This summer, we wandered in uncharted territory – Baltimore, Annapolis, the Civil War sites – Antietem, Gettysburg, and Harper’s Ferry. I grew up on the side of Missionary Ridge where many of my friends had cannons, markers, or monuments in their yards for us to climb on. The Chickamauga Battlefield Park and Lookout Mountain added to the Civil War aura. But I’d never been to the "northern" battlefields and so it was a great trip to see those places I’d only read about. One place, Fredrick Maryland stood out in persistent memory. It was a town that got turned into a hospital during all the nearby battles and there was a museum I wroite about earlier [in the museum…] called The National Museum of Civil War Medicine – a high point for me. It’s not very big or particularly well funded or appointed, but it made the grade in content – the story of Clara Barton, the medicines of the times I wrote about earlier, the birth of triage, hospitals, ambulances, and the story of the field amputations.
On the battlefields, the guides made much of the field amputations and the piles of limbs outside the field hospitals – adding to the narrative’s theme of the carnage of our Civil War bolstered by overwhelming numbers of dead and wounded. But in the museum, the amputations were not seen as medical barbarism but rather as a medical advance. There, the story was of inevitable infection, sepsis, and death without quick amputation. The large Civil War miniballs carried clothing into the wound and apparently infection was guaranteed. The guide lead his patter with "This is a trip back to a time when it was the Art and Practice of Medicine that mattered. It was a time before Science came to Medicine. Forget about diseases – and treating diseases. This was a time for treating symptoms." And the medication exhibits drove that home. Also apparent, they were helpless in the face of the dysentery that killed many more soldiers than the bullets in battle. What they had was morphine for pain, ether/chloroform for anesthesia, saws and scalpels for amputations, soap & water for antisepsis, and whiskey – otherwise, many toxic chemicals with no medicinal value of note – used liberally.
Since that trip, I’ve thought a lot about the sources of medical knowledge about medications. There’s the wisdom of the ages [in psychiatry that would be the antiquity, plus drugs from the 1950s]. Then there’s the literature, and expert opinion [CME, meetings], and personal experience. Both the literature/expert opinion avenues have long been shaky in psychiatry, so that most of what I’ve learned has been from personal experience. It wasn’t that way in internal medicine, or at least much less so, and I’ve missed the comfort of trustable sources of information. So I’ve personally been conservative and ridden on the trailing edge of things. I was struck in visiting that old museum, that many of the medications in those pretty old colored glass bottles were toxic, often heavy metal derivatives. They might make one sick, but it’s doubtful they did anything actually useful. The analogy to the present is obvious. People are prescribed and take medications without apparent benefit often, and one wonders why in both cases.
I haven’t talked ADD/ADHD and you are astute to notice. I’ve avoided it for the same reason I avoid Thomas Szasz. But I’ll have a go at it soon.
I’m talking about a small number of patients. Making the diagnosis helped them all, in that the diagnosis and response to medications was explanatory, it gave reason for their failed attempts at change. A few chose to not use medications – explanation was enough. Some used medications for impossible tasks like sitting in a long meeting. Most chose to use medications more or less regularly. So another reason I don’t talk about it is that I’m no expert and my experience is with a particular cohort of patients.
Most people who want to discuss ADD/ADHD want to talk about the overmedication of children, or about whether ADD even exists, or whether it’s a brain disease, or if psychiatrists believe medication is the answer to all mental illness, or if mental illness fits the medical model, or if mental illness even exists, or some other surrogate topic. For one thing, I don’t know the answer to many of those things. For another, I have no interest in being a straw man in those discussions. As they say, been there, done that, got a tee shirt.
I have no question that children have been massively overdiagnosed and overtreated. They have. I also have no question that both ADHD and ADD exist as syndromes. I’ve seen them both. I have no question that stimulants have an effect that is paradoxical in those cases. In the 60s, taking stimulants to stay up all night and study wasn’t drug abuse, it was the sign of being a good student. The diet pills were ubiquitous in the dorms and frat houses of my youth and they didn’t calm anyone down, including me. I have no question that either version is psychological based on my own experience and seeing patients who had chased their symptoms through many kinds of psychotherapy including analysis.
Some incorporate the symptoms as a temperment – multitasking can be a skill in many walks of life. For others, it can be a real disability. People with the ADHD version get a lot of negative feedback about behavior they really can’t change and have painful self esteem issues. People with ADD [no H] take a private hit because of things they see others do that they can’t do. Example: a born techie had dropped out of engineering school because he couldn’t do triple integrals and become a Social Worker, spending his spare moments with HAM radios and building computers. He felt like a total failure. On medication, he bought a Calculus Book and worked those long triple integrals with ease. He didn’t go back to engineering school, but just the explanation and the mastery was worth its weight in gold to him. That’s one of many such examples.
I wrote this long response because I was asked, but I would make several points. In seeing the kind of cases I saw, the biggest errors were applying one’s training and interests to a case without making sure it fit. It’s an error I’ve made myself, probably more times than I know. I came to call those categorical errors. In practice, I saw a lot of those – things like undiagnosed ADD or learning disabilities; kids who grew up with severe visual deficits corrected later but hadn’t considered how much it effected their development and self concept; people whose symptoms were underpinned by life events, actual trauma, or peculiar environments of development; people who had crazy or addicted parents – the invisible "elephant in the room" problem. It was ironic to me that I’d left the world of mainstream medicine to chase the workings of the psyche, but how much the psyche lead back to the more concrete life narrative – the physical, circumstantial, and interpersonal experiences of life.
So I guess I put ADD/ADHD in the category of a syndrome with fairly typical signs and symptoms. I don’t know the why of it, only the what. For many, treatment with stimulants is helpful, for others unnecessary. When I see a case, I see my task as to be sure the diagnosis fits and to help the patient understand it in so far as I understand it, focusing on its ramifications. What I learned from my daughter was that the use of medication is a journey for the patient to negotiate, not for me to direct. All of the patients read the books and haunt the Internet and that’s fine with me. They’ve been good teachers. I have no clue how to translate the fact that it’s overdiagnosed and overtreated in general into the management of a single case, so I have little to say about that. The cases I saw were underdiagnosed.
The two most important lines in this post are:
been there, done that, got a tee shirt.
and The cases I saw were underdiagnosed.
Mickey,
There is no doubt in my mind that someone can be ADHDish although I don’t think it should be a mental disorder. And if someone wants to take medication, as long at they are fully informed, I don’t have a problem with that.
Regarding that engineering student who was able to succeed with medication, there is one problem. Unfortunately, for many people, it doesn’t work forever. So he could making a choice based on meds that are going to poop out on him in a few years. If he understands this may occur, ok, but I fear many people don’t.
Finally, I wanted to alert you and your colleagues as someone diagnosed with sleep apnea that many kids with the conditions are wrongly diagnosed with ADHD.
http://well.blogs.nytimes.com/2012/04/16/attention-problems-may-be-sleep-related/
In my opinion, anyone who goes to a psychiatrist and has any type of sleep issues should be routinely screened for possible sleep disorders and referred appropriately. To your credit, when I made a similar type point in the past, you were very gracious about this.
Hi again AA,
The engineering student stayed in social work. He just wanted to know there was a reason for his difficulties with Calculus. Thanks for the sleep apnea point. I don’t see kids, but there’s more sleep apnea in adults than I would’ve thought. I can see how it could mimic ADHD [and/or depression]. Most of the cases I’ve seen had chronic fatigue and daytime sleepiness. Like ADD, it’s another sleeper.
I can only view this situation from the outside. Friends have had their children diagnosed by teachers, often for the teachers failing to provide a stimulating experience. A pedi friend hates the start of school as she receives notes demanding a child be medicated to levels that do not exist. Remember also that a school may encourage medicating a child so as to receive additional funding for “special” programs to accommodate the very children they are having medicated.
Working in Scouts as an adult a number of years ago we had one kid on a boat load of medication. We, the adults could not be around his mother for very long without becoming frustrated. Taking him on a camping trip we got some of the older kids to run him until he was tired, Frisbee, hikes, etc. The second day he was the best kid in the group until we started home. You could see him winding up as we got closer and closer to dropping him off. Environment does play a role.
The result of all of this is kids today all feel they need medications. Get a scrape and they want to go to the ER. Wash your hands several times a day with bacterial soap. They have internalized the pharma mantra of a pill for every person, and every person taking a pill.
Today, in our check a box world, we do not allow for any personal traits and heaven forbid we gear a job to a person’s traits, or give kids a recess and allow them to run and play.
Steve Lucas
Steve,
As a parent, I struggled with the point you make, as did my wife, as did my daughter. She stopped the medication in the 5th grade because she could. She restarted it in high school because she absolutely couldn’t sit down and read a book [and there were lots of books]. It was on and off until she discovered that her symptoms had a big impact on her close relationships, and has taken it fairly continuously since her mid thirties [now 42]. She’s a Child Psychologist and would agree with you in many cases.
Even though she has spent most of her life off of medications and has actively resisted it more than not, she spontaneously says that she’s glad it was diagnosed early. She’s seen the same thing I saw, people who internalized the symptoms or the negative feedback from the world and had self esteem issues of major import. Knowing that whatever-ADHD-is was the problem was helpful even if it was not medicated.
I actually agree with your point except when I see a case where I don’t. I also agree with your point about schools. Telling others that you are or are not on medications or involving the teachers is often a mistake because they incorporate it into their view. “Have you taken your medicine, Johnny?” isn’t good for kids.
Most people have a strong opinion on this topic one way or another and bolster it with examples like you and I are doing right now. On most topics and particularly this one, I’ve tried not to let my overall view contaminate my view in any specific case [which is plenty hard to do], but worth the effort. ADHD and ADD kids are as different one from another as kids are in general and deserve a non-generic evaluation.
I’m out on a limb with this post because I’m breaking my own cardinal rule – one case at a time. I just threw in my 2¢ because I was asked.
Mickey,
Thank you for your thoughtful and obviously personal comment.
Steve Lucas
What is so disingenuous with the patients who come in and complain, both bitterly and demandingly, is this alleged tolerance effect with dosages they claim were effective prior, usually on the higher side to begin with. Studies show REPEATEDLY there is no real tolerance of stimulants for real ADD symptom relief, where legitimately experienced, and thus the most likely red flag for the drug seeker, not psych pt needer.
It is time for insurers to step in and set boundaries for adults with alleged new onset dx of ADD, starting with mandatory Psych testing to define both cognitive limits, and catch axis 2 BS/Lie scale admissions. Also, while I am NOT a fan of insurers setting limits with meds dosages, on stimulant rxs I would agree, and to use it to try to annoy and get seekers to move on.
All drugs have a ceiling dose, and it is time for the stimulants to have it firmly noted and adhered to with consistency. Also, I want to see both MD pez dispensors and docs who are not to get a free pass for “just trying to help people with what they want so they don’t suffer” to get the spotlights shined on them both; this “just honestly helping” is not an excuse, but just validating the adage “the road to hell is paved with good intentions”
Plus, if these docs who write copious rxs for stimulants are doing such a great favor, why do they seem to abandon their patients at the drop of a hat and dump them on responsible docs like me to wade through the morass of irresponsible prescribing at the least, reckless prescribing more likely!?
Thanks for the post and your revelations of COI, appreciated and respected.
Joel Hassman, MD
I have no clue what Joel Hassman is talking about. I have seen friends, who I would not consider drug seeking, develop a tolerance to stimulant medication. The ones who didn’t were the ones who took it only inconsistently (and they told me it was because they didn’t want the drug to lose its effectiveness). I don’t trust studies on this one. I don’t think it’s any different from someone who does well on an antidepressant and then develops a tolerance or even an allergic reaction after having been fine on it for years. Certainly, I have seen that as well. I don’t work in medicine, but I have seen such things in my personal life. If you can develop tolerance to your Lexapro then why not your Ritalin?
I have ADD. Tried Ritalin…never again! It worked well for about a couple of weeks or so. Then I got all of these weird panic attacks and severe anxiety. And then I was done with stimulants.
I have an iron-clad attention span for a lot of things, but I’m wondering if I took an amphetamine analog, would I be able to learn calculus? It never held my attention before. Maybe I have a form of ADD? It’s hampered my learning software coding, too.
Thank you for the generosity of this personal reflection. I deeply appreciate what you do and what you have taught me. In my own journey of reflection and figuring out how to continue (or whether to continue) in this profession, I can not skirt the topics you mention in the first part of your final paragraph.
No, to Johanna, people are confusing a secondary gain they are feeling with the use of stimulants with the primary gain of seeing an improvement in honest and true ADD symptoms. Read up on it at length, I will try to find the most recent resource that debunks this “tolerance” effect people try to falsely claim with using stimulants.
My favorite one is the complaint from alleged ADD patients that they are not getting the “pick me up” or “burst of energy” with stimulants they experienced at first. Umm, in ADD the real complaint is in fact fatigue or lack of consistent energy.
Also, there is not a true and pervasive surge of self confidence and vitality with the meds early on in treatment. Oh, there is always the role of suggestibility in any intervention, but again, when the “patient” comes back and talks of “invincibility” and “a rush of energy”, that is not a therapeutic effect.
And listen to the quick retorts of denial, deflection, and minimization that is inherent in addiction agendas to try to legitimize the need for more. Hey, I have been writing for these meds for almost 20 years, are you telling me my observations and attention to patterns are wrong?
Honest ADD patients almost always say in so many words in the first or second follow up basically this: “I don’t really see much, but my spouse/boss/friends tell me I am doing better”. That is the sign I am looking for to know I am treating an ADD patient.
Colleagues, tell me, am I really off base?
Yeah…that wasn’t really my experience with ADD. My school pushed it when I was 11 cuz I’m a slow learner. No hyperactivity. And they thought I had ADD. The pdoc agreed, but then I got really moody on the ritalin and I stopped it. Same thing as an adult. I didn’t get high off of it, but I got awful rebound. And then I started getting the craziest PMS from hell. I would get really moody and panicky.
Most likely you’ve never seen that happen when the person has ADD and on stimulants. But it happened…twice. PMS and stimulants don’t mix well for me. And I am the only person on the planet that this happens to.
I noticed a difference on it in the first week. I normally have a lot of trouble following conversations involving more than just one person. I started following conversations better right away. I did actually make me less slow. I will give it that.
Oh, yeah, I’m sort of low-energy, too. Funny, I can read a novel for hours and even miss my bus stop. But when it comes to advanced math — totally ADD.
Alto: You’re a hoot!
I almost always agree with 1bom. As a practising psychiatrist in the Netherlands I regocnize so much of how psychiatry took the wrong road during the past few decades.
This time I disagree with 1bom. Ad(h)d in my opinion is typical of the mistakes in psychiatry in looking at human problems and medicalizing them. Chemical imbalances galore in adhd literature! Labeling people, children in particular, with a so called neurobiological disease is so wrong. Teaching them that there is something basically wrong with them is not a relief at all, perhaps in the short term it might be, but in the long run it’s disastrous, just as in depression. People are turned into victims of a non existing disease. While their brains are absolutely fine!
I am not saying that being ‘hyperactive’ and having problems concentrating cannot be a problem. In our society it can be a problem indeed. But so are so many other things. Being able to love more people intimately than just one can be a problem, preferring to go to bed in the early morning instead of in the late evening can be a probleme, not liking raw food can be a problem, being left handed can be a problem, but please!, let’s not make diseases out of problems with our innate tendencies that are at odds with society’s demands.
And treating them with powerful mind and brain altering drugs, like amfetamines.
I’ve seen so many kids feeling guilty because of their ‘disease’ and trying their best to compensate, or getting angry, and so many adults who can never function without stimulants again because of unbearable withdrawal symptoms.
Adhd is one of the most useless (it’s nothing more than a description and by no means an explanation) and dangerous (medicalising, drugging) ‘diagnoses’ in psychiatry.
Henk,
I knew when I wrote this that it would evoke multiple responses. I wrote it because I was asked. All I really have to add to what I said is that I’m sure of only a few things. My personal dealings with this topic don’t have to do with drug company advertisements, or the DSM-anything, or the APA, or some belief that mental illness is brain disease. And it certainly didn’t have anything to do with any quick decisions, short sessions, etc. nor is it a recommendation.
Thank you Mickey for your respons. I appreciate your opennes about your personal experiece and your sincerity.
It’s just that the whole thing around adhd (concept, medication, medicalisation) makes all my alarm bells go off.
Thanks Mickey. I understand that the concept of ADHD (despite the lack of scientific evidence) has helped you to rationalise the behaviour of your daughter. It must be a disease! What is it otherwise? It has enabled you to cope. However, I still do not understand why you will not discuss or debate the ideas of Szasz. Eh?
Nick,
That’s kind of an insult – “rationalize” – but that aside, where do I say “it’s a disease?” And about Szasz, wasn’t this enough?
Is it an insult? How? You have stated that you are certain that ‘psychotic’ states are a medical disease. Yes? As you know I respect you and your work. Although I may present an argument. Ok.. I will have to read and digest your comments on Szasz….