Nathan Shachar and ADHD Denialism

Nathan Shachar is a Swedish author and editorial columnist at a large Swedish newspaper called Dagens Nyheter. For his essay writings on South America, he was awarded the Gerard Bonnier’s prize in 1998. He is also a long-time proponent of anti-psychiatry, claiming that the entire category of breathing-related sleep disorders is nothing more than an attempt to pathologize snoring. In reality, it includes conditions ranging from chronic snoring to obstructive sleep apnea. On top of this, he states that opposing structural sexism and racism in society is akin to “living in a temple of orthodoxy” and “bullying dissidents”. Needless to say, he has a history of playing fast and loose with empirical evidence and rational thinking.

His recent opinion piece promoting ADHD denialism in the Swedish newspaper Östgöta Correspondenten is no exception. He regurgitates many of the classic anti-psychiatry conspiracy theories about psychiatrists being shills for evil pharmaceutical companies and claims that the media and the school system have been “seduced by the siren song of the medicine men”. His choice of phrasing betrays a deep mistrust and contempt for psychiatry. Throughout his article, he presents six different false and/or misleading statements. He claims that the mainstream scientific model for ADHD is “circular” and “contradicts all scientific logic” because it attempts to go from symptoms to causal processes. He apparently does not understanding that this is the general case with any medical condition, whether psychiatric condition, autoimmune or infectious disease. He grossly misrepresents a report from the Swedish Council on Health Technology Assessment (SBU), spreads fear mongering about the side-effects of ADHD medications, ignores research on executive function in ADHD and references a medical doctor who has never published anything on ADHD in the scientific literature.

There is nothing wrong with using knowledge about symptoms to research causes

Shachar complains about the practice of researching causes of ADHD by using knowledge about symptoms. He thinks this is a fundamentally flawed approach, even going so far to call it “circular” and claim that it “contradicts all scientific logic”. However, this is not a flawed approach at all. In fact, it is an almost universal feature of medical research. Throughout history, the symptoms have almost always been noticed first and then the contributing causes have been identified. Plague was known before Yersinia pestis, rheumatoid arthritis (RA) was known before the genetic risk factors associated with RA was identified and so on. This is neither circular nor does it contradict “scientific logic”.

SBU supports current practice on ADHD diagnosis

The Swedish Council on Health Technology Assessment (SBU), roughly equivalent to the U. S. Institute of Medicine, released a report in early 2012 dealing with diagnosing and treating ADHD and autism spectrum conditions. They concluded that using a single rating scale alone was problematic due to low reliability, but they supported the current practice of using multiple rating scales coupled with a clinical investigation (p. 26):

The diagnosis of children and young adults with ADHD is today carried out with the aid of several different rating scales, which each by themselves alone lacking scientific evidence. The rating scales are filled out by parents, teachers and the young adult it pertains to. We have not evaluated how the weighting between these different informants look. To make the diagnosis today, it requires additionally a clinical evaluation and an evaluation of the level of disability in the child/adult.

In conclusions, the results show that none of the diagnostic tests that have been evaluated can be used by itself to make the ADHD diagnosis. Instead, this report supports the current practice, that the foundation for the diagnosis is the clinical evaluation and that the diagnostic tests for ADHD should be used as a basis for the gathering of information that is then evaluated by the clinician.

Shachar butchers this report and claims that it show that none of the diagnostic criteria for ADHD is based on scientific evidence. In reality, the SBU report supports the current practice of clinical evaluations together with multiple rating scales is used to make an ADHD diagnosis. In other words, Shachar twisted an already fallacious quote out of context to mean something entirely different.

Fear mongering about side-effects ADHD medication

Like many anti-medicine quacks, Shachar trouts out what he believes are side-effects of ADHD medication: desensitization, personality changes, changes in body weight and even bipolar disorder. In reality, the most common side-effects of methylphenidate includes faster heartbeat, chest pain, fever, join pain and rashes (Mayo Clinic, 2012a). It is also worth pointing out that reported side-effects are not the same as established side-effects. To reach that level, support from scientific studies need to be presented. So far, no study has shown that the proposed side-effects by Shachar are real.

Let us look at the claim about bipolar disorder in particular. Shachar specifically claims that some individuals who are diagnosed with bipolar disorder have previously been diagnosed with ADHD. He implies that this means that ADHD medication cause bipolar disorder. In reality, the symptoms of ADHD resemble those of bipolar disorder to a certain extent, so it is more likely that those rare individuals have their bipolar disorder misdiagnosed as ADHD (Mayo Clinic, 2012b).

Factors contributing to ADHD

Shachar claims that the “orthodox viewpoint” is that ADHD is a genetically caused disorder of the dopamine system. However, this is an oversimplification. Modern science considers ADHD a complex and heterogeneous condition that involves genetic risk factors, executive function deficits and social risk factors as well (Singh, 2008; Novella, ). By making a straw man out of the mainstream scientific position, Shachar has loaded the dice in favor of pseudoscientific ADHD denialism from the start.

Tomas Ljungberg’s “essential study”?

Shachar seems shocked that an “essential study” carried out by medical doctor Tomas Ljungberg (a docent in pharmacology at Karolinska Institutet in Stockholm) was not discussed at the ADHD day organized by the Swedish Society of Medicine. However, a quick pubmed search shows that this individual has not published any studies on ADHD. All three studies listed are about children with impaired language development. Shachar is presumably talking about a book called ADHD i nytt ljus (“ADHD in new light”). It is a self-published book via a front called “Exiris Förlag och Konsult AB” that has zero employees and is owned by Ljungberg himself. So why exactly should unpublished speculations be placed on the same table as evidence-based scientific knowledge?

Conclusion

Nathan Shachar dismisses mainstream scientific investigations of the causes of medical conditions and twist the results of an SBU report that actually supports the current practice of focusing on clinical evaluations and not the results of single rating scale in isolation. He fails to understand the heterogeneity of ADHD and falsely characterize the mainstream scientific account of the nature and causes of ADHD. He spreads fear and uncertainty about side-effects of ADHD medications by claiming that they cause bipolar disorder, when those few individuals with bipolar disorder with a history of ADHD diagnosis probably represents misdiagnoses. Shachar promotes the same old conspiracy theories and pharma shill gambit, even going so far as acting surprised when the Swedish Society of Medicine does not entertain self-published claims by a person who has done no ADHD research.

References

Mayo Clinic. (2012a). Methylphenidate (Oral Route). Accessed: 2013-10-12.

Mayo Clinic (2012b). Bipolar disorder: Risk factors. Accessed: 2013-10-12.

Novella, Steven. (2012). Responding to a Szaszian. Accessed: 2013-10-12.

Singh, Ilina. (2008). Beyond polemics: science and ethics of ADHD. Nat Rev Neurosci, 9(12), 957-964.