Diagnosis has gone beyond science — ADHD, PTSD or clinical depression are just words, sanctified by common usage says Matthew Parris

The introduction is also posted on Spotify as a podcast by “Gerry at The Health Equation”

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Gerry Gajadharsingh writes:

“I have never met Matthew Paris, but I respect him as a good journalist who usually considers very carefully what he writes.

The headline of his recent article in The Times was brave and controversial, not surprisingly, there was a lot of pushback in the comments section of The Times Online, but I suspect that many of the negative comments are missing his point.

So, the focus of his article should be about the following paragraph.

Neurodivergence has become a bandwagon, so overladen as to devalue cruelly the plight of the much smaller numbers of adults and children whose sometimes grave mental difficulties struggle for definition amid the careless use of words and phrases such as autistic, clinically depressed, attention deficit hyperactivity disorder (ADHD) and bipolar.

It is clear that the NHS simply cannot keep up with demand in both physical medicine and mental health medicine. It has a significant demand and supply issue. And no matter how much money the taxpayer throws at the NHS it simply will never be able to keep up with supply, due to an unrealistic expectation of the population at large that the NHS can cure all or any of the symptoms that they happen to present with.  A large percentage of patients have so-called medically unexplained symptoms and or functional symptoms. Which means no obvious pathology/medical cause can be found and therefore medical treatments such as medication often simply not work. Many of the drivers of symptoms on both physical and mental health levels tend to be lifestyle and behaviour.

More than nine million of us are now “economically inactive” — choosing not to work. Society simply cannot afford this number of economically inactive people.

Ministers know the system is being gamed and will say so in private. But they flinch from sounding uncaring and confine themselves to nudging claimants to seek treatment. This does not mean all of these economically inactive people or those claiming benefits and enhanced health benefits are gaming the system, but nobody quite knows how many people actually are, the suspicion is quite a lot.

So, if you put your head above the parapet and say the situation is unsustainable, which I think is a reasonable question, you are likely to stir up a hornet’s nest.

It seems that many people want a label/a medical diagnosis for what they experience or feel. It’s almost as if people now need validity to explain how they feel or behave.

Apparently 25% of Gen Z (born after 1997) declare they now have mental health problems compared with an average of 8 per cent of all adults, with 900,000 of them not actively seeking work.

Another recent controversial article by the eminent psychiatrist. Professor Sir Simon Wessely, an NHS board member who was also president of the Royal College of Psychiatrists from 2014-17, was also published  this week, to quote one paragraph

“They were talking about loneliness, homesickness, exam stress, academic pressure, concerns about climate change, which we probably wouldn’t really classify as mental disorders because they don’t really respond to the kind of psychological treatments we give.”

And I think that’s an important point, people think if they get a label/medical diagnosis they’ll get access to the correct medication and or psychological therapies. When you have an eminent Psychiatrist challenging this group think I think it’s worth considering.

However, depression and anxiety diagnoses have risen sharply since 2000 and particularly since 2010, while ADHD (attention deficit hyperactivity disorder) and autism referrals have risen fivefold since the pandemic.

So, what to do?

The terms “internal locus of control” and “external locus of control” refer to a psychological concept that describes how individuals perceive the source of control over their lives and outcomes.

Internal Locus of Control: If you have an internal locus of control, you believe that you have significant control over the events and outcomes in your life. You attribute success or failure to your own actions, decisions, and efforts. For example, if you succeed in a task, you might think it’s because you worked hard or made smart choices. Conversely, if you fail, you may believe it was due to something you could have done differently.

 External Locus of Control: On the other hand, if you have an external locus of control, you tend to believe that external factors, such as luck, fate, or the actions of others, the economy, climate change, immigrants etc are the primary influences on the events and outcomes in your life. For example, if you succeed, you might attribute it to being in the right place at the right time, or to someone else’s help. If you fail, you might blame outside circumstances or bad luck.

People with an internal locus of control generally feel more empowered and proactive, while those with an external locus of control may feel more at the mercy of their environment and circumstances.

It is well accepted that people who experience better health have an internal locus of control, conversely, if you have an external locus of control you tend to do worse from a health aspect, both in physical and mental health.

My wife and I were discussing the other day how on turning up to our children’s sports day (about 20 years ago) we were told sports days had become non-competitive. There are no winners and there are no losers, everyone wins!  This was an anathema to me as a competitive fencer and to my wife who was sports captain at school. Winning AND losing is part of life and teaching our youngsters that they can all win, I suspect is detrimental.

Not doing well at something in life, I think, teaches people resilience, it is often motivational by aiming to do better. Overcoming hurdles builds confidence and lack of self-confidence or paradoxically over confidence causes lots of problems. Many commentators have decried the lack of sport, drama, music and other non-academic activities in school as a policy of successive governments. These soft subjects are integral to an overall well-being of the person.

It’s also probably not a coincidence that the massive rise of social media during the past 15 to 20 years suggests a chronological connection with a worsening of how we feel. Humans need other real humans to interact with, not a screen. In this interactive always on world that we now live in, more people ironically feel lonelier.

While 36 per cent of the general population of young adults have tried illegal drugs, a survey of festivalgoers in England found that up to 87 per cent of attendees have done so. Research has found that almost two thirds of festival attendees take drugs when they are at festivals.

Not everyone who uses recreational drugs will develop mental health problems, but certain individuals, particularly those with a family history of mental illness or those who begin using drugs at a young age, may be more vulnerable.

While some people use cannabis to relax, heavy or frequent use, particularly of high-potency strains, has been linked to an increased risk of developing mental health issues such as anxiety, depression, and psychosis, especially in individuals predisposed to these conditions.

Stimulants such as cocaine and methamphetamine can lead to acute mental health problems such as anxiety, paranoia, and hallucinations. Chronic use can cause longer-lasting issues, including persistent anxiety, depression, and psychotic symptoms.

In conclusion, while not all recreational drug use leads to mental health problems, there is a significant risk, especially with an underlying vulnerability and or frequent or heavy use. The effects can range from short-term issues like anxiety or paranoia to long-term conditions like depression, psychosis, or even permanent cognitive impairment.

MDMA (Ecstasy)While often associated with euphoria and increased sociability, MDMA can cause anxiety, depression, and memory problems, especially with heavy or long-term use.

Opioid misuse (heroin and opioid painkillers) can lead to severe depression and anxiety. Withdrawal from opioids is also associated with intense psychological distress, including anxiety and depression.

Taking ADHD medication (usually stimulants such as Methylphenidate/Ritalin or amphetamines/Aderall) is rife amongst university students, non-medical use (i.e., using the drugs without a prescription) is relatively common. Studies estimate that around 15% to 25% of students have used ADHD medication non-medically, often for purposes such as enhancing academic performance or coping with academic stress.

The primary reasons students report using these medications non-medically include the desire to improve focus, stay awake longer, and boost academic performance, especially during periods of high stress, such as exams or when facing deadlines. Sports bodies ban performance enhancing drugs, for good reason, not so in academia it seems.

Non-medical use of ADHD medication carries significant risks, including dependence, cardiovascular problems, and legal consequences. The misuse of these drugs can also negatively impact mental health, contributing to anxiety, depression, and other issues.

Last year there were 787,000 exclusions from school, the primary reason for these exclusions was persistent disruptive behaviour. There is an avalanche of teachers leaving the profession because of the disruptive behaviour of their students. Many of these excluded students fail to gain adequate education, thus struggle to get a job with many ending up living their lives on benefits.

Estimates suggest that as many as 1 in 10 children start school without being fully potty trained, which means thousands of children across the country may require additional support in managing toileting during their early school years.

Children who are not potty trained by the time they start school may experience stress, embarrassment, or anxiety, especially if they require assistance with toileting in a setting where most of their peers are independent in this area. This can lead to issues with self-esteem and social integration.

When our children started nursery, the head teacher was formidable, I suspect many of the parents were scared of her, however she was absolutely loved and respected by the children primarily because of the routine, discipline, respect and empathy encouraged in all of the children, they all felt safe, a keystone of going onto to have a happy and successful life. By the way it was a requirement that by 2 ½ years when our children started nursery, they had to be potty trained.

Now in the UK, children are generally not required to be fully potty trained before starting school. The Equality Act 2010 protects children from discrimination based on their needs, including those related to continence. Schools are expected to provide reasonable adjustments to accommodate children who may not be potty trained, which could include offering support with toileting if needed.

To conclude the causative factors of the “mental health crisis” that we seem to be facing in our youngsters is multifactorial. We need to think not only how we get this current generation through their individual crisis, but also make attempts to stop the next generation developing similar problems.

There are no doubt people suffering from diagnosable and some times serious mental health problems where psychiatric intervention, medication and psychotherapy, will often be necessary. But just as with physical medicine many of these less severe problems will be functional and teaching people to develop a more Internal Locus of Control and to develop strategies to cope better in the world they live in, I think, would do them and society more good, then simply trying to search for label which may or may not be correct.

The Times

Matthew Parris

Among the courses most in demand among aspirant undergraduates this year, psychology leads the march to become the most popular degree course in Britain. Employment prospects in the fields of therapy and counselling are expanding rapidly alongside an ever-increasing public interest in mental health, psychiatric diagnosis and the problems of those believed to be neurodivergent.

Neurodivergence has become a bandwagon, so overladen as to devalue cruelly the plight of the much smaller numbers of adults and children whose sometimes grave mental difficulties struggle for definition amid the careless use of words and phrases such as autistic, clinically depressed, attention deficit hyperactivity disorder (ADHD) and bipolar. You now hear people talking about these things in pubs and coffee shops.

The bible of this branch of medicine, published in the United States is Diagnostic and Statistical Manual of Mental Disorders (DSM). The first edition in 1952 listed and described 106 disorders (including, at the time, homosexuality). In this century the fifth edition of the manual was published, which listed more than 400 mental disorders. In its reach into our popular culture, “mental health” is an exploding branch of the discipline it believes itself to be a part of: medical science. Read Dr Lucy Johnstone’s Psychiatric Diagnosis (to whose argument and explanation I am indebted) for an understanding of a veritable spasm of interest, attention and claimed scientific expertise in the field.

But is psychiatry (the study of diagnosis and treatment) a science at all? Does psychology (the study of the mind, and behaviour) deserve the name of science? These questions matter as government struggles for ways of pushing, pulling or nudging our fellow citizens back into work.

More than nine million of us are now “economically inactive” — choosing not to work.

There are many good reasons why people may do so, but the fastest-growing group within this inactive cohort are those including mental health disorders in their claim for a personal independence payment (PIP, a substantially enhanced welfare benefit, PIP can also be claimed by those in work). Such maladies, having no visible physical symptoms are almost impossible to disprove. You can learn online how best to pitch your claim.

The situation is spinning, like DSM-5, out of control. There exists a mutually-reinforcing relationship between the clients of any branch of medicine and the practitioners employed to treat them. And because both need to believe, a second mutually-reinforcing relationship arises between therapists and the supposed theory that underwrites therapy. Just as surely as (when my grandmother was born) the patients, the leech-doctors and the professional blood-letters depended on theoretical phlebotomy: the hypothesis that illnesses were caused by an excess of blood, or bad blood.

Where then is science’s theory of the mind, and mental disorder? In Middlemarch George Eliot refers to “the serene light of science”. The light of science is anything but serene. Adam Smith’s “invisible hand” of supply and demand applies to university faculties, research funding and the public appetite for explanation and “cure”, as directly as it applies to the manufacture and supply of biscuits. And by creating, through a system of state benefits paying extra to the mentally unwell, the state has inadvertently created a consumer demand for psychiatric diagnosis.

Ministers know the system is being gamed and will say so in private. But they flinch from sounding uncaring and confine themselves to nudging claimants to seek treatment. And all that does is validate further the supposed science behind the therapy.

Proper science provides acid tests for its own validity. Does the theory, when applied, reliably predict outcomes? Proper therapy is driven by results. Can the success of treatments for physical ailments be measured? Yes. But where are the results for therapies in the field of mental health? It’s difficult. How could we employ placebos? How could we devise “control” groups to see if the treated do better than the untreated?

In an attempt at scientific methodology, a study asked a number of therapists individually and separately to diagnose the same patient, without comparing notes. Their diagnoses differed wildly.

You can, of course, ask patients whether a therapy has helped, but they will always be inclined to say yes. Anecdotally we suspect counselling can sometimes help, but a shoulder to cry on so often does — be it a priest’s, an analyst’s, a shaman’s or any good listeners. This is not science.

How about drugs? It’s important here to clear up a widespread misconception. So far, we have no drugs that target particular disorders or “cure” them. We have chemical coshes that sedate the whole person; and we have stimulants such as Ritalin that can clarify and give focus. We have alcohol, which can suppress inhibitions; and we have hallucinogens. All are mind-altering. But neuroscience (a real and developing discipline) has yet to determine whether any part of the brain can be identified as “causing” any mental disorder, or “treated” by chemical means. Big pharma once invested a lot of money in this attempt, but without results.

It follows that ADHD, autism, PTSD or clinical depression are really only words, sanctified only by common usage, not science, and used across a vast range of human feelings, attributes and behaviours, corralling them into groups that may at least outwardly seem to have something in common, but may have little to do with each other, or share any identifiable cause. We once used descriptions such as “fever”, “hysterics”, and “nervous breakdown” in the same way.

There’s nothing wrong in trying to be a science, trying to posit a theory of the mind, trying to map “mental disorder” or trying out different treatments. But that is where we’re at: in the very low foothills of anything approaching a scientific discipline. The mental health industry is cheating a gullible public, hungry for diagnosis, explanation and a set of named disorders, by pretending to a status it should not be claiming. And hard-squeezed NHS funding should follow results, not the 21st-century equivalent of witch doctors. Until we can measure, we should not believe.