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Adult ADHD?!

Discussion in 'Psychiatry' started by Trismegistus4, Oct 11, 2016.

  1. PSYDR

    PSYDR Psychologist

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    I'm just gonna mention the MTA study, because it seems like something that should be done.
     
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  3. TikiTorches

    Physician Gold Donor Classifieds Approved

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    Too much diversion of these stims...dea doesn't like that
     
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  4. Ceke2002

    Ceke2002 Purveyor of Strange

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    Honestly a lot of the time when I see kids, and adults, who have been diagnosed with ADHD my first thought does tend to be, 'Baulderdash, that child's behaviour is perfectly within normal limits for his/her age; they don't need medication they just need their energy to be channeled better', or in the case of an adult they just need to learn better organisational and life skills in general rather than wanting a quick fix for a condition they more than likely don't even have.

    As someone who is diagnosed with adult ADHD though, sure there are plenty of times when I don't get things done, or don't get things done on time, because my motivation has been wiped out due to a flare up/recurence of a depressive illness, or I'm experiencing a disruption in my sleep patterns that have lead to a reduced ability to concentrate, or I'm just plain slacking off because I can't be ar5ed with stuff. None of that constitutes ADHD in my book. I can't speak for anyone else's experience of the condition, but ADHD to me is more like when you really do want to get something done, and you are motivated, and you are determined, and you knuckle down and really try, over, and over again. Because it doesn't matter how motivated, or determined you are, or how much you try, or even what sorts of lessons or therapeutic interventions you've had in terms of self discipline, or self motivation, or better organisational skills, etc, you still don't end up achieving your end goal, and the more you try the more you mess up until in the end you're just completely exhausted and frustrated beyond all belief. And then you repeat the whole exercise over again the next day, and the day after that, and the day after that, and get the exact same result.
     
  5. birchswing

    birchswing Patient/Interested in Psychiatry

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    I've wondered about this from an evolutionary point of view before. Humans have evolved in a way where the amount of intelligence seems superfluous to extending survival, and as a result our way of living is extremely complex and intricate. Over the hundreds of thousands of years humans have existed, I doubt that many of the tasks that confound people with ADHD were necessary.

    It's kind of like the ability to produce the enzyme necessary to digest lactose past the nursing phase of life. It's not necessary, but some people have it and some don't.

    I personally think ADHD is real. But I could see the argument being made that it is not a disease-state. I think the medication is more about enabling someone to do things in life they want to do. Kind of like Lactaid for people who want to eat ice cream.
     
  6. smalltownpsych

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    Pretty good analogy except that their is a biochemical difference in lactose intolerance whereas people who meet diagnostic criteria for ADHD don't have any measurable neurochemical difference that we can detect at this point.maybe because we haven't found it yet or maybe because it is a variation of normal or healthy brain function. That doesn't mean that this variation wouldn't cause problems or can be treated with medications. We treat other normal biological responses all of the time to alleviate distressing or problematic symptoms.
     
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  7. clozareal

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    If what you mean is that there is no biological marker to help diagnose ADHD, then you are right. However, there is a neurochemical and structural neurological difference in ADHD that has been measured and reported in many modern textbook chapters and research paper introductions on ADHD . It's a problem with norepinephrine and dopamine "tuning" of pyramidal neurons in the prefrontal cortex and its projections to the subcortical structures. Both NE and DA are low in ADHD. Norepinephrine in the prefrontal cortex works to increase attention and dopamine works to decrease noise from other parts of the brain. Stimulants work by increasing both. Nonstimultants also work at increasing mainly NE but also DA in the prefrontal cortex without hitting dopamine in the reward pathways. Alpha agonists work at NE receptors and not DA, which parallels their lack of abuse potential. All of these treatments have measurable neurochemical differences.

    Also, neuroimaging studies show that children with ADHD show a 3-year delay in prefrontal cortex development compared to their peers. It's also the one of most inheritable of all psychiatric diseases with a heritability at about 76%, which means there's a strong genetic component to it.
     
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  8. smalltownpsych

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    Agreed that I might have overstated, although there are some problems with comparing across cultures and also comparing research population with real-world clinical population. Out in the real world, the majority of the kids I see who have been diagnosed with ADHD probably don't have it. It is tough to tell if they really do or not because we don't really know what "it" is. I have seen the ADHD families though, the interview with the parents is often quite telling; however, it seems like that is the minority of referrals, not the 76% that you would expect to see. In all, these criteria are so subjective that it remains difficult to make the type of definitive statements that some of this research makes. We also can't differentiate based on tests which actually measure cognitive ability. Until we can, we need to back off from such strong claims. Trust me, I wish that we could, because I would love to have more ammo to say, "no, this is not ADHD, this is chaotic home or crummy teacher or school system." Just got a wave of October referrals for ADHD from a local kindergarten with new teacher and new principal. :rolleyes:
     
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  9. hamstergang

    hamstergang may or may not contain hamsters

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    Is that a correct way to interpret heritability?
     
  10. smalltownpsych

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    :shrug:
    I don't think so. :oops: My memory was that it has to do more with relative accounting of genetic factors verses environmental factors through the use of twin studies and I never really got a complete understanding of how to translate that to non-twins in the real world other than relative comparisons.
     
  11. splik

    splik Professional Cat at Large
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    there are no psychiatric diseases, and ADHD is not a disease by any definition
     
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  12. clozareal

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    Okay, I mean psychiatric disorder.
     
  13. Trismegistus4

    Trismegistus4 Worried Wellologist
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    Yes, that's an interesting way of looking at it. Hunter-gatherers don't have to sit reading a book for an hour, create PowerPoint presentations, or keep their desks organized. You go out and hunt and gather, or you starve. And just as a person with a lactase deficiency has impaired functioning in a hypothetical society where almost all food is made with dairy products, a person who's not good at sustained concentration on abstract cognitive tasks has impaired functioning in modern first-world society.

    In a sense, I feel bad for these people. But part of the very reason for that is that I identify with them somewhat--I've never been good at making myself stay on task either, and it's frustrating to feel that they're getting away with "cheating at life" by taking a pill that makes them concentrate, whereas I had to do it the hard way. My grades in school were very erratic, only consistently good in my postbac program, when I had the fairly short-term, concrete goal of getting into med school. And even in med school, once things were pass/fail, I had an episode of academic difficulty. One might think it must not be that bad in me since I made it through everything, but how do we know it's any worse in these patients who are coming in complaining of all these subjective symptoms? Some people just aren't as good at life in 21st century advanced technological society as others. Maybe they need to just have menial jobs that don't require as much attention to detail. Or maybe they just never are as good at their job, never get promoted as far as someone who does have better attention and concentration. So what? Does that mean it's my responsibility to prescribe drugs to level the playing field? Should people who aren't that naturally strong or fast be given steroids and other performance enhancing drugs so they can compete at athletics?

    Another thing that's difficult about this is knowing how to steer the conversation. This is my first outpatient job. Previously, doing inpatient, if a patient interaction was not going well, whether because the patient was only interested in begging for controlled substances, or because they were psychotic and totally disorganized, or because they had borderline personality and were telling you you were a terrible psychiatrist who was ruining their life and how dare you ask them that question etc., you could just end it and talk to them at another time, or go get info from their family instead. But now, I'm seeing patients who have made appointments and have an hour of time reserved for a new eval. When it becomes clear in the first 30 seconds of an interaction that the person's sole reason for being there is their goal of walking out the door with a prescription for Adderall in hand, and I'm uncomfortable giving it to them... what do I do with the remaining 59 minutes and 30 seconds? I hate going through the motions of trying to obtain a detailed psych H&P when we both know there is this discussion looming at the end where they're just going to keep begging me for controlled substances.

    Although in the OP I made reference to people wanting to get diagnosed with ADHD for the first time, I think the situations that make me the most uncomfortable are when the patient is already on stimulants, having allegedly been diagnosed by a past psychiatrist, and that person has retired, or the patient has moved from out of state, and they in their mind they're just coming in to get established with a new psychiatrist and continue the meds. How do I know whether they need the medicine or not? Am I just a vending machine?

    On the other hand, now that I'm in the private world, I can see the validity of what smalltownpsych said upthread, about how it's not worth putting in the time to delve into these cases. I just saw a guy for the first time today who was on Xanax 1 mg TID and didn't want to change it. He wasn't running out early, there was no evidence of doctor- or pharmacy- shopping in the state controlled substance reporting system, so I just continued it, because that was easier than fighting with him. Maybe that's the approach I need to take.
     
  14. ahmedqman

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    Maybe we could use this as a thread to pool data and studies that would be relevant to the diagnosis of Adult ADHD as there seems to be a general trend supporting this diagnosis. I mean, the very fact that the DSM-V has adjusted the criteria to account for Adult ADHD shows that this is a problem that we are going to have to face, considering that its symptoms directly intersect with depressive, anxiety, borderline personality disorder, and bipolar disorders, and all the Adult ADHD psychiatrists that I have talked to in my program suggest that "the comorbidity rate of these disorders is high", which makes life even tougher. I have seen an attending attribute a patient who has known impulse control issues, substance abuse, anxiety and restlessness (who has been on multiple mood stabilizers, antipsychotiscs, and antidepressants in the past) and has known history of substance abuse and impulsivity (leading to multiple impulsive drug overdoses with 3 + hospitlizations this year) attribute ALL of his symptoms to ADHD and gave him adderall because he stated the stimulant made him calmer as a child. Then he comes back one month later stating "my life is so much better and now I'm trying to get a job". This reminds me of the "stimulants are magic" thread. I do have a suspicion that this patient also might be a liar though.

    Maybe, for our more senior attendings here on SDN who are keen on looking at both sides of the "debate" (if there is one anymore) can help start of some discussion with articles. One thing I appreciate about the attendings on SDN psychiatry in general is that the skepticism goes both ways for any of our treatments. There seems to be a belief here that psychotropics are helpful, however, sometimes we overblow the effects of them. A couple of the attendings here for sure (I think whopper) is very good at that healthy skepticism, especially surrounding the APA and it's embarassing associations with the pharmaceutical industry.

    Hopefully some of the neuropsychologists on both sides of the debate and pitch in and have a respectful dialogue.

    I will try and find some stuff but my lit search skills are poor (I think I should have taken a stimulant during that part of med school :))
     
  15. thoffen

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    ADHD is essentially a temperament. That temperament is going to be more or less problematic depending on the environment and learned psychologic functioning of the individual, which is of course very variable.

    So, the impressions of needing coping skills, or that the behavior is normal, evolutionary, etc. are right.

    But, for that matter, depression is no different.

    What is clear is that treatment for ADHD can help a lot of people. The risks and caveats can be weighed very conservatively against the benefit, but you aren't doing your job by only considering risk without weighing it against the benefit.
     
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  17. ahmedqman

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    I'd like to lay out a few countertransference issues I have with this diagnosis (and actually, this could be applied to many other psychiatric diagnoses, including substance abuse):

    Yesterday, we received a lecture from a psychiatrist who does Adult ADHD and I learned the following:

    A patient with Adult ADHD can have the following features:
    - Lazy and a procrastinator
    - Bored by work but addicted to video games
    - Impulsively buys video games
    - Routinely late to work and his doctor's appointments
    - Forgets to take his medications
    - Obsesses over something and has an inability to shift focus from one task to another
    - The above symptoms decrease the quality of life (DSM V got rid of social and occupational impairment)

    Is this patient accountable for his actions? Or is he absolved of guilt? We medicalized depression and say "you have a nasty illness" and "it's like diabetes or HTN" to not make our patients feel guilty or personally responsible for their symptoms, so now are we heading down the path where we are medicalizing ADHD?

    Can I be sued for wrongful death if someone died in a car accident and the patient's mother sues for undiagnosed ADHD?
     
  18. Salpingo

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    1. Not to be a jerk, but countertransference is a response to a person, not a diagnosis.
    2. A psychiatrist specializing in adult ADHD has an incentive to expand the diagnosis, so its appropriate to be skeptical.
    3. Its not our job to absolve someone from guilt or hold them accountable. If you feel like behavior is a variant of normal, you don't have to treat it.
    4. If a person wants help with all of the above, the solution isn't going to be just a stimulant -- they have to be pretty committed and motivated to change.
    5. You can be sued for anything, but I don't think any lawyer is going to take that case.
     
    #66 Salpingo, Dec 8, 2016
    Last edited: Dec 8, 2016
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  19. Ceke2002

    Ceke2002 Purveyor of Strange

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    As it is I've managed to accidental myself into a number of places I wasn't supposed to be in thanks to epic amounts of distraction at work..."Wait, there's a velvet rope in my way, stuff it I've been walking in a straight line for the last 50 metres and my brain suddenly can't handle changing directions to go around this obstacle so I'll just step over it instead...ooh, hang on, there's something potentially interesting over there, wait, nope that's boring...oh look someone's handing out samples of food and drink, cool!"...5 minutes later my husband manages to track me down amidst the crowd, quite happily chomping on a plate of hors d'oeuvres with a nice glass of red in hand, and informs me that somehow I've managed to gatecrash a $60 ahead, invite only event for a celebrity guest chef. I would have been brilliant as a cave person with ADHD, knowing me I would have wandered off into the jungle somewhere and come back having accidentally discovered fire. :laugh:
     
  20. Ceke2002

    Ceke2002 Purveyor of Strange

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    From the point of view of someone diagnosed with ADHD/ADD...

    Is this patient accountable for his actions?

    Of course he's accountable for his actions, it's not like he's had a psychotic break and lost contact with all reality. ADHD is a manageable condition, and does not automatically absolve someone of their responsibilities. Anyone who says otherwise, in my book at least, is just making BS excuses to get away with bad behaviour.

    Or is he absolved of guilt?

    Of course no one should feel guilty if they just happen to have a condition that needs to be managed, but again if that same person is just using the fact that they've been diagnosed with said condition as a way to engage in certain behaviours carte blanche, then yes they should feel guilty about that. Being diagnosed with ADHD isn't an automatic get out of jail free card, no matter what some unscrupulous types out there might think.

    We medicalized depression and say "you have a nasty illness" and "it's like diabetes or HTN" to not make our patients feel guilty or personally responsible for their symptoms, so now are we heading down the path where we are medicalizing ADHD?

    I do think it's a pity that both depression and ADHD have apparently become 'medicalised'. I think both conditions are far more complex in terms of the interrelations of biology, sociological background/environment, and individual psychology than just 'Here, take this medication' and then not going on to explore how the patients own attitudes and actions might also be contributing to the onset, severity, continuation, etc, of their condition (because heaven's forbid you actually challenge a patient's internalised world view instead of just wrapping them up in feel good platitudes and throwing pills at them).
     
  21. WisNeuro

    WisNeuro Board Certified Neuropsychologist
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    Most of these are just non-specific observations and/or psychiatric symptoms. Hopefully this was just part of the lecture and he talked about the actual diagnosis while he was at it.
     
  22. birchswing

    birchswing Patient/Interested in Psychiatry

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    Yes, I have trouble with concentration myself (I have visual snow which makes reading harder plus difficulty with sustained concentration that my psychiatrist says can't be sussed out from the benzo withdrawal as a separate condition), but I find I end up having to be creative. For one thing, I am very good at advocating for myself. I get textbooks in PDF and I use my computer to read them to me. When I do have to read a written page, I find I can concentrate better if I copy-edit what I'm reading as I read it for content—I need a couple of things going on at once. If I just try to read a narrative my mind has so many thoughts jumping in. I do much better with output than input. The gymnastics you learn to make up for one deficiency can make you much faster at other things. There are people far more unique than me, though, who have made disproportionately large contributions to our way of living due to their variations in thinking and behavior. It seems it's usually people who are lucky to both be "aberrant" in a particular way but also have enough intelligence and overall stability to be use that variation productively.

    I heard a theory once about low-latent inhibition as it relates to mental illness vs. creativity. Low-latent inhibition is when a person receives more information than is typical. The theory was those with the ability to handle this increased amount of information could be highly creative, and those without the ability could suffer various mental illness.

    Speaking of fire, I recently watched the Cooked documentary on Netflix. There's a theory that humans first cooked meat with fire on purpose after coming across the bodies of charred animals after a brush or forest fire and found that they tasted much better than raw ones.
     
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  23. digitlnoize

    digitlnoize Rock God

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    Any child psychiatrists here? Do you guys think ADHD is an "actual" illness in children? If so, do you think it just magically goes away in adults?

    ADHD is a neurodevelopmental disorder. There is copious evidence that the brains of patients with ADHD are fundamentally different from brains of people without ADHD. ADHD is primarily a frontal lobe disease, with significant alteration in the functioning of the pre-frontal cortex and in the PFC's connections to various areas, notably the hippocampus and amygdala.

    The net result of this is that ADHD is essentially, at all ages, a failure of impulse control. In 6yo boys this most commonly presents as inability to stay in a seat, but in inattentive patients of both sexes and all ages, presents as a failure of impulse control in more subtle ways. They can't control the impulse to not listen to the distraction in the room. They make poor decisions in various ways (impulsive decisions, decisions that don't fully consider the future or the past), etc.

    Untreated ADHD can be disasterous. In children, it is associated with higher risk of substance use, going to jail as an adult, and yes, car accidents. There is no reason to suspect that these risks magically go away when a patient crosses a border between 17yo and 18yo.

    ADHD is a serious illness that requires careful diagnosis and treatment. In fact, I would argue that if you're. It treating it, you're ignoring a key cause of many of your patients' symptoms. Patients with untreated ADHD often feel like they mess up all the time (because they do), like they can't do anything right (because they mess up a lot), that they have trouble making and keeping friends (they do, at all ages...they forget birthdays, they forget to make time for friends, they often had impaired social lives growing up and didn't fully learn normal social skills), that their lives aren't going how they want, that they have to constantly worry about things to keep from screwing them up, that they have to be hyper-OCPD about certain things (like where they put the car keys when they get home or they will lose them), and they get bored easily and so seek out novel experiences that may be damaging (sex, drugs, rock & roll). All of this leads to comorbid depression, GAD, social phobia, and OCPD traits, amongst other things.

    Of course the risk for abuse exists, so careful screening is required and collateral from people like parents, bosses, and old teachers is essential in adults, probably more so than in kids.

    Please don't ignore this diagnosis. For the sake of your patients.


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  24. birchswing

    birchswing Patient/Interested in Psychiatry

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    What do you think about the theory that people who have that trait and also have high intelligence become very creative/productive? And that conversely, those with that trait and low intelligence suffer distress?
     
  25. smalltownpsych

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    Child psychologist here. Don't believe that it is a real illness, but I do think that it can be a valid construct and that a variety of interventions including medication, environmental, social, and behavioral can be beneficial for some of the patients that meet this very liberal and relatively nonspecific diagnostic label. Most of my patients who get diagnosed with ADHD don't benefit much from stimulants to be quite frank and especially if the teachers don't know they have started medication. Usually because they have much bigger problems exacerbating the ADHD or vice versa. I doubt that anyone thinks that these symptoms just go away although many learn to cope or adjust by making environmental choices. I think the skeptics are referring to adult onset ADHD and the difficulty of establishing childhood history.
     
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  26. SeniorWrangler

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    There are two different questions here:
    1) Is adult ADHD a real thing?
    2) Should docs be routinely treating adult ADHD with stimulants in patients who don't have rock solid documented histories of child ADHD, which is most of them?
     
  27. vistaril

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    should is a loaded word. Treating Adult adhd with stimulants is one of THE cornerstones of insurance based outpt med mgt psychiatry in the US today. Thats just the reality. Taking this away would be like taking away emgs from neurologists.

    When I was doing outpt med mgt psychiatry(well lets be honest thats about the only kind of outpt psychiatry that exists now), these patients constituted a full 35% of the practice.
     
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  28. SeniorWrangler

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    Wow. That's depressing.
     
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  29. digitlnoize

    digitlnoize Rock God

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    They're also the most effective treatment for the illness, and one of the most effective treatments in all of medicine. Strattera's not bad, but it's not as effective as stimulants. Other things like alpha agonists and wellbutrin have much lower efficacy.
     
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  30. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty
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    Stimulants…are like benzos….the best and worst thing about them is that they are so effective for the vast majority of people taking them, with little regard for the actual symptoms being treated.
     
  31. PistolPete

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    Can you expand on this some more? Don't we know what symptoms are being treated by stimulants? Maybe you mean to say that ADHD is a dirty diagnosis, and that we are treating inattention/hyperactivity but don't often know the true cause?
     
  32. Shikima

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    Word your question differently/simply in this context; What am I needing to treat with amphetamines? Why must I use this?

    In a greater context, this goes for any medication - What am I needing to treat with Xanax? What am I needing to treat with Zoloft? etc..
     
  33. birchswing

    birchswing Patient/Interested in Psychiatry

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    I'm confused. You're saying they're effective, but not for the symptoms being treated. What are they effective for then? Surely you would agree benzos do effectively treat anxiety in the short-term. I'm not familiar enough with stimulants to personally say they're effective for inattentiveness and lack of focus, but people on these forums seem to say they're the most effective class for ADHD.
     
  34. smalltownpsych

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    What I took from it is that people find both benzos and stimulants to be effective even when they don't have any symptoms. Drug companies love to sell medicines to people who don't really need them as it helps to expand their market. Both medications operate on the reward system of the brain so they can create a "need" in anyone who takes them. It is true that stimulants do help many patients who do actually meet the stricter diagnostic criteria and lack of comorbidities that the research tends to use, but are they really helping the majority of the patients who are taking them?
     
  35. digitlnoize

    digitlnoize Rock God

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    Low dose stimulants in people who have ADHD do not affect the reward pathway and these patients don't become addicted. The reward pathway addiction model only applies to those abusing stimulants at high doses or who don't have ADHD.

    First, everyone needs to go reread the Stahl chapter on stimulants.

    Second, ADHD is not some made up disease. It's been described and recognized since the 18th century and treated with stimulants since the early 20th century. It is an illness which impacts almost every area of a patients life leading to anxiety, learned helplessness, and depression. If you're wondering why you should treat it, there's your answer.

    Claiming that benzos and stimulants are the same is flat out wrong. Benzos help short term anxiety but cause significant long term problems. Stimulants help ADHD and do NOT cause significant long term problems, including addiction for most people.

    Are you guys really so jaded from med seekers? Can you not tell a person with ADHD from one without?




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  36. Jules A

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    Something that is usually easy to identify is someone with a personal stake in a particular diagnosis.
     
  37. erg923

    erg923 Regional Clinical Officer, Cenpatico National

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    The symptoms that compose the disorder might as well be are the cough of psychiatry. So, no, I can't just "tell" by listening to them and looking at them. The retrospective nature of the diagnosis for adults who often have secondary gain makes it even more difficult. Please feel free to share your secret though.
     
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  38. digitlnoize

    digitlnoize Rock God

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    Well my secret is that I see kids, lol.

    But seriously, in adults there are many tell tale signs. First off, always get collateral. Contact old high school or middle school for records. Pull old report cards. Talk to their parents.

    Second, do you observe any signs of ADHD behavior? Are they always running late to their appointment? Do they leave their belongings in your waiting room? Do they mix up your instructions? Can they listen to you talk for an extended period or do they zone out and are not able to repeat back what you said? Is their interview kinda circumstantial but not that bad, but kinda? Do they feel that they constantly make little mistakes? Do they worry about messing up all the time? Do they have OCPD traits? Why? Is it because if things are out of place they can't find them? Do they have a "key hook" or "special place"? Before they had it, or if it were moved, would they constantly be losing their keys?

    Now, keep in mind each of these things taken in isolation are not diagnostic of ADHD. But, as a gestalt picture, combined with Vanderbilt scales and collateral (and ruling out MDD, GAD, and SA, of course, although these can be, and often are comorbid with ADHD), you can be reasonably sure they've got it, IMO.


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    #86 digitlnoize, Dec 21, 2016
    Last edited: Dec 21, 2016
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  39. erg923

    erg923 Regional Clinical Officer, Cenpatico National

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    This thread was really more about assessment and treatment of possible AD/HD in adults.
     
  40. digitlnoize

    digitlnoize Rock God

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    I know. That's why I gave adult tips. Edited OP to be more clear.
     
  41. smalltownpsych

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    I'm addicted to a low dose stimulant and I don't have ADHD - it's called coffee. I don't think I said that people don't have attention all problems or problems with hyperactivity and that stimulant medications won't help those people significantly. I was mainly questioning which group is larger. The real ADHD people or the people taking stimulants for a wide variety of other reasons. Not all of those other reasons being substance abusers either. Oppositional kids, kids with emotional regulation problems, kids with specific learning disabilities, energetic boys, shift workers, people with anxiety, people with depression, people with Borderline PD.
     
  42. WisNeuro

    WisNeuro Board Certified Neuropsychologist
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    As someone who spent over a year heading up a grant on ADHD looking at functional neuroanatomical, neuropsychological, and psychophysiological differences, I'm on board that this is a distinguishable disorder. Over and mis-diagnosed, yes, but very much a real thing. If it's not real then we might as well say that anxiety and depressive disorders are not real either. I'm sure if we really wanted, we could discuss the ontology of any disorder for days on end.
     
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  43. digitlnoize

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    Why do you think those problems exist? Let's see:

    ODD is very comorbid with ADHD. It often improves once you treat the ADHD. Ever wonder why it develops? Bad parents, right? Well, only half right. See, it turns out that kids with ADHD screw up all the time. They're more clumsy, they do more stupid or risky things because they're bored or just not paying attention. They procrastinate, especially in tasks they find boring. When they do perform a task, let's say "sweep the floor" they miss some areas and don't do a great job. Not on purpose, but because they can't plan or pay attention to details. So, the parent had to nag at them. "How did you miss this? Are you blind?" Now, we sit here and say the parent should be more diplomatic and nurturing, which is easy to say, but it's easy to forget that this happens CONSTANTLY in their daily life and it's frustrating for both parent and child. The result is that the child starts to resent the parents' constant intrusion into their life and becomes oppositional. Usually this then creates a feedback loop and it gets worse.

    Many of the emotional regulation problems I see are really just bad ODD or, framed another way, emotional impulsiveness. You see, ADHD does not just affect physical impulsiveness, it also affects emotional impulsiveness. Kids with ADHD tend to be very emotionally reactive, although they can learn control.

    Learning disorders are very comorbid with ADHD. They can be separate, but I don't see it much.

    Energetic boys...this isn't ADHD. Now, evidence suggests that we are likely over diagnosing the hyperactive type ADHD. But we're missing the inattentive type in droves. And the reality is that the hyperactivity only gets you in trouble with teachers. It's the inattentive symptoms that are truly problematic for most people, especially chronically.

    Sleep disorders, including shift work sleep disorder should be ruled out and corrected of course. No, you shouldn't prescribe a stimulant to someone who just needs to stay awake in night shift. That's what caffeine is for ;)

    Depression, anxiety, and BPD are all often comorbid with ADHD, and I believe under recognized when they're comorbid, particularly anxiety and BPD. ADHD-induced depression doesn't really look like MDD. It looks like very low self esteem. People with attention problems feel bad about themselves because they literally mess up all the time. And they know it. This creates anxiety too. They worry about forgetting stuff. They worry about messing up. They have less developed social skills, and worry that they said or did something wrong in social interactions. They often have comorbid social phobia. In fact, if you have a patient with social phobia you should be screening for inattentive symptoms HARD. Border lines too, although less so, and it's much harder to pick apart from their pathology than these other disorders, and I probably wouldn't Rx a stimulant to an adult borderline unless I was 110% CERTAIN of my diagnosis.

    Now, I'm not saying ADHD is the end cause of all these disorders. Obviously you can have MDD, GAD, social phobia, ODD, and BPD without having ADHD-I. But, you should be aware of the effect of the illness on the patient and how it can manifest as these other illnesses. Because it happens all the time.





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  44. Shikima

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    Excellent biopsychosocial review of ADHD when looking at the DDx.

    Quick note about shift-work disorders; sleep schedules/timing with strategic use of caffeine is primary, but Modafinil is also an option to help.

    Also behavior sleep restrictions plays an important role in both children and adults.
     
    #92 Shikima, Dec 21, 2016
    Last edited: Dec 21, 2016
  45. smalltownpsych

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    I completely agree with what you are saying on the one hand and that untreated ADHD, whatever that might be (as Wis said we could argue that for days for many of our dx's), can lead to many problems, but what I see more often in my clinical practice is counter to this. Maybe it is because I don't see the kids that are benefiting from the medications. Of course, the patients who need more intervention than medication alone will be the ones that I see in my office for ongoing treatment. Nevertheless, I also think there is a sampling error the other direction. Everyone involved is motivated to have the medications work. I wouldn't make medication referrals if I didn't have some hope that they would help. I just don't see the benefits that one would expect to see if your perspective was accurate.

    I have been involved in interventions that have worked for a significant majority of these types of patients, but the level of intervention was far beyond anything available in the community setting. We were getting adolescents (roughly 30% of our population were on stimulants) off of medications and decreasing medications at an astounding rate. We charged about 7k a month to do it though. Nevertheless, some of the things that we did could be implemented, but they would seem extreme to our society.
    Some of what we did:
    • Kids doing daily and weekly chores
    • 3 days a week of class time with only 4 hours a day
    • group therapy 3x a week
    • minimal electronic devices (schoolwork only)
    • roughly equal time dedicated to vocational and artistic classes as academics (minimal didactic, maximum hands-on)
    • highly structured schedule with minimal downtime
    • constructive work projects for punishing misbehavior
    • culture that relied on adult modelling of exemplary behavior (I got to fire people who couldn't behave better than the kids)
    Here is a link to a program similar to the one where I was at that does collect some data on this. http://www.montanaacademy.com/OUTCOMES/MATURITYRESEARCH.aspx
    My dream is to start a similar program and foster more research into these factors so that we can actually help these kids and our society instead of just looking to a medication as a solution as though we were trying to cure polio.
     
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  46. WisNeuro

    WisNeuro Board Certified Neuropsychologist
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    If someone was managed well on medication, why would they come to a psychologist for continuing therapy/treatment? Of course you wouldn't see those people. We have to remember that we are seeing only segments of people in our clinics. If I applied my clinic base rates to the population at large, then I'd have to assume that half of the people that seek medical care are malingering.
     
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  47. AcronymAllergy

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    And these are all reasons that make diagnosis of ADHD in adulthood, without access to childhood/adolescence records, parent/teacher report, etc., so very difficult. Especially if you're also working with populations that have higher base rates of these other conditions (e.g., MDD, BPD, substance abuse, anxiety, PTSD) to begin with.

    The difficulties that may have been initially induced by ADHD, sometimes combined with a chaotic (or at least less-than-supportive) home environment and comorbid LD, are now complicated by an adolescence and early- to mid-adulthood replete with all sorts of confounding experiences, poorer relationship and health outcomes, and other factors.
     
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  48. smalltownpsych

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    I think I said that, but I also was referring to the patients that I refer for medication evaluations who do come to see me first. I am not sure how much that population differs from the population that presents to PCP first. Just my clinical observations and so could still be skewed, but I don't think that these medications are really helping as much as is often touted and that as long as we look to this as the best intervention and neglect the bigger socio-cultural issues at play, we might be doing a great disservice to our patients. Keep in mind that it is much easier to research and discover medication effects or even manualized CBT than extensive environmental and structural interventions.
     
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  49. WisNeuro

    WisNeuro Board Certified Neuropsychologist
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    Yes, this speaks to the base rate bias problem. You are likely seeing those that have comorbid conditions and/or mitigating psychosocial factors, not the simple cases. I'm all on board that medications are not the panacea here, but I also wouldn't be too dismissive of its use in well-diagnosed patients.
     
  50. Therapist4Chnge

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    This was my point. The vast majority of people who take a stimulant report positive effects, regardless if they actually have ADHD or related diagnosis where stimulants have been shown to be effective. Whether or not there is an actual positive effect for cognition (as some research does not support that it's helpful for non-ADHD patients), the patient perceives they do. A similar pattern occurs for patients who utilize benzos….again, whether it is warranted or not. They could be on a baby dose of xanax for 20 years, but if they don't have their worry-no-more pill when they get anxious….lord help us all. My point was that both types of meds have a high reported (positive) effect, which is a problem because this encourages further usage.

    It's an okay read, but far from sufficient if you want my honest opinion…as someone who has done and continues to do research on stimulant medications.

    I'm not sure people are claim that it is made up, but the base rate compared to the prevalence at which it is diagnosed are often very different. I believe that it exists, though I conceptualize it as a much more heterogenous entity than what the DSM outlines.

    I neither stated nor implied that benzos and stimulants are the same. I was pointing out that they can cause the same problematic behaviors. I didn't specify addiction because that is not what I meant. I was referring to the fact they are viewed positively and effective by most patients (regardless of dx) and usage patterns are often problematic because they can be very behaviorally reinforcing.

    Not at all, but there is a subset of patients who are drug seeking. I think I'm actually pretty good at differentiating ADHD from other stuff (based on my grant funding). My personal opinion is that I actually believe that an adult should be allowed to take whatever medications they want, though my professional opinion is limited to the referral question and if someone has a dx or not. It is up to the managing physician as to how they want to proceed with treating (or not) the referred patient.
     
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  51. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    Which is exactly why I refer out all my potential adult ADHD patients to psych for a full evaluation (and look askance at PCPs who do it themselves) - without a solid childhood history there are just way too many confounding factors for us non-psych trained doctors to tease out.
     
  52. quitejaded

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    I have adult ADHD. I was coping horribly and a professor forced me to get tested. I went to a psych and she did an attention test with me. It was embarrassing... she'd note "you kept looking out the window..." and I said "I was just thinking ..." anyway, she said it was extremely obvious I had inattentive add. Then I was able to get meds. I never even knew that you can see a gp for ADHD meds. I would never ever trust a gp with my med management, no offense. I honestly do not trust you guys to care much about my mental health or know what you're doing. I suppose if I had Bad insurance I'd have no choice but I saved my diagnosis report in case anyone ever questioned my diagnosis.

    Anyway, please don't be an dingus. Refer your patients to a psych...
     

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