interesting articles on adult ADHD

[erg923]

I have never tried any of these drugs, but I almost want to, just to find out why people who don't satisfy diagnostic criteria for ADHD become so convinced they "work," rather than just realizing they like the way they make them feel.

Actually, I think this is pretty easy to understand. I had a broken leg this past year and even under pain "enjoyed" by Percocet in the evening. When I have a sinus infection and get Rx steroids, the energy (almost manic) boost for 24-36 hours generally serves me well. I have taken clonidine before and during certain stressful events and would be lying if I said i did not notice the "effects." I go to a glass of fine Scotch after some long work days (less so now compared to when I was seeing patients all day). I think the difference is our level of psychological insight (primarily), our knowledge that this isn't an appropriate/healthy long term cure/solution, and our various other domestic and occupational responsibilities that make this a non-starter for the long-term. Also, don't forget our relative difference in terms of distress tolerance, delayed gratification, and general self discipline of life and time.

I can easily understand how people become drug seeking, but we just don't do it/continue it due to the factors I mentioned above.

Try a month of adderal and see what it does for your "notes issue."

---

Members don't see this ad.

 

[clausewitz2]

Actually, I think this is pretty easy to understand. I had a broken leg this past year and even under pain "enjoyed" by Percocet in the evening. When I have a sinus infection and get Rx steroids, the energy (almost manic) boost for 24-36 hours generally serves me well. I have taken clonidine before and during certain stressful events and would be lying if I said i did not notice the "effects." I go to a glass of fine Scotch after some long work days (less so now compared to when I was seeing patients all day). I think the difference is our level of psychological insight (primarily), our knowledge that this isn't an appropriate/healthy long term cure/solution, and our various other domestic and occupational responsibilities that make this a non-starter for the long-term. Also, don't forget our relative difference in terms of distress tolerance, delayed gratification, and general self discipline of life and time.

As an aside, these reactions to Percocet/steroids are not at all universal. Plenty of folks hate taking Percocet because they get nauseous and don't really get that euphoric feeling. And I think probably all of the psychiatrists on this board have taken care of people who have become crushingly depressed or suicidal after receiving steroids. It is not simply a case of "this strongly psychoactive medication will always and consistently have this sort of effect". Likewise, some people are going to take adderall and say, "it's fine, I guess" and not notice a huge amount of benefit. While I am not arguing for the obviously false "if you respond to stimulants you must have ADHD", but simply pointing out that there are idiosyncratic factors that govern how rewarding these things are and thus resultant drug-seeking behavior beyond our obviously superior insight.

That said, I am with you on the steroids. I love me some prednisone.

 

[WisNeuro]

As an aside, these reactions to Percocet/steroids are not at all universal. Plenty of folks hate taking Percocet because they get nauseous and don't really get that euphoric feeling. And I think probably all of the psychiatrists on this board have taken care of people who have become crushingly depressed or suicidal after receiving steroids.

I'm one of those. Tried them after a surgery and only took a couple. I'd rather deal with most pain than that nausea. Tried Tramadol at one point too. All that does is give me a headache and make it hard to sleep, nothing for pain control. Works for me, though, I generally try to avoid taking any kind of medication unless necessary. Trying to stave off any maintenance medications for as long as I can into middle age and beyond.

 

[Shikima]

I took Percocet after T&A in my 20s.... I was retching so violently that I got petechiae in my face and blew a vessel in my conjunctiva.

 

[smalltownpsych]

My daughter is the react negatively to narcotics, vomited after taking a vicodin for post-tonsillectomy pain. That was awful for her. Myself, on the other hand, when I took a loretab after a tooth surgery during a time when I had a high stress load with a number of suicidal teens and no good treatment options, found that there was a dramatic effect. Within 30 minutes of taking the medication, my level of stress had dropped to the point where I felt like I was lying on the beach in the middle of a two-week vacation. What patients? Who cares? I wasn't feeling high or euphoric in anyway, it had just effectively removed all emotional distress. Powerful stuff for some brains!

 

[AcronymAllergy]

As an aside, these reactions to Percocet/steroids are not at all universal. Plenty of folks hate taking Percocet because they get nauseous and don't really get that euphoric feeling. And I think probably all of the psychiatrists on this board have taken care of people who have become crushingly depressed or suicidal after receiving steroids. It is not simply a case of "this strongly psychoactive medication will always and consistently have this sort of effect". Likewise, some people are going to take adderall and say, "it's fine, I guess" and not notice a huge amount of benefit. While I am not arguing for the obviously false "if you respond to stimulants you must have ADHD", but simply pointing out that there are idiosyncratic factors that govern how rewarding these things are and thus resultant drug-seeking behavior beyond our obviously superior insight.

That said, I am with you on the steroids. I love me some prednisone.

Saw the former a week or two ago. The latter I don't hear all that often in folks I suspect have ADHD, although it's of course been reported. What I will more commonly hear is intolerance of side-effects that they (or their parents) say outweigh the perceived benefits.

Never had steroids, but Vicodin made me supah high.

 

[Amygdarya]

My dog got manic on steroids

 

[randomdoc1]

Lol. My cat was on cloud 9 on buprenorphine. But he had a paradoxical reaction to benzo, it disinhibited him and he picked fights with the other cat XD.

 

[Trismegistus4]

Try a month of adderal and see what it does for your "notes issue."

Wow, you people have tried some drugs! I am pretty naive about drugs, whether street or prescription. Actually, it occurred to me recently, that even with as common as marijuana has become today, with probably the majority of my patients telling me they've at least tried it like it's nothing, not only have I never tried it, I'd have no idea where to get some if I wanted to. So many people move to a new city and in no time they have a marijuana supply, but for me, if I made up my mind that I wanted to try it this weekend, I'd have no idea where to start. I literally would not be able to do it, because I wouldn't know where to get any. Not that I want to. The "just say no" campaign of the 80's worked on me, and I didn't feel like I fit in with other kids very much so I had low susceptibility to peer pressure. When some of my friends started experimenting with marijuana in high school, my reaction was not "hmm, if my friends are doing it, it must not be that bad after all" but "AAAAAHHHHH! BAD KIDS use drugs! My own friends are using DRUGS and turning into BAD KIDS! RUN AWAY!" and I stopped hanging out with them.

And the same things goes for trying a month of Adderall. This isn't a backhanded way of asking where to get it, just pointing out that I'd have no idea. I'm always amazed when I hear of some doctor or pharmacist getting in trouble for abusing prescription drugs--how can they possibly think they'd get away with it? Aren't these things tracked and monitored in triplicate by the DEA? The only way I could possibly think of to score some Adderall would be to go doctor shopping and act like a drug seeker myself, which I'm not willing to do.

Anyway, the real reason I'm bumping this thread is that I've been reminded of another problematic supposed ADHD presentation which I've encountered from time to time before, but just had 2 different patients do in the past week. It's when ADHD is not the patient's initial reason for presentation, but rather, a patient whom you've already been seeing for a while, for some other problem, comes in for a routine follow-up appointment and tells you about their history of ADHD for which they took stimulants (which they never told you about before, not even in the initial eval when you asked about past psych diagnoses and past psych meds) and how it's flaring up again and they need to be on "their" Adderall again. The first patient who did this in the past week is very reasonable, not a drug seeker, and is open to further evaluation and exploring different options. But the 2nd, whom I just saw today, is a drug seeker, who's already got me prescribing Ativan (though not enough to take daily, she routinely asks for more, and calls the office and begs the MAs for early refills,) and has in the past asked me to prescribe Percocet! This is actually the kind of person to whom I'd want to say "I don't prescribe stimulants to adults" flat-out to nip this in the bud, but I was caught off-guard by the fact that she was an established patient coming in for routine follow-up; as I mentioned upthread, the last guy I said that to was a new patient whose chart I'd reviewed, revealing multiple red flags for stimulant abuse. So I asked this lady questions about various ADHD symptoms, and of course she was pan-positive, in many cases interrupting and blurting out "yes" before I'd even finished the question. Then, when I didn't prescribe a stimulant, she got about as close to admitting malingering as a person can get: "I said yes to all those questions, didn't I? What was the point of you asking me all those questions?"

Unfortunately, I referred her to the psychologist in our department who does the testing, which I fear is only delaying the inevitable. The symptoms are so subjective, and non-observable. If someone claims to have them, who am I to say they don't? And thus, unlike with benzos, I'm left without a legitimate-sounding reason why I can't prescribe stimulants in that particular case. This is why I can't deal with ADHD-related complaints at all. The only solution is not to see such patients, or if they do sneak in, tell them outright "I don't diagnose or treat ADHD or prescribe stimulants. If that is what you feel you need, go elsewhere." And I don't have the support of my employer to do either of those things.

 

[thoffen]

Have you discussed this with leadership? Are you looking at other jobs? This sounds miserable. In the patients' defense however you are sending mixed message that you will prescribe a stimulant if they try other things first.

I attempt to educate my adult ADHD stimulant seeking patients about my concerns and also inform them I will not be prescribing a stimulant for them, period. If we find their attention isn't improved by addressing possible comorbidities there are non-stimulant options. I always inform them they are under no obligation to continue with my services if our philosophies are incongruent. Most won't come back but I have had several who did well on alternatives and also a couple, literally two, I started on stimulants after legitimate trials of the other options. I also discharge patients who make threats which includes that they can't hold a job because I won't prescribe a stimulant or will relapse on whatever substances they used if I don't prescribe benzos.

Can you clarify more? The scenarios you describe in substance-seekers seem like misdiagnoses of ADHD or otherwise ADHD being a less important clinical problem than malingering or character disorder for which the harm of the treatment outweighs the benefit. In which case, obviously, you shouldn't prescribe stimulants bar none.

I also think it's perfectly reasonable to try strattera and intuniv before a stimulant treatment as a general approach. Or to withhold stimulants if diagnostic uncertainty exists provided some sort of evaluation and management you are doing is going to resolve that uncertainty. It is also my experience that people with ADHD and comorbid mood and anxiety disorders often do not get better without treatment of the ADHD as the defensive operations of anxiety, depression, hypomania, obsessionality, etc. may have functional roles in overcoming deficits or distress caused by ADHD symptoms. Thus, even if the symptom ratings or obvious impairment attributable to the illness appear to be less significant than those of mood/anxiety disorders, ADHD may need to be higher on the problem list. Character disorders gets a lot more complicated, but the same principle can apply.

For many, therapeutic intervention (directly for executive function, for handling comorbid symptomatology better, insight into illness and reasonable self-expectations, etc.) is undervalued. However, patients with ADHD are more likely to need more direct structural intervention to enable success. This will often belie their perceived capacity of self-efficacy based on observed cognitive capability and often someone's own impaired expectation of self-efficacy. You may have to directly tell them what to do, when, and who to see, or to break the usual therapeutic frame and do something for them or engage outside supports to fill that role. Often when put in these positions, we readily see dependent or manipulative dynamics that are misattributed. If anything, my experience with genuine and relatively uncomplicated ADHD persons is that they will have a hard time asking for assistance and be more comfortable allying with you to beef up their sense of self-efficacy. This may produce short-term rewards, but is really a bad thing because the shame of being unable to sustain this motivation will be impairing and likely to seek outlet through mood or anxiety symptoms.

 

[erg923]

Wow, you people have tried some drugs! I am pretty naive about drugs, whether street or prescription. Actually, it occurred to me recently, that even with as common as marijuana has become today, with probably the majority of my patients telling me they've at least tried it like it's nothing, not only have I never tried it, I'd have no idea where to get some if I wanted to. So many people move to a new city and in no time they have a marijuana supply, but for me, if I made up my mind that I wanted to try it this weekend, I'd have no idea where to start. I literally would not be able to do it, because I wouldn't know where to get any. Not that I want to. The "just say no" campaign of the 80's worked on me, and I didn't feel like I fit in with other kids very much so I had low susceptibility to peer pressure. When some of my friends started experimenting with marijuana in high school, my reaction was not "hmm, if my friends are doing it, it must not be that bad after all" but "AAAAAHHHHH! BAD KIDS use drugs! My own friends are using DRUGS and turning into BAD KIDS! RUN AWAY!" and I stopped hanging out with them.

And the same things goes for trying a month of Adderall. This isn't a backhanded way of asking where to get it, just pointing out that I'd have no idea. I'm always amazed when I hear of some doctor or pharmacist getting in trouble for abusing prescription drugs--how can they possibly think they'd get away with it? Aren't these things tracked and monitored in triplicate by the DEA? The only way I could possibly think of to score some Adderall would be to go doctor shopping and act like a drug seeker myself, which I'm not willing to do.

Anyway, the real reason I'm bumping this thread is that I've been reminded of another problematic supposed ADHD presentation which I've encountered from time to time before, but just had 2 different patients do in the past week. It's when ADHD is not the patient's initial reason for presentation, but rather, a patient whom you've already been seeing for a while, for some other problem, comes in for a routine follow-up appointment and tells you about their history of ADHD for which they took stimulants (which they never told you about before, not even in the initial eval when you asked about past psych diagnoses and past psych meds) and how it's flaring up again and they need to be on "their" Adderall again. The first patient who did this in the past week is very reasonable, not a drug seeker, and is open to further evaluation and exploring different options. But the 2nd, whom I just saw today, is a drug seeker, who's already got me prescribing Ativan (though not enough to take daily, she routinely asks for more, and calls the office and begs the MAs for early refills,) and has in the past asked me to prescribe Percocet! This is actually the kind of person to whom I'd want to say "I don't prescribe stimulants to adults" flat-out to nip this in the bud, but I was caught off-guard by the fact that she was an established patient coming in for routine follow-up; as I mentioned upthread, the last guy I said that to was a new patient whose chart I'd reviewed, revealing multiple red flags for stimulant abuse. So I asked this lady questions about various ADHD symptoms, and of course she was pan-positive, in many cases interrupting and blurting out "yes" before I'd even finished the question. Then, when I didn't prescribe a stimulant, she got about as close to admitting malingering as a person can get: "I said yes to all those questions, didn't I? What was the point of you asking me all those questions?"

Unfortunately, I referred her to the psychologist in our department who does the testing, which I fear is only delaying the inevitable. The symptoms are so subjective, and non-observable. If someone claims to have them, who am I to say they don't? And thus, unlike with benzos, I'm left without a legitimate-sounding reason why I can't prescribe stimulants in that particular case. This is why I can't deal with ADHD-related complaints at all. The only solution is not to see such patients, or if they do sneak in, tell them outright "I don't diagnose or treat ADHD or prescribe stimulants. If that is what you feel you need, go elsewhere." And I don't have the support of my employer to do either of those things.

RE: Adults

I would have to assume the psychologist is, hopefully, just completing a more thorough history of symptom development/onset than you (and most psychiatrists) seems to have time for? And maybe just ruling out if they are intellectually disabled or perhaps just have a severe learning disability? This is really the only reason to request objective cognitive testing in adults for these cases...because: There is no test, or set of tests, that is diagnostic of AD/HD (unlike AD, LBD, FTD, and multiple other neurological conditions). And, individuals with AD/HD may or may not have deficits in attention as found by administering sustained vigilance tests. In the end, tests that seek to answer if a person has attention deficits are really not helpful or discriminatory at all for this condition! This is a consistent finding for the past 10-20 years, and I don't understand why the message has not gotten thru to some (most?) mental health practitioners. I always tell people, if you are already pretty confident (in either direction) about whether ADHD is the correct diagnosis, there are no cognitive test results in the world that should undermine your confidence. The psychometric sensitivity and specificity simply does not exist for you to change your conclusion based on it. The DSM criteria are there a reason, and if cognitive functioning and profiles were diagnostic of the condition, they would be included in the DSM. But they aren't.

You might want to ask your facility's psychologist about this issue so you can feel more confident and more in the loop?

Attention problems are ubiquitous aspects of almost all psychiatric conditions, and in life in general. Some people are simply not as good at this as others are. If they cannot accept this, they may have unreal expectations of themselves, be narcissistic, have chaotic lives/circumstances, be in the wrong career/job for them, etc. I think taking a hard line on this is necessary unless we want to venture into cosmetic psychiatry.

And by the way, when I was a younger "skate rat", and tried some stuff. But I still wouldn't label myself and "trying alot of drugs."

 

[Jules A]

Can you clarify more? The scenarios you describe in substance-seekers seem like misdiagnoses of ADHD or otherwise ADHD being a less important clinical problem than malingering or character disorder for which the harm of the treatment outweighs the benefit. In which case, obviously, you shouldn't prescribe stimulants bar none.

I also think it's perfectly reasonable to try strattera and intuniv before a stimulant treatment as a general approach. Or to withhold stimulants if diagnostic uncertainty exists provided some sort of evaluation and management you are doing is going to resolve that uncertainty. It is also my experience that people with ADHD and comorbid mood and anxiety disorders often do not get better without treatment of the ADHD as the defensive operations of anxiety, depression, hypomania, obsessionality, etc. may have functional roles in overcoming deficits or distress caused by ADHD symptoms. Thus, even if the symptom ratings or obvious impairment attributable to the illness appear to be less significant than those of mood/anxiety disorders, ADHD may need to be higher on the problem list. Character disorders gets a lot more complicated, but the same principle can apply.

For many, therapeutic intervention (directly for executive function, for handling comorbid symptomatology better, insight into illness and reasonable self-expectations, etc.) is undervalued. However, patients with ADHD are more likely to need more direct structural intervention to enable success. This will often belie their perceived capacity of self-efficacy based on observed cognitive capability and often someone's own impaired expectation of self-efficacy. You may have to directly tell them what to do, when, and who to see, or to break the usual therapeutic frame and do something for them or engage outside supports to fill that role. Often when put in these positions, we readily see dependent or manipulative dynamics that are misattributed. If anything, my experience with genuine and relatively uncomplicated ADHD persons is that they will have a hard time asking for assistance and be more comfortable allying with you to beef up their sense of self-efficacy. This may produce short-term rewards, but is really a bad thing because the shame of being unable to sustain this motivation will be impairing and likely to seek outlet through mood or anxiety symptoms.

I'm not sure what you are asking me to clarify.

 

[thoffen]

I'm not sure what you are asking me to clarify.

Sorry. The policy. Are you saying you have adults for which you have a confident diagnosis of ADHD without contraindication to stimulants whom you are intentionally not providing stimulants to? I provided a lot of ideas about how I could interpret your policy as a reasonable treatment approach, but the way you wrote it makes me wonder if some patients are being left out in the cold for no clinical reasoning I can appreciate.

 

[Trismegistus4]

I would have to assume the psychologist is, hopefully, just completing a more thorough history of symptom development/onset than you (and most psychiatrists) seems to have time for? And maybe just ruling out if they are intellectually disabled or perhaps just have a severe learning disability? This is really the only reason to request objective cognitive testing in adults for these cases...because: There is no test, or set of tests, that is diagnostic of AD/HD (unlike AD, LBD, FTD, and multiple other neurological conditions). And, individuals with AD/HD may or may not have deficits in attention as found by administering sustained vigilance tests. In the end, tests that seek to answer if a person has attention deficits are really not helpful or discriminatory at all for this condition! This is a consistent finding for the past 10-20 years, and I don't understand why the message has not gotten thru to some (most?) mental health practitioners. I always tell people, if you are already pretty confident (in either direction) about whether ADHD is the correct diagnosis, there are no cognitive test results in the world that should undermine your confidence. The sensitivity and specificity simply does not exist for you to change your conclusion based on it. The DSM criteria are there a reason, and if cognitive functioning and profiles were diagnostic of the condition, they would be included in the DSM. But they aren't.

She's definitely taking a thorough history, but she's also administering something called the Integrated Visual and Auditory (IVA-2) Continuous Performance Test, as well as the Adult ADHD Self-Report Scale (ASRS), the Montreal Cognitive Assessment, the Millon Clinical Multi-Axial Inventory III (MCMI-III), and the Personality Assessment Inventory (PAI). She's then writing that the diagnosis of Attention-Deficit/Hyperactivity Disorder "should be considered," because of course she knows that she can't officially rubber-stamp the diagnosis and tell us the patient needs a stimulant.

I know there's no formal cognitive test for ADHD, thanks to you all here on SDN, but no one else in this place knows or cares, I guess. This is just one more hoop to make the patient jump through before we inevitably dispense what they want like the vending machines we are.

 

[Jules A]

Sorry. The policy. Are you saying you have adults for which you have a confident diagnosis of ADHD without contraindication to stimulants whom you are intentionally not providing stimulants to? I provided a lot of ideas about how I could interpret your policy as a reasonable treatment approach, but the way you wrote it makes me wonder if some patients are being left out in the cold for no clinical reasoning I can appreciate.

Thanks, the majority of adults seeking stimulants from my service do not meet criteria. There are a few that do who I will assess on a case by case basis with careful consideration of risks vs benefit and indications of functional impairment. While I realize stimulants are the gold standard for ADHD that does not mean they are appropriate for every situation or that I am obligated to provide them. Although I may take criticism I feel ADHD is over diagnosed and believe stimulants will become more and more problematic as the numbers continue to increase. Attention-Deficit/Hyperactivity Disorder Medication Prescription ....

Although an interesting point was raised about cosmetic psychiatry and I suspect we will see more of this in the future I have zero interest in providing medications for this purpose nor do I feel obligated to continue a diagnosis that is inaccurate or a medication I feel is inappropriate. This also applies to the majority of my <12yo patients with deplorable homes, low frustration tolerance and trauma history who present with an erroneous Bipolar diagnosis on Lithium, Depakote and an antipsychotic.

I personally do not believe a majority of those with childhood ADHD are unable to function without a stimulant as adults. I discuss this with them in detail. They are free to seek care elsewhere if my prescribing philosophy isn't in keeping with their needs.

 

[erg923]

She's definitely taking a thorough history, but she's also administering something called the Integrated Visual and Auditory (IVA-2) Continuous Performance Test, as well as the Adult ADHD Self-Report Scale (ASRS), the Montreal Cognitive Assessment, the Millon Clinical Multi-Axial Inventory III (MCMI-III), and the Personality Assessment Inventory (PAI). She's then writing that the diagnosis of Attention-Deficit/Hyperactivity Disorder "should be considered," because of course she knows that she can't officially rubber-stamp the diagnosis and tell us the patient needs a stimulant.

I know there's no formal cognitive test for ADHD, thanks to you all here on SDN, but no one else in this place knows or cares, I guess. This is just one more hoop to make the patient jump through before we inevitably dispense what they want like the vending machines we are.

I can get on board with a ASRS. And maybe an IVA-2 ..but the rest seems lazy. Or perhaps milking the insurance company? Seems like alot, of uh, tests....

And, I mean, come on dude?! Do they meet the criteria or do they not??? This takes time but is not rocket surgery either.

If you send someone for differential diagnostic assessment to a psychologist, most of the time, you should expect an solid answer and evidence to support, otherwise WTF is the point?

I would gently challenge the point of her evals if you aren't getting answers. It would seem an abrogation of her job duties.

Psychiatric diagnoses, including AD/HD are porous... and don't understand the mentality of waiting until we are "absolutely sure of the right diagnosis" before proceeding with treatment. Historically (1900-1980?), psychiatric diagnosis unfolded during the treatment phase (consistent with its true nature/manifestation).

 

[WisNeuro]

She's definitely taking a thorough history, but she's also administering something called the Integrated Visual and Auditory (IVA-2) Continuous Performance Test, as well as the Adult ADHD Self-Report Scale (ASRS), the Montreal Cognitive Assessment, the Millon Clinical Multi-Axial Inventory III (MCMI-III), and the Personality Assessment Inventory (PAI). She's then writing that the diagnosis of Attention-Deficit/Hyperactivity Disorder "should be considered," because of course she knows that she can't officially rubber-stamp the diagnosis and tell us the patient needs a stimulant.

I know there's no formal cognitive test for ADHD, thanks to you all here on SDN, but no one else in this place knows or cares, I guess. This is just one more hoop to make the patient jump through before we inevitably dispense what they want like the vending machines we are.

Eww, what a garbage ADHD assessment. Most of that is completely useless filler. And yeah, if she's doing an assessment, she needs to be giving a diagnosis. Otherwise, you could just give the ASRS or WURS and come up with "ADHD should be considered" without a useless several hour long "assessment" session.

 

[thoffen]

Thanks, the majority of adults seeking stimulants from my service do not meet criteria. There are a few that do who I will assess on a case by case basis with careful consideration of risks vs benefit and indications of functional impairment. While I realize stimulants are the gold standard for ADHD that does not mean they are appropriate for every situation or that I am obligated to provide them. Although I may take criticism I feel ADHD is over diagnosed and believe stimulants will become more and more problematic as the numbers continue to increase. Attention-Deficit/Hyperactivity Disorder Medication Prescription ....

Although an interesting point was raised about cosmetic psychiatry and I suspect we will see more of this in the future I have zero interest in providing medications for this purpose nor do I feel obligated to continue a diagnosis that is inaccurate or a medication I feel is inappropriate. This also applies to the majority of my <12yo patients with deplorable homes, low frustration tolerance and trauma history who present with an erroneous Bipolar diagnosis on Lithium, Depakote and an antipsychotic.

I personally do not believe a majority of those with childhood ADHD are unable to function without a stimulant as adults. I discuss this with them in detail. They are free to seek care elsewhere if my prescribing philosophy isn't in keeping with their needs.

Appreciate the response. You'll get no argument from me on those where indication is lacking and on the interactions with the diagnosis and stimulants and society and "cosmetic" psychiatry. It is hard to talk about the other patients who have ADHD and do not intersect with this population. I find this population highly under-appreciated and likely to have difficulty adequately reporting their symptoms and level of distress and in many cases attaching to the diagnosis of ADHD or the benefit of stimulant treatment themselves. Unfortunately, strong countertransference reactions to patients inappropriately seeking stimulants biases a look at those patients whom stimulants should be strongly considered.

In that population, you seem to be arguing that you are relatively more likely to conclude that risk outweighs benefit from treatment.

I do want to challenge your bar of "unable to function without a stimulant as adults". Such an absolute is impossible to define, and ludicrous as a boundary for provision of treatment on its face. What you might be trying to say is that you find in many cases the benefit of stimulants on function to be small and the risk of stimulants to outweigh them. Certainly that's fine, but I would like to hear more about your risk assessment in patients whom you believe the diagnosis to be accurate. Separately, though, I fear you may be underappreciating the distress that ADHD imparts. People with ADHD are shrouded in shame from an early age from being met with constant failures to meet expectations that have been inappropriately ascribed to laziness or malice. Stimulants are not the solution to self-esteem repair, however, they may be very important in modifying biologic impairments that enable therapeutic or psychoeducational or relational interventions to take effect. In my experience, distress is far more clinically relevant for an adult with ADHD than dysfunction. The ADHD adult is also likely to have difficulty in communicating that distress or appropriately attributing it to its origin, often to the extent of meeting full criteria for mood and anxiety disorders. It takes an aware clinician to partner with a patient in understanding their distress.

Unfortunately, for applying criteria, we are left with overt symptoms which are largely behavioral and highly transparent to the self-rater. I think the ASRS is a poor measure of the significance of a person's ADHD and a poorly specific diagnostic instrument. It's still a useful tool, but it's hard for me to imagine that anything other than expert clinical evaluation could be appropriate for adult ADHD diagnosis. And that's exceptionally challenging because inter-relater reliability is going to be poor.

All I can suggest is that clinicians who do treat ADHD try to narrow in on people who aren't overtly stimulant seeking but you at least suspect of having the illness and try to appreciate in greater detail how that person has been affected by the symptoms and less how the symptoms operate in the present.

 

[Ceke2002]

My daughter is the react negatively to narcotics, vomited after taking a vicodin for post-tonsillectomy pain. That was awful for her. Myself, on the other hand, when I took a loretab after a tooth surgery during a time when I had a high stress load with a number of suicidal teens and no good treatment options, found that there was a dramatic effect. Within 30 minutes of taking the medication, my level of stress had dropped to the point where I felt like I was lying on the beach in the middle of a two-week vacation. What patients? Who cares? I wasn't feeling high or euphoric in anyway, it had just effectively removed all emotional distress. Powerful stuff for some brains!

Opiates are weird sometimes. Nearly all opiates, including heroin, tend, or have tended to make me violently ill even if I did get varying levels of euphoria off them. These days I prefer to only take those opiates which don't give me that narcotic high, which oddly enough includes Fentanyl. I have no idea why but Fentanyl is the only one of that class of drug which doesn't a) make me sick, and b) make me feel anything beyond just being a bit chilled and sleepy.

Dexamphetamine was weird as well. I had street access to it before I was prescribed it legitimately, and when I was taking it recreationally to get high it would always trigger this compulsive urge to go and score meth. The strange thing was though that it didn't have that same effect when I was taking a properly prescribed amount as directed by my prescribing Psych at the time. Never did work that one out.

 

[Trismegistus4]

I can get on board with a ASRS. And maybe an IVA-2 ..but the rest seems lazy. Or perhaps milking the insurance company? Seems like alot, of uh, tests....

And, I mean, come on dude?! Do they meet the criteria or do they not??? This takes time but is not rocket surgery either.

If you send someone for differential diagnostic assessment to a psychologist, most of the time, you should expect an solid answer and evidence to support, otherwise WTF is the point?

I would gently challenge the point of her evals if you aren't getting answers. It would seem an abrogation of her job duties.

Psychiatric diagnoses, including AD/HD are porous... and don't understand the mentality of waiting until we are "absolutely sure of the right diagnosis" before proceeding with treatment. Historically (1900-1980?), psychiatric diagnosis unfolded during the treatment phase (consistent with its true nature/manifestation).

Eww, what a garbage ADHD assessment. Most of that is completely useless filler. And yeah, if she's doing an assessment, she needs to be giving a diagnosis. Otherwise, you could just give the ASRS or WURS and come up with "ADHD should be considered" without a useless several hour long "assessment" session.

Yeah, I know, it's not very helpful. There are certainly patients I'm happy to have a baseline MOCA on, but overall this is not helpful to me in ruling in/ruling out ADHD. Like I said, it's just one more hoop to make the patient jump through so we can defer starting a stimulant for another month or two, so we can sleep a little easier at night. Temporarily.

Not that sleeping easily at night is feasible in the long run. I was just clicking through my schedule yesterday and realized that for 2 weeks straight, every day, I have had at least one patient on my schedule who is either already getting a stimulant from me, or pestering me to diagnose them with ADHD and start a stimulant. It's gone from an issue that came up in exactly one encounter with one patient in all 4 years of residency, to a daily occurrence. This is unbearable.

A thought I keep having is that this just isn't why I went into psychiatry. It would be as if you did your internal medicine residency, then a cardiology fellowship, then joined a cardiology practice, but found that when you showed up to your first day of work you were being asked to practice heme/onc.

 

[erg923]

Yeah, I know, it's not very helpful. There are certainly patients I'm happy to have a baseline MOCA on, but overall this is not helpful to me in ruling in/ruling out ADHD. Like I said, it's just one more hoop to make the patient jump through so we can defer starting a stimulant for another month or two, so we can sleep a little easier at night. Temporarily.

Not that sleeping easily at night is feasible in the long run. I was just clicking through my schedule yesterday and realized that for 2 weeks straight, every day, I have had at least one patient on my schedule who is either already getting a stimulant from me, or pestering me to diagnose them with ADHD and start a stimulant. It's gone from an issue that came up in exactly one encounter with one patient in all 4 years of residency, to a daily occurrence. This is unbearable.

A thought I keep having is that this just isn't why I went into psychiatry. It would be as if you did your internal medicine residency, then a cardiology fellowship, then joined a cardiology practice, but found that when you showed up to your first day of work you were being asked to practice heme/onc.

Then don't send assessment referrals to this person. They are milking it and not providing clinically useful...anything, apparently? Especially if she is literally documenting "AD/HD should be considered." Well, no ****! That's why I sent them there in the first place, right? If she asks why you are no longer sending her cases, tell her why. Don't be afraid to challenge and/or educate based on what you are learning here and elsewhere about AD/HD assessment.

As much as I hate to say this, for AD/HD, I think it holds true. Use the DSM. The criteria were established for a reason (there really is some science behind the decision to adopt/include certain diagnostic criteria), and the "not otherwise accounted for by" clause is there for a reason too. Don't be afraid to use/adhere to it.

 

[Trismegistus4]

Then don't send assessment referrals to this person. They are milking it and not providing clinically useful...anything, apparently? Especially if she is literally documenting "AD/HD should be considered." Well, no ****! That's why I sent them there in the first place, right? If she asks why you are no longer sending her cases, tell her why. Don't be afraid to challenge and/or educate based on what you are learning here and elsewhere about AD/HD assessment.

As much as I hate to say this, for AD/HD, I think it holds true. Use the DSM. The criteria were established for a reason (there really is some science behind the decision to adopt/include certain diagnostic criteria), and "The not otherwise accounted for by" clause is there for a reason too. Dont be afraid to adhere to it.

But I like having a way to stall the patient for another month or two!

I brought this up in another thread and was accused of "a concrete reading of the DSM," but the criteria are so vague and subjective, and if course if you ask people about them directly, they can easily malinger and just say "yes." It's also been brought up in other threads that we really should be circumventing the subjectivity of self-reporting by gathering history from parents, reviewing pediatrician's notes, reviewing old report cards or parent-teacher conference reports, but as someone else said, this is unpaid grunt work and I'm not spending half an hour on the phone with somebody's mother at 5:00 every day after seeing patients all day. And I do try to use teh "not otherwise accounted for by" clause, but there are people who claim a debilitating inability to concentrate despite not meeting criteria for anything else I can detect.

 

[erg923]

But I like having a way to stall the patient for another month or two!

I brought this up in another thread and was accused of "a concrete reading of the DSM," but the criteria are so vague and subjective, and if course if you ask people about them directly, they can easily malinger and just say "yes." It's also been brought up in other threads that we really should be circumventing the subjectivity of self-reporting by gathering history from parents, reviewing pediatrician's notes, reviewing old report cards or parent-teacher conference reports, but as someone else said, this is unpaid grunt work and I'm not spending half an hour on the phone with somebody's mother at 5:00 every day after seeing patients all day. And I do try to use teh "not otherwise accounted for by" clause, but there are people who claim a debilitating inability to concentrate despite not meeting criteria for anything else I can detect.

Well, using the DSM does not equate to doing checklist psychiatry unless you make it so. Clinical judgment is all over the DSM and its criteria sets. I understand its not something you want to do. So your current setting is probably not for you, as you have said before. I'm just trying to push back on this notion that we have to do all this fancy testing of cognitive and personality functioning to arrive at this diagnosis. You dont. You do the best you have with what we got.

 

[smalltownpsych]

But I like having a way to stall the patient for another month or two!

I brought this up in another thread and was accused of "a concrete reading of the DSM," but the criteria are so vague and subjective, and if course if you ask people about them directly, they can easily malinger and just say "yes." It's also been brought up in other threads that we really should be circumventing the subjectivity of self-reporting by gathering history from parents, reviewing pediatrician's notes, reviewing old report cards or parent-teacher conference reports, but as someone else said, this is unpaid grunt work and I'm not spending half an hour on the phone with somebody's mother at 5:00 every day after seeing patients all day. And I do try to use teh "not otherwise accounted for by" clause, but there are people who claim a debilitating inability to concentrate despite not meeting criteria for anything else I can detect.

I hate referrals like this. Don't kick the can to me. If you want to rule out learning disabilities or get an idea of what their cognitive function, then send them to me by all means, but if it is just another hoop to jump through, then ugh! I would suggest using your clinical judgement and experience and begin differentiating between the straight-up drug addicts, the people who can really benefit from stimulant medication, and the folks who are more iatrogenically dependent because of poor or inaccurate diagnoses in the past and then come up with strategies to address each of these rough categories.

 

[erg923]

I hate referrals like this. Don't kick the can to me. If you want to rule out learning disabilities or get an idea of what their cognitive function, then send them to me by all means, but if it is just another hoop to jump through, then ugh! I would suggest using your clinical judgement and experience and begin differentiating between the straight-up drug addicts, the people who can really benefit from stimulant medication, and the folks who are more iatrogenically dependent because of poor or inaccurate diagnoses in the past and then come up with strategies to address each of these rough categories.

A psych/neuropsych testing requests that states: "To asses level of cognitive functioning" without something else to pull the trigger will be denied everytime when sent for peer review.

 

[erg923]

A thought I keep having is that this just isn't why I went into psychiatry. It would be as if you did your internal medicine residency, then a cardiology fellowship, then joined a cardiology practice, but found that when you showed up to your first day of work you were being asked to practice heme/onc.

Awww, @Trismegistus4 Do you feel like this?

 

[Trismegistus4]

Well, using the DSM does not equate to doing checklist psychiatry unless you make it so. Clinical judgment is all over the DSM and its criteria sets. I understand its not something you want to do. So your current setting is probably not for you, as you have said before. I'm just trying to push back on this notion that we have to do all this fancy testing of cognitive and personality functioning to arrive at this diagnosis. You dont. You do the best you have with what we got.

I understand and agree with you. It's just that I keep encountering this conundrum wherein patients insist they have ADHD/have a functionally impairing inability to concentrate when I don't think they meet criteria for the diagnosis. I can't see any way around that other than telling such people flat-out "I don't do that," which I don't have my current employer's support to do.

I hate referrals like this. Don't kick the can to me. If you want to rule out learning disabilities or get an idea of what their cognitive function, then send them to me by all means, but if it is just another hoop to jump through, then ugh!

Don't get me wrong. We no longer refer out to psychologists in the community for ADHD testing (most of the time when we did was before I joined this place, but AFAIK they didn't decline these referrals.) This task is part of what this in-house psychologist is "for." It was announced to us as good news that she was going to start doing this testing. I realize it's not helpful, but this is what the powers that be at my workplace have decided on and I didn't have input into it.

I would suggest using your clinical judgement and experience and begin differentiating between the straight-up drug addicts, the people who can really benefit from stimulant medication, and the folks who are more iatrogenically dependent because of poor or inaccurate diagnoses in the past and then come up with strategies to address each of these rough categories.

Into which of your three categories would you place the people who have never been diagnosed with ADHD nor taken a stimulant, and whom I don't think meet criteria, but are certain they have ADHD and need a stimulant? I mean, I guess if you're on board with the "cosmetic psychiatry" philosophy, if you agree with Jose Canseco that there's nothing wrong with performance-enhancing drugs, you could say such people can really benefit from stimulant medication!

 

[hamstergang]

I understand and agree with you. It's just that I keep encountering this conundrum wherein patients insist they have ADHD/have a functionally impairing inability to concentrate when I don't think they meet criteria for the diagnosis. I can't see any way around that other than telling such people flat-out "I don't do that," which I don't have my current employer's support to do.

You don't tell such patients that you don't treat ADHD or prescribe stimulants, you tell them that you don't think they have ADHD. That's it, end of appointment. They came to you for your opinion and you gave it -- why is there anything else to do?

 

[Attending1985]

I hate referrals like this. Don't kick the can to me. If you want to rule out learning disabilities or get an idea of what their cognitive function, then send them to me by all means, but if it is just another hoop to jump through, then ugh! I would suggest using your clinical judgement and experience and begin differentiating between the straight-up drug addicts, the people who can really benefit from stimulant medication, and the folks who are more iatrogenically dependent because of poor or inaccurate diagnoses in the past and then come up with strategies to address each of these rough categories.

If you suspect abuse/diversion do UDS at start of therapy then random UDS and pill counts during treatment. We have stimulant contracts that everyone is required to agree to which states this will be done and scripts will automaticasl be discontinued permanently if patient fails. I know that doesn’t solve all of your problem but it may solve some.

 

[Trismegistus4]

You don't tell such patients that you don't treat ADHD or prescribe stimulants, you tell them that you don't think they have ADHD. That's it, end of appointment. They came to you for your opinion and you gave it -- why is there anything else to do?

Because they keep trying to argue with you that yes, they do have it, listing off multiple symptoms they have that align with the DSM criteria, asking you "how can you say I don't have it when I have all these symptoms?" or asking you "then why can't I concentrate" or pleading "but I'm about to get fired from my job/fail out of grad school for lack of focus?" What do you say then?

 

[hamstergang]

Because they keep trying to argue with you that yes, they do have it, listing off multiple symptoms they have that align with the DSM criteria, asking you "how can you say I don't have it when I have all these symptoms?" or asking you "then why can't I concentrate" or pleading "but I'm about to get fired from my job/fail out of grad school for lack of focus?" What do you say then?

"I'm sorry but I disagree for the reasons I already stated. If you'd like to get a second opinion, here are some other referrals."

And eventually, "I'm sorry but we really have to go. I see that we still don't agree so why don't you check out those other doctors I gave you the name of?"

You're not trying to win the argument or convince them. You reached a conclusion and their after-the-evaluation arguments shouldn't change that. So the goal at that point is just to get them out of your office as you don't feel you can help them.

 

[smalltownpsych]

I understand and agree with you. It's just that I keep encountering this conundrum wherein patients insist they have ADHD/have a functionally impairing inability to concentrate when I don't think they meet criteria for the diagnosis. I can't see any way around that other than telling such people flat-out "I don't do that," which I don't have my current employer's support to do.


Don't get me wrong. We no longer refer out to psychologists in the community for ADHD testing (most of the time when we did was before I joined this place, but AFAIK they didn't decline these referrals.) This task is part of what this in-house psychologist is "for." It was announced to us as good news that she was going to start doing this testing. I realize it's not helpful, but this is what the powers that be at my workplace have decided on and I didn't have input into it.


Into which of your three categories would you place the people who have never been diagnosed with ADHD nor taken a stimulant, and whom I don't think meet criteria, but are certain they have ADHD and need a stimulant? I mean, I guess if you're on board with the "cosmetic psychiatry" philosophy, if you agree with Jose Canseco that there's nothing wrong with performance-enhancing drugs, you could say such people can really benefit from stimulant medication!

I would most likely place them in the category of person with substance abuse problem. Are they on probation or some type of diversion program or are they using it to counter effects of etoh consumption? Also, if they are using it to enhance performance, which is popular for some college students apparently or maybe some imdustries, then do you really want to play into that. “No” is a complete sentence. As hamstergang said, you don’t have to convince them of anything. In fact, I frequently help my patients to learn how to avoid arguments and improve communication by not explaining or justifying, or trying to convince. Whenever I do find myself trying to convince a patient of something, I know I’m in trouble. Sometimes I’m able to extricate myself, other times I don’t recognize until after patients leaves. Then I’m shaking my head and trying to figure out what that was all about as far as my own countertransference and/or being pulled into an enactment.

 

[AcronymAllergy]

And RE: records review, if the psychologist is performing the evaluation, this is something she could/should be doing (and can include when billing for test interpretation, records review, and report writing). I agree that the MoCA, in this situation, doesn't really make any sense. I could see MMPI/PAI/MCMI if there's question of other contributing MH factors, and for a few other reasons (e.g., response bias).

 

[randomdoc1]

I feel your pain Trismegistus4. An appropriate ADHD evaluation requires a lot of grunt work that is poorly reimbursed if at all. I did this when I first started my practice and had the time, but in most cases, I find people have already made up their minds and just leave angry they're not getting 70mg of Vyvanse with 10mg Adderall IR five times a day for break through (jk). Some reasonable protocols you can apply which could weed some folks out who truly are not in it for the right reason include random UDS (with confirmation as you can sometimes get false positives) and getting an ROI to speak with someone who can give a good reliable developmental history. If they refuse, then I say I'm not able to give them an appropriate evaluation (my understanding is there is data that shows how we see things now can strongly distort our perceptions of ourselves in the past). You can also try to apply the Barkley and I believe there is a way you can bill for that as an MD but again, I would inform them I really need a person I can speak with who can give a reliable history. I also would not tell them specifically I am getting a Barkley and just say I will be using some scales (because some patients will try to get their family to give scripted answers), I just say I need to gather collateral and slip in the Barkley questions while also asking about other psychiatric symptoms. But it ultimately boils down to getting a good developmental history. Also, another place where the truth really comes out as to if they really do have ADHD is if they truly have impairment in 2+ settings. Most of the people who came to me just complained about work and apparently everything else was great...that doesn't really match up well. I'm just looking forward to setting up my own shop, you've probably seen my other threads. I'm getting a nice sexy website up and found a sleek and smokin' hot building to rent from full of other medical specialties. I'm in good enough financial standing that I can afford the high end look of the place and I'll be subspecializing in depression, anxiety, some PTSD, applying TMS. I'm just telling folks that sorry, ADHD is not my specialty, but here is a list of people who may be able to help and have a nice day.

 

[Trismegistus4]

"I'm sorry but I disagree for the reasons I already stated. If you'd like to get a second opinion, here are some other referrals."

And eventually, "I'm sorry but we really have to go. I see that we still don't agree so why don't you check out those other doctors I gave you the name of?"

You're not trying to win the argument or convince them. You reached a conclusion and their after-the-evaluation arguments shouldn't change that. So the goal at that point is just to get them out of your office as you don't feel you can help them.

Thanks for post this. Reading it helped me to take a step back and look at this issue from a bigger-picture perspective. For some reason I've become mired in this idea that once someone comes in for an initial visit with me, I'm obligated to have an ongoing relationship with them. Probably because I'm new to this type of setting and there isn't much collegiality or support here. The other psychiatrists just get through seeing their own patients, check out, and go home. So I don't have anybody to bounce ideas off of.

What about the people who claim, or even have documentary evidence (e.g., pediatrics notes) of, a childhood diagnosis? That is particularly frustrating because many of them just breeze in saying "I just moved in from out of town, I've been on ADHD meds since I was 10, I saw a new PCP here and asked him to continue them, but he wanted me to see you" or "I had ADHD as a kid, but stopped taking meds in high school, and now I need to restart them because I'm about to take another crack at college," expecting you to just quickly sign a scrip for Adderall and send them on their way. Do you still have no problem, after getting their history and deciding they don't meet criteria because, say, they don't have symptoms in 2 or more settings, saying "nope, I don't think you have ADHD and I'm not going to prescribe a stimulant" while they're dangling this peds note in front of your face?

Also, another place where the truth really comes out as to if they really do have ADHD is if they truly have impairment in 2+ settings. Most of the people who came to me just complained about work and apparently everything else was great...that doesn't really match up well.

That's interesting. I definitely get a fair amount of that, but I also get a lot of people who are pan-positive by history, and thus I can't tell the difference between genuine symptoms and malingering. With many of them it's like playing whack-a-mole... every time you counter one objection, another one pops up. For example, when dealing with people who don't have a childhood history of ADHD, every one of them will say "but that was the 80's, it was virtually unknown back then!" or "I couldn't focus or concentrate at all in school, but I got by by getting tons of extra help and taking twice as long as all the other kids and my parents helping me with my homework!" or "all my teachers thought I had it, but my parents didn't believe in it so they never got me tested!" or "my doctor diagnosed me with it, but my parents didn't believe in meds so they never gave me treatment!" I mean, what do you say to that?

I'm just telling folks that sorry, ADHD is not my specialty, but here is a list of people who may be able to help and have a nice day.

Was it you who said in another thread that you had to just stop taking ADHD referrals because they had become like 50% of your new patient referrals? So true, and so sad.

BTW, @thoffen mentioned Strattera upthread. Has anyone ever had a patient who did not have a problem with the cost of Strattera? For the umpteenth time this past week, I prescribed it for a patient who then called in the next day after going to the pharmacy, saying it was $150 after insurance and asking me to prescribe something else because that was too expensive. I swear, this happens every time, with lots of different insurances, and I have almost never gotten someone to actually take Strattera, because of cost. Could this vary by geographical region? Anyone else run into this so often?

 

[Trismegistus4]

I would most likely place them in the category of person with substance abuse problem. Are they on probation or some type of diversion program or are they using it to counter effects of etoh consumption? Also, if they are using it to enhance performance, which is popular for some college students apparently or maybe some imdustries, then do you really want to play into that. “No” is a complete sentence. As hamstergang said, you don’t have to convince them of anything. In fact, I frequently help my patients to learn how to avoid arguments and improve communication by not explaining or justifying, or trying to convince. Whenever I do find myself trying to convince a patient of something, I know I’m in trouble. Sometimes I’m able to extricate myself, other times I don’t recognize until after patients leaves. Then I’m shaking my head and trying to figure out what that was all about as far as my own countertransference and/or being pulled into an enactment.

Would you say someone has a substance abuse problem if they want a stimulant because they think they have ADHD even though they don't meet criteria? The most common presentation, for me, is of someone looking back over their life, deciding they've never really lived up to their full potential because of procrastination and motivation problems, reading about ADHD, strongly identifying with the diagnosis as they've read about it ("the more I read about it, doc, the more everything I read describes me to a T!") and coming in to me convinced that they have it. But they don't satisfy the diagnostic criteria. These are often not people who have a history of any substance abuse, have never tried a stimulant (at least, not that they're admitting to me,) and are not currently taking one. You could perhaps say they want in a subconscious way to use it to enhance performance, but this is not the way they consciously frame the issue, and it's not something they have tried to date.

Forgot to add: the countertransference is huge for me in these cases, because of the procrastination/motivation issues*, which is probably why I'm in such distress over this, and why I strongly prefer to just recuse myself from the world of ADHD concerns entirely.

*I.e., "listen, lady, I could say all the exact same things about myself, and if I'd thrown my pride and sense of shame out the window, gone doctor-shopping and drug-seeking in medical school, and scored myself stimulants, I probably would have studied hard enough to get a 260 on Step I, honored all my 3rd year rotations, and matched into radiology instead of psychiatry, and I wouldn't be sitting here listening to you beg me for stimulants!"

 

[Ceke2002]

Would you say someone has a substance abuse problem if they want a stimulant because they think they have ADHD even though they don't meet criteria? The most common presentation, for me, is of someone looking back over their life, deciding they've never really lived up to their full potential because of procrastination and motivation problems, reading about ADHD, strongly identifying with the diagnosis as they've read about it ("the more I read about it, doc, the more everything I read describes me to a T!") and coming in to me convinced that they have it. But they don't satisfy the diagnostic criteria. These are often not people who have a history of any substance abuse, have never tried a stimulant (at least, not that they're admitting to me,) and are not currently taking one. You could perhaps say they want in a subconscious way to use it to enhance performance, but this is not the way they consciously frame the issue, and it's not something they have tried to date.

Forgot to add: the countertransference is huge for me in these cases, because of the procrastination/motivation issues*, which is probably why I'm in such distress over this, and why I strongly prefer to just recuse myself from the world of ADHD concerns entirely.

*I.e., "listen, lady, I could say all the exact same things about myself, and if I'd thrown my pride and sense of shame out the window, gone doctor-shopping and drug-seeking in medical school, and scored myself stimulants, I probably would have studied hard enough to get a 260 on Step I, honored all my 3rd year rotations, and matched into radiology instead of psychiatry, and I wouldn't be sitting here listening to you beg me for stimulants!"

The thing is though, for those of us with a bona fide diagnosis of ADD/ADHD it's not something that just effects one area of our lives. It's not like we struggle to study effectively, or get to work on time, but everything else is just hunky dory. I voluntarily don't drive, because I'm too much of a risk to other road users; my husband often needs to have the patience of a saint, because my ADD can put a strain on him and in turn our marriage; my established friends have often needed to give people who are meeting me for the first time a 'pre introduction' talk, because my ADD has been known to effect my ability to socialise and/or hold a conversation properly; attending a sporting event is a nice day out, but otherwise useless for me. I could go on, but my point is this is something that impacts a wide area of people's lives, and not necessarily just those that are most obvious.

 

[AcronymAllergy]

Agreed RE: it should/needs to be affecting other areas of their lives. This is why collateral report is so important. The patient him/herself may not realize or think to mention ways in which other aspects are affected, in part because friends/acquaintances, and sometimes even (or especially) family, can be more forgiving and patient than bosses, so the receipt of criticism isn't always as frequent or direct. Generally speaking, if it's ADHD, other people who've spent any extended measure of time with the person will have noticed.

 

[Jules A]

Forgot to add: the countertransference is huge for me in these cases, because of the procrastination/motivation issues*, which is probably why I'm in such distress over this, and why I strongly prefer to just recuse myself from the world of ADHD concerns entirely.

Important to recognize but worth noting in my experience there is significant countertransference in the opposite direction also. I know a couple of psychiatrists on stimulants who seem to have a notable number of adult patients receiving this diagnosis. Same with benzodiazepines, two of the most anxious physicians I know hand them out like Skittles.

I remain mindful of the small population of adult patients who have distress secondary to ongoing ADHD symptoms however the majority I am getting are either drug seeking or looking for performance enhancement, the latter being high functioning, successful professionals with no apparent shame or shortage of self-esteem.

 

[cara susanna]

I do ADHD assessments for adults in my current position (I'm aware that we can't really test for ADHD but no one here seems to believe that, especially the prescribers). I generally give a computerized attention test, a self-report ADHD measure, and thorough clinical interview. Even then, sometimes I can only say that I can't rule it out or confirm it based on testing alone. The childhood history is really the hardest part.

 

[WisNeuro]

I do ADHD assessments for adults in my current position (I'm aware that we can't really test for ADHD but no one here seems to believe that, especially the prescribers). I generally give a computerized attention test, a self-report ADHD measure, and thorough clinical interview. Even then, sometimes I can only say that I can't rule it out or confirm it based on testing alone. The childhood history is really the hardest part.

Is it the CPT? If so, just stop, that thing is godawful terrible.

 

[cara susanna]

Is it the CPT? If so, just stop, that thing is godawful terrible.

Yup, CPT. I'm aware of the issue, I was at a VA with a very reputable neuro dept on internship and they were very opposed to ADHD testing. But, like I said, people here expect it and won't even prescribe stimulants without the patient having taken one. Hopefully I can work to promote education on this in the long-term.

 

[WisNeuro]

Yup, CPT. I'm aware of the issue, I was at a VA with a very reputable neuro dept on internship and they were very opposed to ADHD testing. But, like I said, people here expect it and won't even prescribe stimulants without the patient having taken one. Hopefully I can work to promote education on this in the long-term.

Ugh, that thing has like 0 specificity and no real validity check.

 

[MacDonaldTriad]

"Adult ADHD" isn't in the DSM. It isn't covered by any major textbook and many providers do not treat it. You may rationalize that you are providing a service to people who are being denied help by others, but I would argue that a less altruistic motivation is more likely.

 

[WisNeuro]

Adult ADHD is not in the DSM, but, people who legitimately have the disorder in childhood do sometimes grow up to be adults. All depends on where you want to put your cut points for minimizing type I or II errors in treating people.

 

[Jules A]

Adult ADHD is not in the DSM, but, people who legitimately have the disorder in childhood do sometimes grow up to be adults. .

Agreed. And so we are left to consider what is the likely percentage of adults who continue having symptoms to a degree so significant it requires a stimulant?

 

[Attending1985]

I luckily don’t get that many ADHD evals but I inherited a ton of patients from an NP who are on stimulants. From her notes it seems she literally put some on stimulants our of pity. It has been exhausting to say the least. Some I have gotten off of them with failed uds some have come off willingly when we discuss that they likely don’t have ADHD. Others I have left on. I look at is as if they’re not failing uds or pill counts and they’re telling me it helps them be a more productive member of society (may or may not be accurate) maybe it’s not the worst thing? I’ve never thought of just saying I don’t prescribe stimulants to adults. I guess I’ve seen a few who I think genuinely have significant attentional problems that do better on a stimulant than combinations of other psychotropics they’d be prescribed otherwise.

 

[smalltownpsych]

Would you say someone has a substance abuse problem if they want a stimulant because they think they have ADHD even though they don't meet criteria? The most common presentation, for me, is of someone looking back over their life, deciding they've never really lived up to their full potential because of procrastination and motivation problems, reading about ADHD, strongly identifying with the diagnosis as they've read about it ("the more I read about it, doc, the more everything I read describes me to a T!") and coming in to me convinced that they have it. But they don't satisfy the diagnostic criteria. These are often not people who have a history of any substance abuse, have never tried a stimulant (at least, not that they're admitting to me,) and are not currently taking one. You could perhaps say they want in a subconscious way to use it to enhance performance, but this is not the way they consciously frame the issue, and it's not something they have tried to date.

Forgot to add: the countertransference is huge for me in these cases, because of the procrastination/motivation issues*, which is probably why I'm in such distress over this, and why I strongly prefer to just recuse myself from the world of ADHD concerns entirely.

*I.e., "listen, lady, I could say all the exact same things about myself, and if I'd thrown my pride and sense of shame out the window, gone doctor-shopping and drug-seeking in medical school, and scored myself stimulants, I probably would have studied hard enough to get a 260 on Step I, honored all my 3rd year rotations, and matched into radiology instead of psychiatry, and I wouldn't be sitting here listening to you beg me for stimulants!"

It doesn't sound like a substance abuse problem although keep in mind that those who do are very practiced at hiding it. Whether or not the person has potential for abuse, if you don't think they have ADHD, then try to provide the help that they need. Be upfront and direct about it. Medications have risk and your job is to minimize risk by only prescribing medications when appropriate. I find it hard to say no too and got sucked into something messy with a school district a few weeks back because of that.

 

[erg923]

Thanks for post this. Reading it helped me to take a step back and look at this issue from a bigger-picture perspective. For some reason I've become mired in this idea that once someone comes in for an initial visit with me, I'm obligated to have an ongoing relationship with them. Probably because I'm new to this type of setting and there isn't much collegiality or support here. The other psychiatrists just get through seeing their own patients, check out, and go home. So I don't have anybody to bounce ideas off of.

What about the people who claim, or even have documentary evidence (e.g., pediatrics notes) of, a childhood diagnosis? That is particularly frustrating because many of them just breeze in saying "I just moved in from out of town, I've been on ADHD meds since I was 10, I saw a new PCP here and asked him to continue them, but he wanted me to see you" or "I had ADHD as a kid, but stopped taking meds in high school, and now I need to restart them because I'm about to take another crack at college," expecting you to just quickly sign a scrip for Adderall and send them on their way. Do you still have no problem, after getting their history and deciding they don't meet criteria because, say, they don't have symptoms in 2 or more settings, saying "nope, I don't think you have ADHD and I'm not going to prescribe a stimulant" while they're dangling this peds note in front of your face?

1. Again, your work environment leaves much to be desired in terms of lending itself to good practice. I mean, really, you guys don't talk...consult, have discipline meeting, rounds, nothing? I don't even work in a clinical service setting anymore and yet all the psychiatrists, psychologists, and clinical officers still at least have disciplinary specific meetings to discuss relevant business and clinical issues. Unless you are leaving tomorrow, I would take some initiative here and try to change the culture for the better. Again, I understand you may not want to, or think this is your job (its really your medical directors job, I suppose?) but why not? What could it hurt?

2. Lastly, to echo what other people have said: This is not a negotiation. You are NOT a used care salesman. Patient centered care does NOT mean patient dictated care. As unpleasant as it is, sometimes you might wants to say (after laying out your clinical rationale) "I'm not going to debate this with you any further. Here is where you can find other equatable services." Unless you are working for some high end private practice, your medical director should support your clinical judgement here. You have actually suggested that she said you should exercise it, perhaps more so than you have thus far with this population????

 

[Trismegistus4]

Important to recognize but worth noting in my experience there is significant countertransference in the opposite direction also.

It's called "transference" when it's the patient's feelings about the therapist.

"Adult ADHD" isn't in the DSM. It isn't covered by any major textbook and many providers do not treat it. You may rationalize that you are providing a service to people who are being denied help by others, but I would argue that a less altruistic motivation is more likely.

"Adult ADHD" isn't in the DSM, but "ADHD" is, and unfortunately, "The patient is under the age of 18" is not one of the diagnostic criteria.