{"id":42987,"date":"2014-01-09T02:24:28","date_gmt":"2014-01-09T07:24:28","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=42987"},"modified":"2014-01-09T02:24:28","modified_gmt":"2014-01-09T07:24:28","slug":"adhd","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2014\/01\/09\/adhd\/","title":{"rendered":"ADhD…"},"content":{"rendered":"\n

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…<\/a>] called The National Museum of Civil War Medicine<\/a> – 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.<\/p>\n

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.<\/em>" 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.<\/p>\n

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.<\/p>\n

This post is a response to the question Sandy<\/a>, Joel<\/a>, and Nick<\/a> asked about why I never mention ADD\/ADHD. I said:<\/div>\n
\n
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.<\/div>\n<\/blockquote>\n
There are a number of reasons. First, I have a mega-Conflict-of-Interest – my only child, a daughter, is the poster-child for whatever ADHD is. So most of my experience is obviously as parent cum doctor. I’m not a Child Psychiatrist, so my experience otherwise is with adults in an unusual way. After leaving academia, almost all of my referrals were people who had essentially been treatment failures in various treatments – medications, psychotherapies, etc. I had my failures too, but enough success to be rewarding. I was surprised how many of the failures were from missed diagnoses, and one among the missed was ADD without hyperactivity. The only way I could justify that statement would be with long case histories which are not appropriate here.<\/div>\n

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.<\/p>\n

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<\/em>, 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<\/em>. <\/p>\n

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<\/em>. 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. <\/p>\n

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 ADH<\/font><\/strong>D 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<\/font><\/strong>] take a private hit because of things they see others do that they can’t do. Example: a born techie<\/em> 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.<\/p>\n

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<\/font><\/strong>. 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.<\/p>\n

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<\/em>.<\/p>\n

I know I get kind of cranky when people want me to defend what psychiatry thinks<\/em>. Or what is or is not a disease<\/em>. Or the APA<\/em>. Or what is right treatment<\/em>. We all know that the APA and a lot of psychiatry is out of whack right now. It bothers me too. But that’s not what this blog is about. It’s about the segment of academic and practicing psychiatrists who have gone over to the dark side with commercial interests and have colluded with the dissemination of misinformation. All those Civil War docs gave out bad medicine because they didn’t know any better. It’s a hundred and fifty years later and we have the ability to know a lot more than they did, but that capability has been regularly mucked around with and I find that infuriating… <\/div>\n","protected":false},"excerpt":{"rendered":"

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 […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-42987","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/42987","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=42987"}],"version-history":[{"count":9,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/42987\/revisions"}],"predecessor-version":[{"id":42996,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/42987\/revisions\/42996"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=42987"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=42987"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=42987"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}