I'm thinking about this issue again because I've seen/will see several relevant patients last week and this one. Last week I saw a follow-up who described leaving stove burners on and getting into a car accident when she stopped her stimulant. She was really scatter-brained and hypertalkative. I almost believed her, and decided to give in and restart her stimulant. Then today I saw another follow-up who was started on a stimulant by another psychiatrist in our practice for what I believe are questionable reasons, but she's stable, not on a high dose, not doctor- or pharmacy-shopping, and not asking for an increase, so frankly it's just easier to continue it. And tomorrow I have a new patient on my schedule who's being referred by his PCP whom I can see in the chart he's been begging for stimulants because his alleged ADHD is impairing his job performance, and another follow-up I just saw a week ago, who actually called the office today and got himself on the schedule tomorrow after telling the MA he had a "panic attack all weekend" and that the doctor doesn't understand how dire his need for Ritalin is. (He's already on Klonopin.)
I was hedging my bets in the OP and being a little diplomatic, but I'll come out and say it: deep in my gut, I don't believe in ADHD at all, in children or adults. I think it's a completely fake and phony condition. People who supposedly have it simply lack self-discipline and need to try harder. The fact that people can concentrate better and work harder while on meth doesn't mean doctors should prescribe meth to people. But then, I know some people here will refer me to scholarly journal articles supposedly proving that ADHD exists. And I'll admit to being closed-minded. I don't want to even read those articles because I don't want to believe it.
But, because the medical community does accept ADHD, and I'm terrified of being accused of malpractice, I feel the need to play along to some degree.
Just look at the
DSM criteria for ADHD. They're so subjective, they're every bit as susceptible to the
Forer effect as a mother convinced her child is an
"Indigo child" because he
's "empathic, curious, and strong-willed" and "possesses a clear sense of self-definition and purpose." Give me a break. "often fails to give close attention to details or makes careless mistakes?" How often? How close? How careless? What kind of details? Everyone could give more attention to details or make fewer mistakes than they do. "often has difficulty sustaining attention in tasks or play activities?" Again, how often? How much difficulty? Difficulty implies the person is trying, but is unable to accomplish the task. But how do we know whether he's really trying? "is often forgetful in daily activities?" How often? We've all misplaced our keys, or went to the supermarket without a written list only to find upon arrival home with our 5 bags of groceries that we forgot to get the one thing we originally went to the store for. Heck, I can easily claim I meet these criteria. Just today, I didn't leave the office until almost 7PM, because I had a full schedule, got behind on finishing notes, got a bunch of patient calls and refill requests, and then at 5:00 after the last patient left, the office manager and I spent what seemed like forever trying to figure out how to get a prescription to print on the right printer--and so, I was so stressed after all that that I wound up surfing the internet for half an hour before finishing my notes, even though I wanted to get out of there. Should I claim I have ADHD because I failed to just hustle and finish my notes and leave? Did I "need" Adderall to make myself not surf the internet for half an hour? No, I could have just done it. I simply didn't make myself.
Not all of the psychological testing is like that. It also frequently includes neuropsychological testing that is hard to fake and has built-in measures to detect malingering: the T.O.V.A, the Conners Continuous Performance Test, the WAIS (for various reasons), various other Weschler memory scales, etc. Also, a lot of the time, the psychologist will ask the patient for report cards from childhood, accounts from parents, etc, since ADHD impairment must be obvious from childhood for the diagnosis to be valid. This all has at least a little theoretical backing from the literature, but it is also partially to try to weed out malingerers, in my opinion.
Weeding out malingerers would be great, but honestly I'm not even that concerned about malingering in most of these people. I don't get the impression most of them just want to get high off stimulants, or gain a leg up over their classmates on the bell curve, or sell the meds on the street, or whatever. I think they genuinely are like I was this afternoon--surfing the internet for half an hour before finishing their work, then getting ticked off at themselves for not making themselves finish it sooner so they could GTFO--and they feel there must be something wrong with them. If they've tried a stimulant and it "helped," that strengthens their suspicion. I think they read that subjective list of ADHD criteria, see themselves in them, and want relief. They want to be less lazy or lackadaisical and more like that type-A coworker they have who seems to have it all together. Even the guy I mentioned above who "needs" Ritalin despite paradoxically being on Klonopin, I don't get the vibe of an abuser from him. I think he's just a scatterbrained guy with a bunch of nonspecific symptoms who wants to just throw meds at them until he finds the right combination to help himself calm down and stay focused. Everyone would like to be able to concentrate better and work more effectively. But the psychiatric profession has created this named and identified "illness" which people can then identify with and feel as though they have an "answer"--and stimulants are a very effective treatment for this "illness." As MacDonaldTriad said in that thread birchswing linked, how many illnesses can you name where patients get angry at you when you tell them they don’t have that illness?
You might not be aware, but there was a flood of news reporting on adult ADHD in the last year or so. A lot of information disseminated about how it has different symptoms than classic ADHD. I posted a thread here a while ago on a research study on this exact topic (recognition of a distinct adult ADHD phenomenon describing its characteristics).
It seems like it's the medical community leading patients who then surprise another part of the medical community:
http://www.mayoclinic.org/diseases-conditions/adult-adhd/home/ovc-20198864
My thread:
http://forums.studentdoctor.net/threads/late-onset-adhd.1200273/
I read your thread and it's describing something different. Most of these adult patients I'm seeing are older than college-aged, and not in school. They either feel their job performance is failing, or they feel they can't focus well enough on daily life.
IMO, 90% of the time, we don't know the answer to the real question: why NOW? I always ask patients what made them come to the ED or IOP this week as opposed to last month or next week. Investigating that question will often make it clear to the patient that a stimulant is not necessary.
I would say in at least 50% of the cases, I've seen so far, the person is already on stimulants, or has taken them in the past, and the answer to "why now?" is that they recently ran out of the last stimulant prescription they had, because they moved from out of state, or their previous psychiatrist stopped taking their insurance, or their PCP isn't comfortable continuing stimulants so they put in a psych referral.
Great discussion in this thread! I think adult onset ADHD is something that is new and that we will increasingly have to provide expertise now and in the future.
That's sort of the problem for me. As I said, I'm getting these referrals from PCPs, whom the patient presented to first, complaining that they've recently realized they have ADHD and need a stimulant, and the PCPs are referring them to psych because we have "expertise." But how much "expertise" can I have if I learned zero about adult ADHD in residency and don't believe in it anyway? I'm struggling to decide what to do here, in a way that a) eases my own conscience, and b) doesn't harm patients.
I struggle making this diagnosis all the time. Part of me thinks that this Adult ADHD is a bunch of BS, and part of me thinks that I'm being too dismissive. Considering the ADHD and GAD symptoms overlap all the time, if someone has anxiety issues and tells me that they struggled with attention issues and distractibilty all through childhood but were able to compensate for it, I've seen some of my clinic attendings override my GAD diagnosis and do a trial of a stimulant. If the anxiety gets better, they go "the worry was secondary to ADHD as untreated ADHD can cause a GAD like presentation".
So the question is, given that the literature actually suggests that most people don't abuse it, are you okay with accidentally dispensing PEDs (due to incorrect or nebulous diagnosis) instead of treating actual pathology?
I've literally seen some of my colleagues say "hey, as long it isn't hurting them, what's wrong with it?"
Most of us probably had a grave fear of controlled substances drilled into us by residency attendings, with some almost giving the impression that no controlled substances were ever indicated in any circumstances. I think it's inevitable as we get out in the real world, that we begin to question that. More and more, as I start cautioning against benzos and the patient starts getting all ornery, I find that small nagging voice in the back of my head going "you know, he's been on clonazepam 0.5 mg BID for a long time, he's not abusing it, he never requests early refills, he never requests an increase, you've checked the state pharmacy reporting database and he's not doctor- or pharmacy-shopping or going to the ED... would it really kill him if I just continued it?" And connected with that is the fact that giving in is much easier than constantly fighting with people. When it's been a long busy day, it's 4:59, and you just want to get the guy out of your office so you can go home, it's much easier to just renew the prescription than to have yet another pointless argument that only prolongs the inevitable. (I sometimes wonder if that's how some of these old docs get in trouble with the state board or the DEA. Not that they intended to set up a pill mill, but they just got sick and tired of fighting with every single patient who requests controlled substances.)
