ODD (Oppositional Defiant Disorder) and a Big WTF?!?

Great Debates
161

Calling the set of symptoms a syndrome doesn’t equal understanding what caused them.

It’s still useful for people trying to address a condition or phenomenon to have something to call it, a shorthand term for a paragraph-and-change’s worth of descriptives and qualifiers. Don’t get me wrong.

But certainly not every constellation of problematic behavior suddenly becomes a biological condition of the brain just because someone draped an acronym over it.
Parents are in a difficult position. It is generally the parent who is going to consent to treatment for their kid who is diagnosed with ODD or ADD or ATDT or FDHD or STP or whatever (not to mention things like autistim, schizophrenia, bipolar, depression, etc, which are also being dropped onto kid’s charts). The parent generally will retain the right to decline treatment, but the school may say that the child cannot attend untreated, and failure to have your children attend school can cause one to lose custody.

Not that schoolteachers and administrators have it easy. A few disruptive kids can make it nigh impossible to conduct classes. Even if the treatments available for disruptive behavior may not be magic bullets or wonder drugs for the disruptive kids themselves, it is tempting to praise them for making it possible for the other kids to experience the classroom as a classroom rather than an arena or a zoo.

But all these hard places and difficult situations pale before what the child must face: you don’t get to say “no” to going to school, you have no choice; and whether it’s due to your dislike for being there or for some other reason (including, for the sake of argument, a tendency for your mind to maintain a different chemistry or synaptic pattern or something), if your behavior disturbs others there and you get told that you have to take medications that change the way your brain works, you have no choice about that either. You don’t get to say “No thanks, I’d rather stay home”.

Og knows I sure got beaten up by a few bullies, and badly taunted and humiliated, for a dozen years’ worth of school, and I’d like to see something done to stop it.

But I don’t like the looks of this.

162

[sup]EMPHASIS ADDED[/sup]

[sup]EMPHASIS ADDED[/sup]

Hentor, this is what my “muscle tic” comment is directed at. I feel that DSeid is completely justified in being concerned about the “pressure to pathologize.” While I fully understand the need to identify and label behavior types, I remain extremely disturbed by established medicine’s propensity for pigeonholing behavioral disorders without necessarily supporting the most effective treatments for them (i.e., promotion of therapy over medication). Again, I comprehend that disorders must be identified before they can be adequately treated. I just remain skeptical about what those treatments sometimes are.

Hentor, if you have the time, would you please expand upon the various drugs you mentioned that are being investigated for treatment of ODD and CD? I’m curious as to their main route of effectiveness, what symptoms they alleviate, their side effects and how they achieve their desired ends. I’d appreciate it a lot. Please understand that I do not in any way belittle your own efforts at reducing your patients’ suffering.

163

** I’ve never claimed that you claimed the system was perfect. Stop insisting that I have!

Although much of medicine isn’t actually scientific, it is rapidly becoming more so. In many cases, it is possible to objectively evaluate the accuracy of diagnostic systems – there are objective standards for whether a condition is present because there are objective definitions for that condition.

Since it has become clear that many people in this thread don’t understand science or statistics, I’ll make this absolutely clear. A false positive occurs when a standard falsely identifies a presented condition as belong a specified category. A false negative occurs when a standard incorrect identifies as presented condition as NOT belonging to a specified category. These are called Type 1 and Type 2 errors, respectively.

We can determine the margin of error in several ways: by applying the standards to known cases, and by watching how cases identified with the standard develop over time. For example, imagine we’ve developed a blood test for a certain type of cancer. To test how effective it is, we might obtain samples from cancerous and healthy people and see how often the standard is wrong. We might also observe people tested and see whether they develop cancer over time.

In psychology, there are no objective tests. That’s because there are no objective definitions for psychiatric conditions. The ultimate standard for the conditions isn’t an objective reality which we have limited tools for observing, but the opinions of human beings. The conditions (by which I mean the diagnostic categories) exist only because the psychological community agrees they exist.

We can argue about the degree to which diagnostic criteria for measles or skin cancers are accurate, but we have no way to argue about the diagnostic criteria for depression or schizophrenia because we have no way to evaluate them.

164

In addition to the lack of objective tests that TVAA mentions (i.e., the “lack of a ‘serum schizophrenase test’ problem”), whereby the distinction between symptom and cause is elided, there’s also a problem that does not necessarily appear just because of the lack of objective tests but is a problem with psychiatric diagnostic categories:

If you take a patient who has all the classic symptoms of Alzheimer’s syndrome and have an evaluation performed by one physician, then bring the same patient to another doctor who has no awareness of the diagnoses given by the first physician, and have the second doctor do an evaluation, and then you follow up by bringing a person of comparable age who does not have Alzheimer’s and repeating the process, you tend to get really good overlap – even without a core sample of the brain showing fiber tangles.

Apparently, if you do this type of experiment with people with regards to psychiatric diagnoses, the overlap reliability kind of sucks.

165

Bingo.

In addition, the supposed “standards” of the DSM are more like the recipe I posted earlier: give them to ten different people and let them reach their conclusions independently, and you’ll have ten different diagnoses.

Admittedly, this is an inevitable problem in medicine, even when there are highly accurate and objective tests that can be performed. But it’s really, really bad in psychiatry.

The fact of the matter is that the standards that are actually used aren’t derivable from the DSM. They have to be learned implicitly – spending enough time comparing your conclusions to others, and learning which patients are “actually” schizophrenic and which are “actually” depressed and which are “actually” paranoid, etc., is necessary.

166

Fascinating. I’d love to read about that study. Do you have a cite?

Zenster, I do not prescribe medications. I am not the best to describe mechanisms of action of medications. I am sure that you can find literature regarding those medications, their side effects, and their mechanisms of action on-line with very little effort.

TVAA, I grow less impressed with your understanding of science by the post. I also tire of your games about what you are saying versus implying versus rhetorically presenting. Furthermore, in all your repeated ranting about having an objective referent, you seem ill-prepared to give one yourself. I still await the asked for cites for your old assertions, let alone your repetitions here.

167

Cites? Try the DSM, editions I-IV.

There isn’t a single operational definition in them.

There are plenty of conditions that don’t exist unless the patient himself feels they’re a problem. There are plenty of conditions whose defining criteria refer to vague and indefinite value judgments. Then there are a few whose major symptoms are objectively verifiable – at least, they don’t involve such obvious subjectivity. After all, it’s quite clear if a person hears voices and has hallucinations, holds odd beliefs without evidence, etc.

Unless of course they belong to a religious community, or display beliefs and behaviors common to another culture. Then they’re not pathological at all. Of course, then we run into the question of what a “genuine” religious tradition or culture is.

Oops, there’s that subjectivity again!

The fact of the matter is that the vast majority of psychiatric conditions have no known cause, no distinct physiological abnormalities, and no non-symptomatic treatments. This is by definition: conditions whose causes and physical symptoms are known are within the field of neurology, not psychology.

Drop the “you don’t understand science” line. I’m reasonably certain that I’m more familiar with the philosophy and application of science than the majority of posters to this board, including you.

Even a rudimentary study of the history of psychiatry and psychology demonstrates that there have been countless attempts to understand mental illness by an appeal to known psychological and physiological forces – and they’ve all failed. Time after time, people are convinced that they’re found the one true explanation, and been shot down by the evidence.

168

Look, Vorlon. I apologize for my testiness. I have fatigued of this debate, in which I have engaged for several years with you, from the Snopes board to here. In fact, it seemed that the DSM discussion you were last involved in there drove you from that board, although I could be wrong. Frankly, your mastery of science is simply well below what you wish it to be or to appear. (For example, consider the definition of “operational definition.” But I digress…)

The fact is, you are simply full of opinion about what the problem with psychiatry, psychology and the mental health nomencature is. However, your opinion appears to be informed by viewing films such as One Flew Over the Cuckoo’s Nest and scanning the web for lay discussions on the topic rather than on any scientific investigation of the matter. Where you might raise valid points, you instead attempt sweeping indictments, nearly always washing across disciplines, disorders, referents and arguments. Where you might make useful contributions, you seem incapable of doing so, coming across as a zealot rather than someone informed in matters of scientific inquiry and process.

In short, I pity you. I mean that sincerely.

If you wish to talk about specifics, provide some point of reference, some evidence (other than “Cites? See the DSM!”) Provide evidence of a lack of reliability for disorders. You assert that 10 people would see 10 different things - back it up. Surely you have based your opinions on a scientific review of the evidence. Don’t be shy, share it with us! Blind us with scientific practice, don’t try to baffle us with bullshit. If you want us to believe that you are a master of science, be empirical - show us, don’t tell us. Surely the core of your mastery of science tells you that dissemination of information is the key aspect of any scientific endeavor.

Before you do anything, however, please give me the friggin’ but long anticipated cites for your assertion that the method of diagnosing ADHD was ever administering a stimulant.

Your opinion on its own is dubious and suspect.

169

Amen ** Hentor**.

170

I already provided such a cite in the ADHD thread. You posted after me – I presumed you read it?

I don’t think you actually understand what an “operational definition” is, Hentor.

171

Does this ring a bell?

How many times do I need to post this cite before you read it?

I am beginning to doubt whether you’re being honest with us, Hentor. General physicians with less than ten years of experience might not be expected to know that the response to stimulants was once considered a diagnostic property of ADHD, but physicians who’ve been around longer than that have no such excuse.

172

TVAA,

There you go again …

“Since it has become clear that many people in this thread don’t understand science or statistics…”

“I’m reasonably certain that I’m more familiar with the philosophy and application of science than the majority of posters to this board …”

Having read what other people have posted on these boards, I’m reasonably certain that you do not.

You seem to be persistently confused as to the differences between science as a means of forming models of how the world works and as a tool for making predictions, and clinical diagnosis, and the appropriate place, utility, and limits of lab testing in a diagnostic process. These could be interesting threads in and of their own but most pertinent to this discussion is your obstinance in confusing the limits of a current measuring device with whether or not an approach is scientific.

Zenster,

Your skepticism about treatment is indeed scientific. For some treatments the evidence is quite solid, stimulants for ADD for example. For others the evidence is quite weak as clinicians jump on bandwagons on the basis of pharma sales literature or small anecdotal experiences. Clinical use and scientific research are not always the same thing.

173

** Lab work is only an example of an empirical measure, DSeid.

We can make any number of categorical distinctions we wish, but categories are only valid if they allow us to make meaningful distinctions between states. I am not claiming that since our ability to study the brain is limited, medical claims about the nature of potential brain disorders are invalid. I am claiming that many of the commonly-repeated claims about mental illnesses have no basis in current knowledge, and the standards by which these conditions are defined are not in themselves scientific. I don’t know what arguments you’ve been reading, but you’ve missed my point completely.

Our ability to identify the causes of many medical conditions has taught us two important facts:

One: a single disease or condition can sometimes present in many different ways, and although symptoms can be an effective means of diagnosing the underlying cause, this isn’t always the case.

Two: seemingly similar symptoms can have completely different causes. The common cold isn’t one condition, but a host of distinct but symptomatically similar viral infections.

Actual neurological conditions can be asymptomatic. Mental illnesses cannot be – they’re defined in terms of their symptoms. No symptoms, no condition.

174

I have read that one, twice now. Tell me where it says that giving a stimulant was the method of diagnosing ADHD. In fact, it doesn’t.

The entire DSM consists of operational definitions. Each and every DSM diagnosis is an operational definitions. But perhaps my understanding of “operational definition” is deficient. I take it to mean the procedure or method for measuring a construct. As such, each diagnosis is in fact the procedure for measuring a construct - x number of criteria met during y period of time. This is different than the concept of objective measurement - no doubt about that. But operational definitions they very much are. This, by the way, is rudimentary science. Perhaps, however, you can help to educate me by explaining what an operational definition really is.

You radiant much heat, and very little light.

175

In all fairness Hentor,

The article states that the paradoxical response was diagnostic.

176

Well now, then let’s get to the specifics.

Which claims do you believe have been “commonly-repeated” that have “no basis”?

My read of your posts is that you have been stating things as “commonly-repeated” that the real psychological research community does not as a whole endorse. So be very specific here please and substantiate your claims.

And with full acknowledgement of the limits of the DSM as a tool, I will defend the process as scientific. Science is the process of observation of patterns that travel together in the search for predictability and in the service of the attempt to form more accurate models. Use of a standard vocabulary is a needed tool for such an effort within a community of researchers. A tool may be in need of improvement and still be used to good effect in scientific study. As long as resarchers appreciate the limits of their tools. In the effort models and tools are refined. If scientific study waited until the perfect tool existed before commencing study then improved tools would never be created and study would never commence.

And please don’t lecture me about how medicine works. You get a bit confused as you do it. Etiology and disease are not the same thing. They can be but are not always. So to use your medical model analogy: hypertension. Is an identifiable medical condition defined by certain levels of blood prssure in different age groups. Levels picked somewhat arbitrarily by percentiles and by long term risks for complications. Some things about hypertension are similar no matter what the etiology and it is worth study and those with hypertension are worth identifying and treating. For some we can identify a particular etiology: renal artery stenosis, coarctation, a disrder of various hormones or other messengers. For many we have no idea why they are hypertensive. We call them idiopathic or essential hypertension. But we know that it is risk of long tyerm harm and that we can prevent the harm by reducing the symptom and that various approaches have various degrees of success at doing so. Is the study of hypertension unscientific? How about hypercholesterolemia? There are some who have high cholesterol because of identifiable defects in cholesterol management, others just have the symptom, high cholesterol as defined by an arbirtray level chosen because of its association with adverse outcomes … is its study unscientific?

177

Oh my! My apologies Vorlon! I read that over twice and did not see that clause. Because of this, I went back to the DSM-IV, DSM-III-R and DSM-III, as well as the ICD-10. I cannot find any statement in these that indicates that response to stimulant is part of the diagnosis. Given that I missed it in your quote, I will re-read these again to try to make sure I didn’t miss anything.

Do you know where the authors of the website got support for their statement? Do you at least have an idea what time period they are referring to?

178

** The criteria are not operational. I can interpret standards that refer to measurements, clearly defined categories, but the DSM criteria reference abstractions that are highly subjective and NOT well defined.

An operational definition is one that specifies the logical mechanism by which its referent is identified. For example, a pattern of responses on the Beck Depression Inventory can be used as an operational definition of depression. In a study, when the researchers are questioned as to how they knew their subjects were “really” depressed, they could respond “we used this method to identify depression”.

The DSM definitions aren’t capable of this. They do not refer to well-defined concepts: how can we determine whether someone is having “clinically significant” problems? What algorithm is being referenced here?

Have you considered the possibility that you’re blind?

179

** That mental illnesses are well-defined and specific diseases of the brain whose treatments are tailored to known underlying problems.

Essentially, everything the public at large is told about conditions like schizophrenia, depression, manic depression, the personality disorders, etc.

You want examples? Watch television, pick up a few magazines, look at NAMI’s webpage. There are too many to count.

** Sometimes they don’t, which is the whole problem.

The world can considered to consist of an arbitrary number of phenomena that fit into an arbitrary number of categories. A category is only useful if it represents a meaningful distinction: if it doesn’t reflect an underlying pattern in the world, it’s not valuable to us.

The categories used by the psychiatric profession are extremely arbitrary, and there’s no particular reason to regard them as reflecting any kind of underlying reality.

First, can we measure blood pressure? Can we clearly define what we mean by the “negative effects” of hypertension, and analyze the correlation between hypertension and the risk of these effects? Can we look at the underlying causes of the hypertension and treat them appropriately? Can we examine our definition of hypertension objectively and realistically, and approach it as evidence suggests it is (not a discrete condition but a relative one)?

Yes, on all counts.

Can we do any of these things with any mental illnesses?

180

Thank you for understanding the basis of my concerns, DSeid. While not entirely germane to the current discussion, the previous and massive overprescription of powerful drugs like Valium and (especially) Prozac gives me substantial pause as I see other new categories of behavioral disorder evolve. I cannot help but wonder what the downstream ramifications of such routine and powerful alterations in brain chemistry will be.