CorePsychBlog

ADHD Medical Ambiguity: Medical Treatment Can Encourage Denial

Image by {Alicia} via FlickrADHD Denial is Pervasive:
Both The Public and Some Medical Treatment Contributes to ADHD Denial

Responding to an article on the pervasive issues with the public regarding denial of ADHD as a medical illness written recently by Bryan Hutchinson over at ADDerWorld I realized that several aspects of the current medical diagnostic and treatment grid can also contribute to ADHD denial.

Said another way, if this 'medical finding/result' isn't right, the denial/conclusion becomes: he/she couldn't have ADHD.

New Article Up on ADHD Denial

So, I took a few moments to organize some thoughts over at EzineArticles on ADHD denial challenges. The title and link for the article: ADHD Denial - Medical Ambiguity Creates Significant Problems These medical oversights walk into my office everyday from other sectors of the medical community. This article describes in detail medical and medication patters that often encourage missed diagnosis and missed opportunities for treatment - that can last an entire lifetime.

A reminder - this is not an article for finger pointing and counterproductive comparisons - it's a report of events that occur in the context of misinformation, and an evolving view of what it takes to actually manage those with ADHD in the current context of modern neuroscience.

What to do?
Do take a look at the article, download and distribute it as you wish,  and do send this specific note to your friends/colleagues, because this kind of discussion of the current sea of misinformation just might help that person in ADHD denial rethink their resistance to change. Notice the email link [and at the Green Share Button] at the bottom of the page here - your email, posting or notification could be helpful.

Grumpy Outed: ADD and Depression For A Lifetime

Image by Brain Toad Photography via FlickHoliday Case Report:
Grumpy was one of the Seven Dwarfs in the classic Disney film Snow White [1937]. This week I met his alter ego. In fact, Grumpy came to my office in Va Beach, and we found a new role for him at ~  a real ~ 50 years old.

As you may recall, the original Grumpy was named Grumpy because his attitude was short tempered, and negative about almost everything, - but clearly, in the end, showed a soft heart and saved the day to protect Snow White from the Wicked Queen.

Like the Disney character, our modern/office Grumpy’s attitude covered some uncomfortable life long challenges that often go overlooked under the limited perspective: “that’s just the way he is.”  My positive findings: On the contrary, he can significantly, dramatically, change in a week.

True History, Actual Case Report:
At over 50 years old, this Grumpy is married, loves his craftsman job, worked hard for years in military service, and after all of these years of working within character, his wife just doesn’t want him to be grumpy any more. She lives on the downstream side of his pervasive negativity and easy irritation. He gets angry too easily, especially when working in his craft, and in spite of his comic costume remains distant, isolated and unable to deal with groups or family. He has an underlying warm heart, but on careful questioning had difficulty separating himself from his character, from the Grumpy character, and quite surprisingly, he had difficulty even seeing his intelligence, humorous characterization, and abiding good will.

Said simply, he presented as caught in character, Grumpy-stuck, with a wish to break out.

We laughed together in this first interview with a psychiatrist, as he elaborated on the role Grumpy has played in his life. Just a few anecdotes indicate that he has 3 Grumpy baseball hats and wears a Grumpy hat everyday, and has between 12 and 15 Grumpy tee shirts, which go with the whole outfit. In my office he presented as short, very robust and muscular in stature, mustache, with Grumpy hat, Grumpy tee shirt and a delightful humorous attitude that belied his actual hopeless feeling of finding himself completely stuck in the Grumpy role. He recounted with great pleasure meeting Grumpy at Disneyland, and missed him on one trip when Grumpy didn't show on a trip with grandkids to Disneyland.

He clearly thought that seeing a psychiatrist would provide no answers, some further humiliation, - and it’s clear he feared further retribution for his “character disorder.” In short, he presented with a pessimistic attitude about recovery as many of these men do.

The findings are what you might expect: He had defensively taken on the Grumpy role as he has suffered for years with an underlying treatable depression based partly upon his limited achievements in high school, wherein he was no longer able to keep up, - after leading the class in grade school. In the military, he performed outstandingly well as a leader, rose through the ranks taking on the difficult jobs, and reached an officer status from admission as enlisted.

His ADD presentation was less than obvious: He wasn’t Inattentive or Hyperactive, he was ADD avoidant, procrastinating on the unpredictable, mastering the predictable, and suffering with abundant cognitive anxiety – an abiding ‘obsessional’ attempt to correct his own uncontrolled self-critical attitude. Grumpy has for years been grumpy largely with himself, and makes a joke of his attitude to soften the blow for others.

The Interesting "Happy" Science Findings:
Antidepressants recently started by another physician made him more Grumpy, as selective-serotonin agents [SSRI like Prozac] characteristically down-regulate dopamine and aggravate underlying ADD. [See multiple references with peer reviewed notes on my website below for more on this common problem.] With a greater sense of futility that last door, that last opportunity at self realization, was swinging shut for the rest of his life.  His thoughts: “Psychiatry doesn’t work, I shouldn’t have gone in the first place, no one can deal with Grumpy, I might as well go off by myself to watch the remaining years go slowly by.”

The simple solution: This intervention strategy is not at all complicated – treat the untreated Adult ADD and the abiding depression simultaneously.  His cognitive, ADD mind, will be relieved of obsessional worry, and his depression will dissolve in less than one week.

"Character disorders with depression" result more from biology than is often appreciated - more on Clint Eastwood's 'Stranger' and Grumpy in a later post on - why guys simply don't get in for review.

The good news: this Grumpy guy will be wearing his Grumpy outfits with a different sense of humor and self discovery… he’s been a great guy all along. He probably still blushes when kissed by Snow White. Together we enjoyed considering how the rest of his life might work out as Happy, that other cool dwarf.

Best wishes to you here in the States for a 'Happy' Thanksgiving -

ADD, ADHD Stimulant Medication Dosage: Underdose or Overdose?

Image via Wikipedia

The Trickiest Measurement: The 'Therapeutic Window' Bottom is Over-the-Top

Remember the 'Top of the Window' is ranging too high in dosage, the 'Bottom of the Window' is too little dosage. The worst thing that can happen when you are working to carefully correct stimulant meds: an overdose upwards because that apparent 'bottom,' the apparent under dose, was actually too much meds and the patient was actually coming out of the 'top.' Here is how that looks clinically using these 7 pointers.

1. When the Med Dose is too High: it can look like the patient is no longer focused, they are hyper, confused, and cognitively not as sharp. Every visit, every medication review, every question in medication adjustment must consider the possibility that these symptoms mean the drug dosage is too high.
2. OverFocus Looks Like UnderFocus: This single oversight is the absolutely biggest problem with stimulant medications today: New medications work so well the top actually appears to be insufficient dosing. Clinically it appears as if they need more medication. The big problem: More meds in this situation can make the patient much worse, perhaps dangerous, certainly more unable to focus, due to that over-focusing.
3. Side Effects are in Evidence: This phenomenon, actually going out the top - while looking like the bottom - always has side effects. Side Effects are often subtle, so inquiry must carefully review these: appetite is down, weight loss occurs, agitation is higher, compliance appears worse. angered more easily, sleep is disturbed significantly when no sleep problems previously occurred.
4. The Patient argues that It Works Well and Can't See the Side Effects. They are so happy to have a new focus they push to have the dose up because they do, so desperately, wish to improve.
5. The School Is Pleased - In A Structured Setting Side Effects Are Less Obvious. This report often throws off the Treatment Team, because the team is not trained to look themselves for these details, but relies to heavily on what the teachers say, ignoring thier own personal concerns.
6. Peer Relationships Suffer. People closest to the patient see odd changes and feel put off by the pressures and new, overbearing attitude that has slowly emerged.
7. Malevolent Odd Actions, Never Before Experienced, Occur. The patient becomes more destructive in odd ways. A manager who never gossips begins to gossip. A child decides to hit his favorite pet, and never did before. A child may start a fire in the back yard, or try to drive the family car... 'just for fun.' The symptoms at first seem quite innocent but in the overall are maladaptive. 

Check out the full article over at EzineArticles.com

Do review these seven tips carefully. Dropping the medication down, even a small amount, under these circumstances will often reveal the person who is evenly focused, who is emotionally more on track, and performing better throughout the day. Dropping the medication down will take them out of the 'Top' and put them back within the best therapeutic dosage, back in the targeted 'Therapeutic Window.'

Bottom Line By following simple guidelines and the metaphor of the 'Therapeutic Window' you will be more able to adjust dosing correctly, and effectively - so you and yours don't feel like treatment failures. I invite you to sign up now for the early bird special set of gifts for my new book "Fixing the ADD Madness: A Patient's Guide to Stimulant Medication Details," [upper right sidebar here]-And enjoy the bonus gift on the thank you page for signing up early -- simply to express your interest in the book: a 1200 word article on The 10 Biggest Problems With ADD/ADHD Medications, and a 17 min audio review of the article.

Brain, ADD, Gluten Are Connected: Dr Tom O'Bryan's Fall Lectures

Image via WikipediaDr O'Bryan Discusses Immune Dysfunction and Brain Consequences

This is a Personal Note To Me From Dr Tom O'Bryan:

"I'm in the midst of my Fall seminar series on the Neurological and Musculoskeletal Complications of Gluten Sensitivity. As you know, and like you, I have a passion to get the word out about the impact of our food selections on the function of our bodies.

These talks are for health care providers, so some of your list may appreciate the fall schedule. [Dr O'Bryan is from Chicago and you can learn more about Dr O'Bryan here.]

These are the cities I'll be presenting my full-day program in before the end of the year:

November 8, 2008     New York, NY
November 9, 2008     Boston, MA
November 16, 2008     Denver, CO
November 22, 2008     Minneapolis, MN
December 6, 2008     Phoenix, AZ

I am quite comfortable in assuring Participants that by the end of the day, they will have a deeper understanding of the 'Big Picture' of this Gluten Sensitivity Syndrome than 95% of their Colleagues out there. So perhaps some of your Dr.s who read your site, will be interested. I'll include in this email one
Summary Sheet of comments about the day. And it is quite representative of what we hear every week.

I also want to connect with the lay public. So in 4 of these cities, we've been able to setup lectures to the local Celiac Support Groups. That 2-hour presentation (with 1-hour for questions) is entitled

'How Wheat Effects the Brain:The Neurological and Cognitive Complications of Gluten Sensitivity'

PRESENTATION OBJECTIVES

The objective of this presentation is to:
1)    walk attendees through the history of medicine's understanding of wheat/gluten sensitivity
2)    recognize the diversity of symptoms patients may present with as a result of wheat/gluten sensitivity
3)    become familiar with the effectiveness of treatment for the various presentations of wheat/gluten sensitivity

For References and City Contacts Continue...

ADD, ADHD Medication: Overview Summary - Therpeutic Window

Image by Shutterhack via Flickr

ADD/ADHD Medication Treatment -
7 Overview Tips For Stimulant Dosage With the Use Therapeutic Window and Correct Medication Dosage - Brief Summary

If you simply pay attention to these basic details the possibility of the biggest two problems with ADD/ADHD medications are almost naturally corrected - no more frustration, no more fear of adverse effects. This article is a summary of three other articles here at EzineArticles with greater details.

7 Therapeutic Window Tips to find the right  dosage and the right ADD/ADHD medication - it's easy if you have basic guidelines.

   1. The Entire Problem with Stimulant Meds can be summarized in two ways- Too Much, or Not Enough. Inside the Therapeutic Window - is the Correct Dosage, not too much, not too little, lasting exactly the right duration through the day. Stimulant meds don't last all day, thus the problem with timing. Everybody is built different metabolically, thus the problems with dosage.
   2. The Therapeutic Window is Specific for each individual adult or child, not based on your mother, father, sister, brother, or great aunt experience with medications in general or stimulants specifically. Yes, some families have medication sensitivities which appear genetically related, but don't necessary exclude a low dose careful trial.
   3. Stay away from the Top of the Window: The dosage is too high and side effects occur such as feeling overfocused, agitated or stoned, If your sleep is significantly disturbed or your appetite is gone, the dose of the medications or the medication itself is simply incorrect - and I always look the dosage carefully first. Start low, go slow, don't increase more than weekly or every other week.
   4. Watch for the Bottom of the Therapeutic Window: At the outset and during the treatment the meds often need adjustment upwards, especially the MPH [methylphenidate-Ritalin like meds] and AMP [dextroamphetamine - Adderall like meds]. Vyvanse often needs little titration - it remains quite stable in dosage over time.
   5. Watch for the Sides to find the DOE, Duration of Effectiveness: Each stimulant medication lasts only a specific duration. If you are under that expected duration and the sides do not cover it properly as noted in the "Sides" article, you are underdosed. If you go past that expected DOE, you are on too much.
   6. Drug Interactions do occur and cause unpredictable problems if they are ignored. This caution involves drugs that interact with the stimulants. The two most seriously interactive meds are Paxil and Prozac, seen over years of long term use of medications. No, these interactions aren't in the literature yet, but these potential interactions do live on the package inserts of these two products. With managed care and money a problem, these problems are on the rise, not diminishing. More later on 2D6, an important metabolic pathway.
   7. Don't Get Into Denial of the Importance of the Window: If you don't think about it, if you don't know it's there, you simply cannot target it. If you don't target the 'Window' you are either shooting geese at night, or simply throwing cans of paint at the barn door. Without clear visualization of the target, without paying attention to the details and the edges, the job will be predictably less than quality.

Bottom Line  By following simple guidelines and the metaphor of the 'Therapeutic Window' you will be more able to adjust dosing correctly, and effectively - so you and yours don't feel like treatment failures. I invite you to sign up now for the early bird special set of gifts for my new book "Fixing the ADD Madness: A Patient's Guide to Stimulant Medication Details"  See the upper right hand sign up box - And enjoy the bonus gift on the thank you page for signing up early -- simply to express your interest in the book: a 1200 word article on The 10 Biggest Problems With ADD/ADHD Medications, and a 17 min audio review of the article.

Article Source: http://EzineArticles.com/?expert=Dr_Charles_Parker

ADD/ADHD - Medication Management Series: Measuring the Top of the Window

Adjustment of meds is all about the Top and Bottom of the Therapeutic Window

Review The Top                                                              

A very quick review: ADD/ADHD Medications Management problems can arise from too much medication [out the Top], and may create a problem at the Top of the Window as I documented in this previous posting.

Also Back to the Top: I recently rewrote my previous article on too much medicine: ADD/ADHD Treatment: 7 Tips on Finding the Elusive Top of the Therapeutic Window [844 words], over at EzineArticles.com   The 7 Tips on the Top Article is now back up for review there and distribution - please drop a comment here if you find these tips useful, or wish to have something added through this series on stimulant medication management.

Start with The Bottom

Now, as you know, I have a series of posts underway here at CorePsychBlog about the Bottom, too little medication, and this week a full 900 + word article will be up over at EzineArticles .com - on bouncing on the Bottom of the Therapeutic Window.

Why Bother?

All this top and bottom stuff is really simple: Too much stimulant medication creates big problems and is often hard to see exactly. Too little medication often leaves portions of the day inadequately covered, poor response, and often associated with problems that the "meds aren't working," - a remark we hear everyday.

If medications aren't working properly on either end, people suffer, - and can suffer for years with simple small adjustments correctly managed over time. The big word used by the docs: Titration - finding that specific opening in that window for that specific person is about 80% of the program.

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ADD/ADHD: Medication - Start Meds At Bottom of the Therapeutic Window

ADD/ADHD Medication Axiom: Start Low and Go Slow - for any Stimulant Med

A couple of quick hint for starting ADD/ADHD meds: Find the Bottom of the Window

• Underdose the Start: I always recommend carefully, slowly starting the ADD/ADHD medication at the outset - lower than the expected endpoint. Most of the new drugs have different rates of metabolism, and it is quite easy to overdose the patient. This happened with Adderall in the beginning, it happened with Adderall XR, and it happens with Concerta and Vyvanse even today. So start much lower than expected, and move slowly up - about every 2 weeks when close to precision.
• Start with The Duration of Effectiveness [DOE] in mind.
• Vyvanse is Especially Tricky: I see many second opinions wherein the docs started with the Harvard study in mind for the 6-12 yr olds. I always carefully ask about the metabolic rates, sensitivity to medications, bowel issues in an effort to predict slow metabolic challenges - that would cause toxicity at the outset.
• Low Start Requires Bottom Awareness: The axiom for stimulant meds: start low, and go slow, watching for the effect to show. Address the ADD Symptoms: When it is working the focus is better, the impulsivity is down, the worries are diminished and the patient can get going with projects - overcoming avoidance and procrastination.

The Bottom looks easy, - but if you don't see it, it can become quite complicated.

Brain Imaging and Innovation: "Iconoclast" is Must Read

Before we get started:
Please go over now and hook up to follow me as a friend on Twitter - there I can give you faster updates on all my many activities! http://twitter.com/drcharlesparker  - I am also planning to organize blog updates here at CorePsychBlog for postings with a specific schedule of topics [more later], and better connections for a variety of interesting activities including video blogs on a variety of topics we all find interesting.

I have always enjoyed developing teams, and anticipate that we can have some more fun with these different levels of staying posted. Very much going on here, and with the Tweets can keep you posted even more easily.

Important next step:                                          
-Strongly urge you to get this book- Iconoclast: A Neuroscientist Reveals How to Think Differently by Gregory Berns, MD PhD - as soon as I got half way through I added to my list of personal favorites at the CorePsych Books [It's down on the shelf of Parker Personal Favorites...]

Def: "Iconoclast: a person who does something others say can't be done." Now that I have your attention...

Why this book is so very cool:
Iconoclast discusses brain imaging evidence applied to the process of creative thinking... and more than that, creative application in groups. Berns actually takes out-of-the-box-creative-thinking and applies it to social networking!

You know how devoted I am to brain evidence in the context of the abundant medication madness , - and if you are a regular reader here, I know this one needs to become tops on your reading list. My partner, Jeff Schlichter, PhD, and I think Iconoclast is so significant we gave it as a gift to all of our outpatient team in Va Beach at Parker, Schlichter and Associates.

Some additional points that are quite memorable -

Fixing the ADD Madness: The Diagnostic Mess

Right Targets Right Interventions
If you don't see the specific AD/HD target, if you don't have a specific objective, how can you hit anything no matter what technique you use? The debate about what to do for ADD treatment goes far beyond just the ADD medications I have repeatedly been reviewing here at CorePsychBlog: See this summary ADD Medication Details post.

Professionals Disagree
I'm out here with an amazing group of folks for a 4 day meeting in LA, some are child psychiatrists, some are psychologists, some are family counselors, and the offline debate is most interesting - each sees the ADD diamond from the lens of their experience and training. The good news is that a big shift is occurring as the most informed know they can't cover it all, myself included.

Excercise is helpful, nutrition is remarkably useful, breakfast and sleep are essential, ADD medicatons do help if they are used correctly, - but none of this works if they have an undiagnosed immune dysfunction [gluten sensitivity], a hormone dysregulation [PCOS], an addiction, brain injury, or psychological problems with a family member - to name but a few.

ADD is simply too complex a picture to just shoot the meds based upon a diagnostic manuel [DSM-IV]that is, quite simply, outdated. It's not wrong, it just isn't sufficient. Yes, it works if you want to talk to a teacher, but has limited value if you really work with those who suffer the complexity of ADD Spectrum Disorders.

Stay tuned will be doing more regular updates here, gotta run to the meeting this AM, driving down to the Westin at LAX from up North near Beverly Dr.

Quick Personal Note
It's been great fun staying with my LA family in West Hollywood, my son who works at Cedar Sinai as an anesthesiologist. my super daughter in law who works as a nurse there, and my grandson who smiles all day, from first blush in the AM until he starts to fade at night - and, at 9 mos old, only fusses if you don't get it - I guess it runs in the family.

It's still early out here, and the little guy isn't up, so I will get out on the road and will update you more when I find a moment with my machine.

ADD Context II: Physics, Reality, and Structure

ADD: A diagnosis over time - A diagnosis of context.

So what do I mean by "context?"

In the last post I told you about the physics professor with ADD - and you may very well have said: Impossible! His "management problem," that "group problem" he has, is not ADD, it is SAD, Social Anxiety Disorder.

Descriptively I agree, but functionally [from the point of view of brain function} it's more than that.

Yes, from one perspective, description and labels alone... he manifests his inability to function, his cognitive anxiety, with groups of people. There, in that people reality, symptoms of cognitive anxiety occur. Groups of people bring a change to his mathematically safe reality. People introduce an exposure to change, to unpredictable variables, and decreased structure unsettles his prefrontal cortex.

The pre-frontal cortex works vigorously to handle reality over time - its executive functions sets the brain and the person to keep in step with changing reality.

People are unpredictable for him, math is not. Groups of people present one context of reality - physics, mathematics is another reality. For him physics is more predictable. Different, less predictable realities significantly alter the process of thinking and acting with ADD.

No, ADD is not like a bacterial infection that remains present until the antibiotic works to kill all the offending bugs. It is a condition that is much more mercurial, often not categorically obvious, not present all day every day, - but exists in specific contexts of reality.

Some show no ADD in Jr High, but serious ADD arises as a freshman in High School - the context, the variables, the real structure has changed.

This simple observation is why so many have problems understanding and treating ADD - they don't get this problem of changing reality, and context. They think it appears categorically, like an infection, all or none - and if you are academically smart, all A's through several graduate schools, you couldn't possibly have that problem

Without understanding and correcting this simple point, we will continue to treat labels, categorical descriptions, and not the people where they live, in some context of changing reality.