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I'm just gonna mention the MTA study, because it seems like something that should be done.
Too much diversion of these stims...dea doesn't like thatProblem with that is d/t stimulants being a controlled substance, there are production quotas. Mind you, I have no clue off the top of my head how often (if at all) that interferes with people's ability to find the medication, but it's something to keep in mind. Perhaps more of a minor point--if a person thinks they're having problems, I want to at least try to be able to tell them what I think is really contributing to their difficulties. Pipe dream, I know. But in my case, if someone's willing to come in to go through 4 hours of testing with me after they've waited a couple months following the referral from their initial MH appointment, I figure that says something. At least some of the time.
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.
I think it's a completely fake and phony condition. People who supposedly have it simply lack self-discipline and need to try harder.
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.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.
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.
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.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.
It's also the one of most inheritable of all psychiatric diseases with a heritability at about 76%
Is that a correct way to interpret heritability?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.
Is that a correct way to interpret heritability?
there are no psychiatric diseases, and ADHD is not a disease by any definitionAlso, 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.
there are no psychiatric diseases, and ADHD is not a disease by any definition
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.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.
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?
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.
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?
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)
?
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.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.
They can't control the impulse to not listen to the distraction in the room.
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.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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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?
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.
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.
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.
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?
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.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.
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?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.
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?
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.
Well my secret is that I see kids, lol. But seriously, 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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This thread was really more about assessment and treatment of possible AD/HD in adults.
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.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?
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.
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.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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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.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.
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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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.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.
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.
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.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?
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.First, everyone needs to go reread the Stahl chapter on stimulants.
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.Second, ADHD is not some made up disease.
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.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.
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.Are you guys really so jaded from med seekers? Can you not tell a person with ADHD from one without?
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.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.