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Posts that she doesn't trust "you guys" (psychiatrists) and wants a referral to a psychiatrist.
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...
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.
Flunk attention test=ADHD. It's obviously so simple, mofos
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?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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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?
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.
And those patients are about the only ones that DON'T want a quick medication fix...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.
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.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.
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.
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.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.
http://medshadow.org/medshadow_blog/my-drug-dealer-was-a-doctor/
An article about this and other medications which are commonly abused by patients and a very popular song that reflects the problem.
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:
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
- 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)
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.
So what happens when you're treating a patient with Adderall & Xanax and then they get into an accident, or develop a condition that requires pain medication? Could they be on all 3 medications or would they have to stop one of them?
We would talk to our doctors in person and not ask an Internet forum for personal medical advice.I was just curious what you all would do in this situation?
The Xanax is taken as needed for anxiety. Is that unusual? I've read that it's common for people with ADHD/ADD to also have anxiety disorders.
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?
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.
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...
23 year old female, history of difficulty in interpersonal relationships, was sexually abused by father from age 4-8.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.
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.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.
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.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.
The government doesn't like drugs.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?
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.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.
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.
You seem to be splitting hairs a bit here.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.
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.Multiple studies have reported that a history of physical and sexual abuse in childhood has a high prevalence among patients with borderline personality disorder, with some studies finding that abuse is a nearly ubiquitous experience in the early lives of these patients http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.160.11.2018
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.What would you say about someone presenting with derealization/depersonalization, minimizing of mood/anxiety symptoms and has GID?
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.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 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.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).
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.
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.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.