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Discussion in 'Psychiatry' started by Trismegistus4, Oct 11, 2016.
Posts that she doesn't trust "you guys" (psychiatrists) and wants a referral to a psychiatrist.
You know, I've been thinking - we ought to prescribe more amphetamines to the public once again. It'll make people more focused and energetic, productivity will go up and the added benefit in addressing the dreaded obesity crisis of the country.
We'll cover psychosis and hypertension with risperdal and metrorololololololol.
Flunk attention test=ADHD. It's obviously so simple, mofos
I believe what he meant was the he refers his patients to a psychologist for psychology assessment/testing. There are very formal attention tests you can do which are standardized and do not sound like what you describe.
There are attention tests, they don't discriminate ADHD at the individual level well at all, though. In patients with ADHD, all the tests can help with is elucidating the cognitive profile and helping to talk with the patients about their strengths and weaknesses, and helping with some recommendations about compensatory strategies. The diagnosis should still be 99% based on clinical history. Any psychologist who says they can diagnose ADHD with cognitive testing does not know what they are talking about, or does not understand how psychometrics work.
But, the child cannot perform well on a ridiculous and artificial task (CPT, TOVA, etc) that lacks any kind of ecological validity because I told him to in my office one day. And his life is chaotic as hell. He must have AD/HD!
Yep, that's all it took for me to be (re)diagnosed with ADD in Adulthood, I just got lost in thought and stared vaguely out of a window and Eureka!
Perhaps real ADHD is a "you know it when you see it" type of thing, and zoning out when your doctor is speaking directly to you during a one-on-one appointment is one of those "you know it when you see it" signs. But 99% of the patients I've seen for adult ADHD have not exhibited any such signs. Instead, they're coming in with a lot of vague, nonspecific complaints that are either entirely subjective--i.e., not observable by anyone else, or things that everyone does to some degree. They complain about how they never really did as well in school as they could have and always had trouble paying attention in class (when I ask about their grades, they often say B's and C's,) if they sit down to read a book they sometimes find themselves having to reread part of a page when they realize they just read a paragraph without really paying attention, their desk at work is a mess, they sometimes misplace their keys or phone (but they find them after looking in a few of the most common spots, they don't totally lose them,) they're not getting as much done at work or around the house as they think they should, they do a load of laundry but after getting it out of the dryer they leave it in the basket instead of folding it and putting it away because they get sidetracked doing something else, etc. Given the fact that, as someone said upthread, stimulants will make anyone feel better, do you really think such people should receive a diagnosis of ADHD and be treated with stimulants?
These cases, in my experience, are some of the more frustrating to diagnose. And make up the majority of the folks I see. They become even more difficult when you also include h/o multiple other medical and mental health conditions.
I've had a handful of "know it when you see it" cases in adults over the past few years. And a handful of "know it when you don't see it." The rest are in the amorphous gray area in-between.
I have a feeling I'd probably be in the 'you'd know it if you saw it' category, considering anyone who spends enough time hanging out with me, or living with me for that matter, IRL will more than likely utter words to the effect of "What the hell is she doing now? " at some point. Even my husband has admitted using some car time to vent frustration over some of the things I've done -- but that was early on in our marriage, these days he's more like to just shake his head and go 'Yep, that's my wife'.
I do agree that 'Stimulants for all!' is not the answer though. Sure they help some people, and some people do need them (in my non medical opinion), but then there are others (like myself) where they did help, meaning they did what they were supposed to do, but the side effects eventually became unmanageable. And of course not to mention those who don't actually have ADHD/ADD and just want some quick fix rather than having to work on things like better time management and self-motivation.
99% of the public wants a quick fix. Our job is not to buy into this - unless we're talking florid psychosis and starting antipsychotics is necessary.
And those patients are about the only ones that DON'T want a quick medication fix...
Which again makes me wonder what the heck I should tell these people. I have a feeling many of them think the very reason they've been sent to my office is for a quick fix. They've already brought the issue up to their PCP, who has effectively punted it to me--I'll read the PCP's note, and it will say "will refer to psych for formal testing for ADHD." Nothing I'm doing is formal, unless you count the fact that I'm wearing a tie.
Now, sometimes, it's not what I feared; sometimes the PCP note will make it sound like the person's seeking an ADHD diagnosis, but when I evaluate them, they're clearly suffering from a major depressive episode, and are quite open to the idea that treating the depression will improve their concentration. I had a guy like that come back for follow up recently; he's already doing much better, and wasn't complaining about attention and concentration nor asking for a stimulant at all.
OTOH, the one patient we've terminated from the practice since I've started here was an "adult ADHD" patient--he went to his PCP seeking stimulants after he was already getting them from me, then called our office, told the MA to "kill yourself" and repeatedly used profanity.
I keep coming back to the idea that so much of what these people complain about are things that describe me. I sometimes have to reread a paragraph after realizing I was starting to daydream while reading, I do laundry and never get around to putting it away, I didn't do as well in school as I could have and don't feel I'm as productive now as I could be. And if I can function as a psychiatrist, I don't believe these people should be considered to have a mental disorder.
I tell them up front, after examining them, that there are many elements in your life including poor sleep contributing to your daily activity distress. I don't believe prescribing you amphetamines will be appropriate. I can offer you a similar medication (Wellbutrin/Strattera) and provide rationale & education (inc side effects) that I won't prescribe a controlled substance. I also talk to them about the benefit of psychotherapy and often times developing mechanisms to address the lack of concentration is going to be more effective.
Now, full disclosure: I have no problem prescribing stimulants til the cows come home for CNS Hypersomnia conditions. It isn't about an aversion towards prescribing them, but I won't just to help johnny make sure he gets all As at university and that he can keep his scholarship (which means he's bright enough already and didn't need them while in HS) or the 42 y/o guy who shows up saying that he thinks he has it and his work productivity needs to be increased.
An article about this and other medications which are commonly abused by patients and a very popular song that reflects the problem.
As one of the PCPs who often writes exactly that on notes, you're doing exactly what I'm hoping most psychiatrists do. In adults, there are so many things that can cause attention issues, I want an expert to evaluate the patient and see what's going on. If it is in fact ADHD, that's fine - I don't mind seeing them back and handling their refills myself. If its not, I want to know what it is so the 3 of us can try and manage it. The biggest thing is that you're better at discerning all of this than I am.
There is also value in my being able to say "the mental health expert says that you have X, not ADHD, so we're going to work on X". I often use the pain management doctors in the same way "The pain specialist doesn't think you need percocet either, so let's try some other pain relief medications/techniques/whatever".
We used to jokingly refer to locum Doctors here as 'Deals on Wheels'. Long as you said the right thing you had about an 80% chance of getting a shot of Morphine, or at the least some Morphine or Endone tablets (at least until some junkies killed one of the locum Doctors to steal drugs, and then they bought in new rules that locums were no longer allowed to carry Schedule 8 narcotics...although some of the dodgier ones still did).
The behaviour modification program, as I found out later on because I was too young to understand at the time, that the Paediatric specialist tried to get my parents to do when I was diagnosed with ADHD as a child consisted of:
Distraction and redirection
Age appropriate daily chores (sans time limits at first, so long as the tasks were completed)
Clear instructions on what was expected in terms of behaviour
Positive verbal reinforcement for good behaviour
Three clear warnings for bad behaviour (with a opportunity to stop or change the behaviour inbetween each warning) and only then a resulting punishment
Medication wasn't really prescribed back then, or at least I expect it wasn't going to be prescribed to a child between the age of 2 and 3 back in 1974-75. And the therapy type approach could've worked really well for me, it actually did work when it was Grandma who was implementing the program (seeing as she was the only one who seemed to understand and take the program on board properly) -- my parents on the other hand...(like I've said before, yeah let's trust a borderline histrionic mother, and a heavy drinking, gambling addicted, seriously paranoid and quite possibly schizotypal/schizoid father to actually carry out a behavioural modification treatment plan properly ).
It was the same with one of my teachers at school. Aside from issues of bullying, Grade 4 primary school was probably one of the only relatively happy years at school that I had, because my teacher at the time knew how to deal with me. I knew what assignments were expected of me each day, and as long as I completed those assignments it didn't matter what order I did them in, or whether I wandered off half way between working on one thing to go do something else, or if I needed to get up and walk around, or go outside and play for a bit, or sit somewhere else for a while and do some art or something -- so long as I wasn't disrupting the class, and I finished what was expected of me by end of school day.
Kids don't *always* need medication. Neither do adults for that matter -- once I got away from the idea, as an adult, that I needed medication, and the medication would somehow just fix me, I made a lot more progress just working on adapting to different things/challenges/etc myself by using some of what I'd learnt in past CBT type treatment programs.
Ask yourself this question, why do I need 3 controlled substances? 1 upper and 2 downers?
I think the first question is, why are they on Xanax at all?
We would talk to our doctors in person and not ask an Internet forum for personal medical advice.
Yes it is common, but it shouldn't be used in that way. If an SSRI doesn't work, something like Buspar (lol…I know, but it can actually work for some benzo-naive people), and then a benzo. If benzo, something longer acting so it isn't quite as behaviorally reinforcing. Even then, it should be considered a stop-gap or used infrequently with non-pharma interventions being tried first. Will a patient actually go through all of this….no. They will say, "just give me Xanax/etc".
Yes to co-occuring mood disorder (in this case anxiety).
Xanax is useful in treating anxiety...if by treating we actually mean perpetuating and in some cases worsening the anxiety. Pretty much the only thing it is good for is alcohol withdrawal, or maybe very intermittent use for specific anxiety producing situations (e.g., claustrophobic patient needs an MRI). But yeah, this is a great conversation to have with your prescribing doc, or possibly your new prescribing doc after you fire the previous one.
I think you have to go back to basics with this kind of thing. To meet criteria for the diagnosis there must be "clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning". That's also quite vague itself, but personally I would usually expect evidence that the symptoms interfere with at least two domains of a person's life. And one of those to a significant degree.
In milder cases it's very much a disorder of modern life- the symptoms wouldn't be an issue if the person was working on a farm or staying at home. But I think that if you have (for example) an accountant in front of you with long term ADHD symptoms, that is no longer able to cope with his work, then it's more ethical to prescribe a stimulant than it is to suggest he finds a new profession.
This thread is the perfect example of why I guess there's no one right way to approach this condition.
My current approach right now is that if I get a whiff of anxiety and depression, I just go ahead and treat that. Then, if after anxiety and depression is treated, refer for psychoeducational evaluation and testing where they do the specialized structured clinical interview with rating scales and maybe some supportive executive function testing using the D-KEFS or whatever.
In a standard psychiatric practice with 60 min new evals and 15 min med checks, I don't think there's a way to reliably diagnose it quickly like we do with depression and anxiety unless the presentation is ultra clean with minimal comorbid mood or anxiety sx.
I once heard a pro ADHD attending treat a schizoaffective disorder patient with a stimulant because the patient was being distracted by police cars as he was concerned that the police were out to get him. And the attending claimed that he got better and that was because of an underlying ADHD.
Never mind the fact that those with primary psychotic disorders like schizophrenia and schizoaffective have known deficits with executive function and cognition... but hey, the patient had bad grades in school growing up and had "trouble focusing!", so ergo, ritalin!
Sometimes treating symptoms really does help, though that sounds like a stretch….
I've seen a stimulant work effectively with a sub-set of agitated head injury patients. Our hypothesis was that at least part of the agitation was due to poor attentional ability and also poor planning/sequencing. Agitation would increase with frustration, which was most problematic when the pt. would try and engage in required tasks. Not all of the patients were frontal injuries, but that was the impetus of our hypothesis. We were able to titrate down on the Seroquel/Risperdal/etc. without needing to jack up the stimulant, it was actually more about timing than dosing. It wasn't a cure all, but it reduced the need for restraints and increased engagement. Stimulants are often titrated down after the first 6-9mon, though it is very much a case by case basis.
So I got a report back from a local psychologist on a patient I sent for ADHD eval. He wrote that her PTSD and Bipolar II (it's really BPD, but that's OK) is the cause of her attention problems and that she doesn't have ADHD.
I'm sending him all of my evals in future...
Out of curiosity, how do you distinguish Bipolar II from BPD? I always ask colleagues about this when it comes up to see what pearls they can offer, since I think it's a fascinating topic, and can lead to misdiagnosis and therefore incorrect treatment.
23 year old female, history of difficulty in interpersonal relationships, was sexually abused by father from age 4-8.
I'm only a family doctor so I can't quote you the best way to tell bipolar II from BPD, but if you were molested as a young female child that in my experience is like 99% sensitive/specific for having BPD.
Could she also have Bipolar II? I guess, but it would be the ultra-rapid cycling kind that there was a thread on recently and I'm not convinced yet that its really a thing.
If they have NSSi, chaotic relationships, and hx of trauma, and hx of suicidality in addition to their mood lability, then its BPD. If it is primarily related to problematic substance use, then it's not Bipolar II. In the rare case that the emotional dysregulation is neither of these and someone still wants a pill to fix it, then let the prescriber dx them as Bipolar II. I actually don't think I have ever diagnosed it myself, but the NP down the hall hands it out daily. At least that's better than the NP at the CMH who dxs them all as schizoaffective.
You sound like a very knowledgeable FP. Good for you! Most FP's I run into have little interest in and knowledge of psychiatry.
Ugh, don't get me started on schizoaffective d/o...
Bipolar II is an episodic affective disorder with at least one discrete episode of hypomania and one of a MDE, whereas Borderline Personality Disorder is a pervasive pattern of maladaptive defenses which may include emotional reactivity but not really in an episodic course. I think this is a situation in which it makes sense to be a little more concrete with the DSM.
Another thing I've noticed is that it's sometimes really tough to distinguish mood and impulsivity issues with regards to ADHD vs cluster B traits or some kind of personality traits. High emotional reactivity, irritability, and impulsivity can be all hyperactive type ADHD (which can exist since childhood) or can be maladaptive traits from a personality disorder, although for borderline, there'd probably see some additional history of trauma, parasuicidal behavior, and chronic paranoia I guess, though I don't see why you couldn't see some of those symptoms in comorbid social anxiety w/ ADHD (I thought ADHD in adulthood is thought to lead to deteriorating interpersonal relationships as well).
I think some concept of the disorder exists, I just think it's just too dirty because there's so much intersection with other diagnosis. You can literally look at an anxious person and get them to meet criteria for ADHD if you just ask the questions in the right way. They can look nearly identical at times.
And the fact that this mistake can easily be made is not necessarily the fault of the provider, I just think we need better ways to reliably diagnose it quickly. Also, I would argue we need a better treatment, that is, a treatment that only works for ADHD and not for normal people, because unfortunately, stimulants work for both, while my understanding is that if you give prozac to a normal person all you'll get is side effects.
And sorry to get sidetracked, but I had to comment on re: schizoaffective disorder. Has anyone ever met someone that actually met criteria for schizoaffective disorder? I feel like it's near impossible to find someone to fit the bill (2 weeks of psychotic symptoms in the absence of mood and most of their symptoms of mood are persistent throughout the year), and all I've seen it used for is schizophrenics with depressive symptoms or aggression/mood instability
This is an aside, but we let people have entirely elective, cosmetic surgeries, so why don't we let people have Adderall for cognitive enhancement? It seems hypocritical of the medical profession to say that boosting your appearance with surgery is OK, but boosting your cognitive performance with a pill is not...
(Partially playing devil's advocate. This post should not be construed as "FlowRate gives everyone stimulants." I don't.)
The government doesn't like drugs.
Most patients with borderline personality disorder weren't sexually abused (see also here). In fact typically there is no increase in sexual abuse alone. Conversely sexual abuse is common in bipolar disorder (see here and here) . 20% of patients have both bipolar II and borderline personality disorder. Childhood sexual abuse is a non-specific factor for the development of adult psychopathology which includes mood disorders, anxiety disorder, substance use disorders, eating disorders, personality disorders, psychotic disorders, somatoform disorders, and dissociative disorders.
The special association of sexual abuse and BPD is one of the most enduring myths in psychiatry.
What would you say about someone presenting with derealization/depersonalization, minimizing of mood/anxiety symptoms and has GID?
You seem to be splitting hairs a bit here.
and it does make sense that sexual abuse alone does not differentiate, but increased physical combined physical and sexual does seem to be a factor. I think the point is that when I am thinking of sexual abuse and correlation with BPD, I tend to think of more traumatic abuse. The patient who had the babysitter touch them inappropriately once is a much different case than the patient who was prostituted by mother for drugs. Both might be classified as having a history of sexual abuse, but it is easy to surmise which is more likely to meet criteria for BPD.
Although I do believe that BPD can co-occur with bipolar I or bipolar II, I think it's pretty rare. 20% seems high to me.
I would say if we are going to use diagnoses (and I tend to avoid using diagnoses where possible) then we should stick to the criteria so that we can justify the diagnosis. That is to say, if the patient has 5 or more criteria for BPD and meets general personality disorder criteria, by all means make the diagnosis.
That said the other things that may tip off the presence of a character disorder is the use of the typical defenses of the borderline personality organization: primitive denial, primitive idealization, splitting, and projective identification. We all uses these defenses at some point, but a personality style with a tendency to use these would suggest BPO (importantly, they may not meet full criteria for BPD but the borderline characterology may be important for our formulation and treatment planning).
In my experience gender dysphoria (GID was the DSM-IV dx) patients in psychiatric clinics very commonly have BPD. It's interesting because identity diffusion is of course a key feature of BPD. On the other hand, you can imagine how a gender non-conforming child may experience chronic invalidation that may lead to the development of BPD.
So just out of interest how does Attachment Theory line up with the development of BPD? What about C-PTSD? As far as I know it's not an officially accepted diagnosis (yet), how many patients do you think legitimately fit a 'diagnosis' of C-PTSD either get misdiagnosed with ADHD, Bipolar, etc, and how many go undiagnosed in these cases?
Any good book recs on the Neurobiological side of Attachment Theory as well?
Although we've gotten off the topic a bit, the tie-in is that a weakness of our diagnostic system is lack of etiologies. Thus, a kid who has experienced disrupted attachment or complex trauma frequently get those diagnoses. Sometimes the medications do seem to alleviate the symptoms though, but I really wish our science was better.
I have a 5 year old patient that I see right now who was abandoned by mom, meets diagnostic criteria for ADHD and the medication does appear to help with some problematic behaviors, but really the symptoms are likely the result of the disrupted attachment/early maternal abandonment that we don't really study because we don't have a disorder for it. In some ways although the medication has helped, the kid's personality has changed dramatically and now does things like spending an unusual amount of time arranging cars in the playroom as opposed to more creative play. I can almost guarantee that this kid will get more medications down the road as they continue to exhibit problematic behaviors.
Do we really know what we are doing? Not really. It is scary to be honest. One of my criticisms of an over emphasis on medication is that it feeds the current reductionistic direction of our field. I also feel the same way about CBT and DBT although I utilize both of those too. How many of us really have an answer for how to really treat these folks who have been scarred in a wide variety of ways from childhood? I really don't find that outpatient psychotherapy every week and cocktails of medication are sufficient.
I can definitely see many areas where the conceptualisation and treatment of certain issues (complex trauma, disrupted attachment, to name a couple) certainly needs to be looked at a lot differently than just focused therapy and a pill or several. It seems like a lot of the time those in the mental health field are given like 5 seconds flat to make a diagnosis, and formulate an effective treatment for their patients, leading to reduced levels of care. I suppose in that situation it just becomes easier to write out a script for Adderal, or whatever else, and that situation kinda sucks, to be honest. It's definitely an area I'm interested in working in, better management of complex issues of trauma et al, that doesn't involve throwing medication at the problem (because ADHD, or whatever).
I worked in a privately funded long term (about 18 months) and expensive (6k per month) residential treatment program that was fairly effective in helping teens and families with some of these types of issues, but the level of intervention that we provided was way beyond the scope of what is typically available. Even then, we struggled with helping some of the attachment and complex trauma cases. For example, I learned that if the kid had a history of aggressive or assaultive behavior towards maternal attachment figure, then we were unable to help. Less complex or severe cases being dx'ed ad ADHD, that was easy, and half the kids we had stopped taking stimulants. We also increased standardized testing scores for all of the kids by an average of about 20 percentile points.
Dear all. I'm a(n educated) layperson who stumbled across this thread while doing some online research (and no, that's not a contradiction in terms) about an issue that's troubling to me personally. Thank you so much for making me feel like all psychiatrists and health care providers think that the people they see are either liers or too pathetic to get their lives together on their own and are 'making up' diagnoses. I was considering seeing a psychiatrist for a problem that quite seriously impacts my life. I won't now. Well done!
You should find a way to keep threads like this private. It's damaging to all us 'pathetic' people with access to the Internet.
Try reading the thread again. This time, pay attention to both sides. While some people here seem to not find their patients trustworthy, others do.
Further, there are several people in this thread that have admitted to the very diagnosis that some others (in the minority here) believe to not be legitimate.
Back to the original topic:
I have the diagnosis and use meds. I was diagnosed as a child, but my parents were opposed to medication. For many years I thought meds were bad so I would not consider using them.
After my child had a neuropsych work-up, the doctor recommended I (his mother) get evaluated at a clinic specializing in ADHD. I was working as an artist at the time and never had considered pursuing treatment since art and adhd get along fairly well. However, life was still very tough due to difficulties with driving. After a year of seeing my son's improvements, I took the dr's advice and scheduled with the adult provider. After a packet that took me a month to complete and a four hour work-up I was diagnosed again. I had to do checklists to monitor symptoms for months while I started meds. Life changed in ways I would have never imagined. The most memorable change was driving. Before meds I approached traffic lights saying "green is go, green is go, green is go" and parked as far away from other cars as possible because processing the sheer volume of information required to back out of a parking space was simply too overwhelming to deal with. I had a car accident about once a year (all but two were very minor) before starting meds.
The other drastic change was to my tolerance for reading. I think I spent the first six months on meds driving where I wanted and discovering the value of reading. I continued seeing the psych for a couple of years. She recommended I apply to college. I did that. Within a few years I started medical school. As I went thru med school I overheard lots of conversations about my colleagues being newly diagnosed. For the most part I find it difficult to understand how a person can get that far with ADHD. Maybe I will understand more after residency.
So far I have not been able to stay off meds very long, but I would like to do that very much. The most problematic issue is driving. It is difficult to explain just how impossible it is to drive safely with an attention problem. And yes, it becomes incredibly anxiety provoking. I take drug holidays, but I never drive unless medicated. (My last car accident was a few months before meds.) If I match in a city with good public transportation I will try to get off meds again.
Funny thing is, I have never once heard anyone else mention driving as an ADHD issue.
its one of the things we specifically ask about in ADHD evaluations. people with ADHD are more likely to get into car accidents,and more likely to die from motor vehicle accidents. it takes quite a bit of executive function to drive.
Thank you for the input. Do you often find that it is such a major and persistent challenge for people?
I totalled a car when I was learning to drive. The instructor was in the car with me.
I failed my driving test when I missed a green light cycle. (The mean old driving test lady claimed it was 2 cycles, but I really doubt that!). I was 21 when I finally learned to drive. Still can't drive if shifting gears is involved.
I really don't get how people find driving to be a minor thing.
Another issue I don't really understand is when people talk about feeling not motivated because of their adhd. This does not line up with my experience at all. I am pretty much always motivated. As soon as I wake up I start thinking about what all I can do that day.