly defined. These conditions are referred to as diseases.
But for conditions that are not so clearly defined, conditions like ADHD that have both neurological and behavioral components, the term “disease” is not a good fit. That’s why they are called disorders rather than diseases.
Unlike diseases, which often arise from a singular cause – a bacterial or viral infection, a toxic exposure, or a genetic abnormality – behavioral disorders quite often have genetic, biological, and environmental factors. Because there are so many contributing factors, medical tests are often not useful for diagnosing behavioral disorders. As a result, doctors rely heavily on the information they get from patient histories, and from their first-hand observations during office examinations.
Physicians then consult the Diagnostic Statisticians’ Manual (DSM), which is a comprehensive guide and diagnostic tool published by the American Psychiatric Association. The DSM clusters behavioral symptoms into categories to label a disorder (like ADHD). This allows physicians to take a patient’s behavioral symptom X, behavioral symptom Y, and behavioral symptom Z, review the behavioral diagnostic categories in the DSM, and dial in to form a diagnosis of Behavioral Disorder A.
The behavioral diagnostic categories are often useful to doctors to help guide clinical treatment – both prescription and nonprescription medications, as well as non-medication treatments. These categories are, in fact, necessary for insurance, research, and educational purposes. Nonetheless, this classification system does have its shortcomings.
Take, for example, the DSM category “Depressive Disorders.” While this category has over a half dozen different disorders, the behavioral symptom “depression” can be found in many other behavior disorders contained in other categories. So, even though many people with ADHD are also depressed, ADHD is not considered a “Depressive Disorder.” This holds true for a host of diagnoses. People with sleep disorders, eating disorders, anxiety disorders, as well as those with cancer, chronic pain, heart disease, and diabetes are often depressed.
Another shortcoming of the DSM and challenge for doctors is the fact that some individuals have more than one disorder. As doctors synthesize clusters of behavioral systems, they may encounter multiple disorders that have significant overlap in behaviors. Is it one, the other or both?
No doubt, the DSM is a helpful and important tool. However, as a singular means for forming a clinical conclusion, it is far from an exact science. Too often diagnosis is subjective, and treatment is limited by the labels doctors place on their patients. In the end diagnosis and treatment are often more of an art than a science.
So, if diagnosis and treatment of ADHD as a disorder is more of an art how do you find an artist? There is no right answer. We are working towards and hopeful for a more methodical way of doing things but for now we have to work with what we have. And we know that those doctors who focus on treating the individual tend to be better at observation and more artful than those just treating a label.