in Specific psychiatric disorders, Thinking about psychiatry

ADHD, Pamela Stephenson Connolly and what are psychiatrists for?


Frontier Psychiatrist has just been on holiday to the Outer Hebrides.  Anyone who reads this blog will know that I am a devotee of theguardian newspaper.  I normally read this online, but as a holiday treat whilst on the Isle of Harris-North Uist ferry I was reading a printed copy.  A normally relaxed gentleman, upon reading this article by Pamela Stephenson Connolly I came close to leaving the comfort of the ferry cabin to go onto the deck and shake my fist at the waves.

Stephenson Connolly writes a column for theguardian’s G2 section on a regular basis as a sort of sexual agony aunt.  Here was this week’s question:

‘My boyfriend is an outgoing type, always the life of the party. Even when we’re alone he wants to joke around. I love him, and sex with him is satisfying when we finish what we start. However, when we’re making love he is easily distracted. It could be the sound of someone moving around in the next flat, or noise outside, but pretty soon he loses his erection. Is this normal? How can I keep his mind on the job?’

To which Stephenson Connolly, ‘a clinical psychologist and psychotherapist who specialises in treating sexual disorders’, replies:

‘It is "normal" – for someone whose brain is wired in such a way that paying attention to one thing at a time is challenging. Your boyfriend may have Attention Deficit Hyperactivity Disorder (ADHD), meaning that he has difficulty filtering out sounds and other stimuli that are competing for his attention.

Don’t take it personally.

You should suggest he be evaluated and treated for ADHD, while remembering that he is probably a bright and creative person, who could do with your help in staying on-task.

Imagine what it’s like to be inside his head. Think carefully about your lovemaking environment and create a place with a minimum of stimuli. Consider darkening the room, eliminating telephones and TV and even installing sound-proofing or using noise-cancelling headphones. If thoughts begin to distract him, encourage him to let you know so you can help to bring him back with your voice, touch or whatever else may work. You will need to experiment a bit. Praise and reward his efforts to stay focused – you will reap the benefits.’

Although she almost says something sensible at the end, it’s hard to believe that someone who claims the expertise of Stephenson Connolly could write something like this (budding psychiatrists, write down your own reasons for Stephenson Connolly’s idiocy and then read the rest of the article – if you can think of any that I don’t mention then please add a comment).

(Those not familiar with ADHD could read this before continuing)

Stephenson Connolly is suggesting a diagnosis of ADHD on extremely flimsy evidence even for a newspaper column.  She should know that ADHD diagnostic guidelines  suggest that symptoms applicable to this sort of diagnosis should be present in  more than one situation, for instance at home and at school.  Our man has his distractability in only one very specific situation.  She should also know that distractability, which is the only symptom mentioned in the ‘letter’, is far from the only symptoms shown by ADHD sufferers.  ‘Always joking around’ hardly counts; what about disinhibition in social relationships, recklessness in situations involving some danger, and flouting of social rules, to name but three?  ADHD can be diagnosed de novo in adulthood, but she should at least mention the possibility of childhood symptoms.

But let’s be charitable and assume that, although unlikely, ADHD is a possibility here.  It’s certainly a Zebra:

Zebra (noun): a very unlikely diagnosis where a more common disease would be more likely to cause a patient’s symptoms – from the common admonition that "if you hear hoofbeats, think horses, not zebras"

Is it not rather more likely that the reason that this man is unable to complete sex with his girlfriend because he isn’t very sexually interested in her in the first place?  Or maybe he’s homosexual?  Is not Stephenson Connolly guilty of grossly medicalizing what is in fact a social problem? Why bring in mental health at all?  

Sometimes after days spent sorting out my patients’ housing problems or imparting common sense where seemingly there is none, I sometimes wonder what psychiatrists are for – but here’s one of the reasons, stopping people who don’t know what they’re talking about, but have a shiny new textbook and an over zealous approach, giving patients potentially stigmatizing diagnostic labels on very limited evidence.

Further reading:

Adult attention-deficit hyperactivity disorder: recognition and treatment in general adult psychiatry Asherson et al BJP (2007) 190: 4-5

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  1. I don’t know… I was diagnosed with adult ADHD and I have trouble concentrating during sex—to the point that often frustrates my husband. Yeah, it may not be ADHD and it could be any other number of things, but if the chief complaint is about him losing attention during sex (she said the rest of the relationship was going well), who’s to assume it’s NOT ADHD. Just my opinion, I’m no psychiatrist.

  2. I guess that the point is that there has to be more than one symptom present in order for a genuine diagnosis of ADHD to be made. Presumably as there are no more symptoms mentioned, it doesn’t fit the diagnostic criteria, therefore it’s not ADHD.

    I personally dislike the woman because when I worked as a waitress at the Hilton in Glasgow one summer she ordered room service and I took it to her. NO TIP!!! She clearly is a rubbish psychologist, because she must have known that this behaviour would cause me to go back to the kitchen and tell the rest of the staff about her diagnosis of Tight Fistedness – and should have known that this in turn may have had a very negative effect on the quality of her next meal…… :>

  3. Get off your high horse before you fall and hurt yourself !! Pamela’s advice is in a bloody newspaper, for God’s sake. It is FICTION, not to be taken seriously (just like the rest of the bloody rag). The primary take home message is that (if) there is a problem, then investigate. You , of all people, should realise that ADHD is a diagnosis of exclusion. During this process other causes of erectile disfunction will (if investigated by a competent GP, necessary for a referral to a Psych) be assessed and their relevancy evaluated.
    What is clear from your article is that you wouldn’t recognise ADHD if it was serves on your plate for breakfast.
    If anyone is touting Zebras, it is yourself.
    ADHD is dimensional, not categorical. One can have crippling ADHD traits with no possibility of a diagnosis under DSM IV constraints.

  4. Some interesting comments, and an interesting insight into PSC’s diet when she was once in Glasgow. Incidentally, I was in that city last weekend and had to ask to be provided with a different room than that initially given to me in the Travelodge as there were blood stains on the curtains and the bed, and bite marks on the TV controller….

    To set it out succinctly, my position on the G2 column is this:

    It is possible that someone who is distractible during sex has ADHD. However other reasons for a lack of interest in sex should be investigated first.

    The article does not properly recognise the myriad of possible causes for this man’s behaviour. It also does not mention that ADHD type symptoms should be evident in other aspects of this man’s behaviour.

    I grant that this is a just a newspaper article, but people are very influenced by such things that people offering expert advice via this medium have a responsibility to be measured in what they say. Someone who has a similar problem with their partner during sex may now be very worried that their partner has an incurable mental health problem, when in fact the actual situation is quite different.

    April: no decent doctor would assume that a patient in this situation didn’t have ADHD – they’d have a long chat with (ideally) both parties and try and try to narrow down the possibilities. However if the person in the article were to go to their GP and say ‘my partner can’t concentrate during sex therefore I’d like him assessed for ADHD’ then their doctor would try to examine the reasons for their concerns and whether the problem could be to do with something else. PSC has concentrated on a single possible cause for the problem stated and I do not think this appropriate.

    Calochilus: to my reading PSC’s column is not presented as fiction and if the advice in response is also a fiction then what is the point of printing it? ADHD is not a diagnosis of exclusion – you cannot ask people about all the other reasons why they may be having such trouble with sex and then if they don’t have those then they’ve got ADHD.

    I accept that ADHD traits are dimensional – we all have different levels of available concentration etc – but as far as ICD-10 and DSMIV are concerned ADHD is a categorical diagnosis, in that you either have it or you do not. I’d be genuinely interested to know about the experiences of people who have ADHD traits but are ineligible for a diagnosis of ADHD – are they diagnosed with something else, or do they feel misunderstood by psychiatrists?

    Do please try and be civil.

  5. Oh dear, I can only hope that the accomodation in the islands was more civilised. The Hebrides are lovely, I’m very jealous. My granny came from Orkney which is a lovely island too, but my favourite has to by Skye – the Cuillins are lovely for walking and climbing. There are some great campsites too…which dispenses with the need to worry about having your shots up to date before you bed down for the night :>

  6. I have knowledge of PSC in two areas. Firstly as the woman in Superman (a sterling performance) and secondly in her car crash tv programme Shrink Rap.
    I have watched Shrink Rap on a couple of occasions. I liken it to having an extraction at the dentist and then feeling compelled to stick your tongue in the hole, knowing fine well that you will find it repugnant.
    My personal favourite/worst was when she sought to analyse Stephen Fry. I love Stephen Fry. Were it not for the fact that he is gay and that we have never met, and that I am married, I would very much like to marry him.
    Anyway, I digress..I found it to be one of the most excruciating pieces of television that I have witnessed to date (except for when Judy Finnegans cans escaped at the TV awards). She tried to analyse him. She failed. His far superior intelligence levels bamboozled her and left her looking foolish.

    I therefore err on the side of FP being right and correct.

  7. Many professionals have reason to criticise Pamela Connelly for this rather idiotic attempt at diagnosis / formulation.

    It’s people like her that give clinical psychology a bad name, but psychiatrists are far from immune from equivalent ignorance (Stuttaford anyone?).

    So rather than “what psychiatrists are for” perhaps “what competent, intelligent, ethical practitioners are for”, no?

  8. Oh, and she deserves even stronger condemnation for the awful mess she’s made of Billy Connelly. Have you read her biography of him? Cringe….

  9. You set out by making a provocative statement. I am provoked !!
    I reiterate , under the laws of defamation, no self-respecting newspaper will print a factual story which could identify ordinary individuals in a light which may be construed as defamatory(Public interest or should that be prurience). There may be a kernel of truth. If, as you infer, you are a competent and practicing psychiatrist, you will admit that this couple of paragraphs may have been distilled from several hours of agonising history taking , which , hopefully, would have run into many pages of cryptic notes. If it is just a random letter to PSC as an “agony aunt” then there are no reasons to assume it is not fiction(ask Pamela). You also appear to have little appreciation of newspaper practice in editing and sub-editing where the copy is cut to the bone, frequently omitting not only salient points but also critical points.Thus, the answer, superficial and brief, is also a fiction.( You appear to fall into the trap that newspapers and television are meant to inform rather than to entertain)
    As for a diagnosis of exclusion, you need to listen to what is actually happening in the wide world of Adult ADHD, where a formal diagnosis and effective treatment often take many years to achieve by reason of comorbidity diagnosis excluding the truth and red herring interventions with useless and counter-productive drugs inhibiting meaningful progress. The insistence tht SSRI’s are a first line of treatment is one of the more notable observations. The correlation between erectile dysfunction and distress in ADHD male patients should not be overlooked as a catastrophic consequence of inappropriate intervention( particularly in those with comorbid Asperger traits).See the PLoS articles on SSRI’s.
    If you cannot accept the mutual incompatibility of a categorical diagnosis of dimensional traits then you seem to have missed the bus. The reality of this problem is in the interpretation by individual psychiatrists, of levels of impairment, where severe impairment in one setting only is not seen as sufficient to allow prescription of appropriate intervention if the level of impairment in other settings is of a minor nature. This may and does have catastrophic consequences for in reality, the expression of ADHD behavioural traits is significantly setting dependent.
    If you have a genuine interest in understanding the dilemmas facing adults with ADHD then may I respectfully suggest that you approach a local ADHD Support Group and offer to sit on their Board of Management as a listener rather than as a pontificator and I suspect you will be horrified at the nature and scale of the problems that pass across their table. As examples, a psychiatrist who will not see ADHD patients and has called police to remove adult patients who enquired about ADHD, a psychiatrist who will not see patients with beards and suggests to female patients that if their spouses are bearded then separation is the road to recovery, a psychiatrist who will not diagnose adult ADHD but remarks how well they do on Ritalin, a psychiatrist who insists that female patients completely disrobe before he will assess their ADHD status and these are some of the more competent ones.
    I happen to live in a jurisdiction where , in order to obtain stimulant medication, one needs two independent diagnoses, from a neurologist and a psychiatrist or two psychiatrists. It is little wonder that, in order to facilitate effective treatment , patients travel up to 1000 kilometres to seek professional help in a jurisdiction that requires only a single opinion.
    You will also have to acknowledge that, as a group, psychiatric patients are the least likely to stand up for their rights, file official complaints (especially ADHD patients) and to take civil action against offending practitioners. The game is not worth the candle.


    Thanks for your long comment.

    I’m aware that newspapers print made up questions for their advice columns. My point is that this is presented to us as a realistic, albeit oversimplified, scenario, and by asking a qualified person to address it then the paper is providing advice by which people may be influenced. I make two points about what she writes:

    1. On the information presented, a diagnosis of ADHD is not the most appropriate first stab at a diagnosis. There are other possible scenarios that should be highlighted first, before reaching for ICD-10 or DSM-IV.

    2. By jumping straight in with a diagnosis of a mental health problem she is medicalizing a problem that may not be medical problem at all and by this being printed in a national newspaper this will encourage other people to do likewise.

    That’s it. I’m not saying anything else. I’m not talking about real world diagnosing of ADHD and the problems with this. I believe that we’re both interpreting the definition ‘diagnosis of exclusion’ differently; I’m using it in the sense of physical medicine, where something relatively benign like irritable bowel syndrome is diagnosed when all other reasonable possibilities have been excluded. I think your experience of it is that as a psychiatric diagnosis ADHD is settled upon when other ones don’t seem to fit – that’s a bit different.

    I don’t doubt that it’s difficult to have ADHD and the experiences you relate regarding this run from the unpleasant to the criminal. The things about which you write should not be tolerated. But by saying that you shouldn’t suggest a diagnosis of ADHD on flimsy evidence I’m not saying anything about this. You’re right to say that taken as a group people with mental health problems get a raw deal, but again in saying that talking about diagnosing of them should be approached carefully I do not set out to diminish this in anyway.


  11. “I think your experience of it is that as a psychiatric diagnosis ADHD is settled upon when other ones don’t seem to fit – that’s a bit different.”
    On the contrary. Psychiatrists will go to inhuman lengths to avoid a diagnosis of ADHD in adults.

  12. Why do you think we are prepared to go to such lengths?

  13. What worries me about PSC’s diagnosis is not whether it is correct (for she may have a longer letter to go on than is published) but the impression it gives that such a diagnosis can be made on the basis of so little information.

    Further, I don’t think it matters whether the letter was genuine or made up: what matters is that the advice is offered as genuine. Whilst some people read advice columns purely for entertainment, I believe that many people read them for information and guidance.

    Thus, I think that it is entirely probable that there are now a number of people that think that wandering concentration during sexual activity plus being the life of the party and a bit of a joker is enough to diagnose a mental disorder.

    No wonder so many people appear to think that many of us with mental disorders are putting it on when the impression is given so often in the media that such little information is sufficient to diagnose a mental disorder.

  14. “Why do you think we are prepared to go to such lengths?”
    I was tempted to give you the opportunity to explain but your prior statement would preclude such.
    Do you want an explanation at the level of the individual?
    Some are luddites such as the venerated Fred Baughman
    “In 1948, ‘neuropsychiatry’ was divided into ‘neurology,’ dealing with organic/physical diseases of the brain, and ‘psychiatry,’ dealing with emotional/behavioral conditions in normal human beings [1]. There was no such thing as a psychiatric ‘disease’ then, and there is no such thing today!”
    Of course there are various flavours of luddites but I won’t digress.
    Others are clearly psychopaths such as Harry Bailey who suicided rather than face a commission of enquiry into his activities (triggered by the Church of Scientology)
    Others are what I would term “functionally illiterate” such as a recent President of the local branch of the national Medical Association who proclaimed that as it wasn’t taught at medical school it was a figment.
    Others are just bone lazy and yet others are well intentioned but totally incompetent
    Doubtless there are a great many good practitioners out there also.Finding them by orthodox means is difficult.
    You may wish to look at institutional difficulties.
    “Bridget Grant, Ph.D., Chief of NIAAA’s Laboratory of Biometry and Epidemiology, and her colleagues found that 1-year incidence rates were highest for DSM-IV alcohol dependence (1.70%), alcohol abuse (1.02%), major depressive disorder (1.51%) and generalized anxiety disorder (1.12%), followed by panic disorder (0.62%), bipolar I disorder (0.53%) and specific phobia (0.44%). One-year incidence rates of DSM-IV social phobia (0.32%), bipolar II (0.21%) and drug abuse (0.28%) and drug dependence (0.32%) were lower but not insignificant. These rates are comparable to or exceed corresponding incidence rates for other common medical diseases such as lung cancer (0.06%), stroke (0.45%) and cardiovascular disease (1.5%”
    Interestingly, not a mention of ADHD, yet any astute researcher or practitioner would be aware of the significance of many of these problems as highly significant comorbidities of (especially untreated) ADHD
    I could go on ad infinitum but one last question. The esitmated incidence of lifetime ADHD has reliably been suggested to be in the order of as much as 4% of the population. If it is so high, why is it that this incidence is not reflected in diagnostic rates given the frequency of diagnoses of derived comorbidities?

  15. Might even not be “HER” whom has written it in the first place. A team of writers trained in giving a “General” over-all diagnosis. Either way a very, very niieve piece of advise. It’s like saying “Pam I don’t like pineapple on pizza…” A response just as silly would be; “You must have taste-bud deficiancy syndrome. Try making it dark in the kitchen the next time you and the pineapple are trying….Other than that I’m fucked if I know anything else about the subject”

  16. She only suggested that the fellow be TESTED for ADHD. She didn’t say he necessarily had it. Yeah, she could have mentioned other possibilities, but I think it’s a perfectly fair suggestion to consider testing.