Clinicians routinely see patients self-diagnosed with ADHD. Many adults are now taking stimulants without a convincing reason. Stimulants are highly addictive medications that are not free of potentially dangerous side effects; their use should be limited to those carefully evaluated and properly diagnosed. In reality, most adult patients seen in clinical settings bitterly complain about noticing increasing problems with inattention and distractibility, and assume that they must therefore be suffering from undiagnosed ADHD. ADHD is a neurodevelopmental disorder present since childhood. Nobody develops ADHD as an adult. The following 5 conditions explain the majority of cases of adult-onset inattention and distractibility.
Depression and anxiety. Poor concentration, short-term memory loss, inattention and distractibility are very common symptoms of both mood and anxiety disorders. It is very difficult to diagnose cross-sectionally ADHD in the presence of a major depressive episode or an active anxiety disorder (GAD, OCD, etc.)
Drugs and Alcohol. In the addition of the well-known deleterious cognitive effects of alcohol and commonly abused drugs (including marijuana), clinicians need to be extremely careful when prescribing stimulants to those with potential chemical dependency issues.
Certain prescription medications. Benzodiazepines and sleep medicines (Ambien, Lunesta, Sonata) are well known for causing daytime probems with focus and attention. Statins (medications used to lower blood cholesterol levels) are showing increasing, convincing evidence thay thay can also cause cognitive problems that may be misinterpreted as ADD. Cholesterol is essential for brain functioning. Antidepressants (SSRIs, SNRIs) as well as some mood stabilizers such as Lamictal, Depakote and Tegretol can cause annoying word-finding difficulties that patient could misinterpret as cognitive impairment.
Non-restorative sleep. Patients with certain sleep disorders (typically, obstructive sleep apnea – OSA) suffer from excessive daytime sedation and sleepiness. They find it very hard to concentrate and stay focused. Even when properly trated, OSA may produce residual problems with cognition, short-term memory, inattention and distractibility.
Overwhelmingly busy schedules. How much water can a sponge take? How many computer programs can you open in your laptop before it slows down and makes mistakes? We live such busy, overcommitted lives that is not hard to understand how the multiple demands simultaneously placed on our brains lead to processing mistakes.
Most adults seen in clinical practice complaining of inattention and distractibility are far more likely to suffer from one or more of these five problems than from the complex, multifaceted neurodevelopmental condition that is ADHD. Careful screening for these conditions may guide treatment and avoid long-term, unnecessary use of addictive medications.
Attention-Deficit Hyperactivity Disorder in Adults, by Paul Wender, MD is a classic textbook of what really is (and is not) ADHD in adults: a serious and potentially devastating condition when not properly treated.
The news of the death of Phillip Seymour Hoffman from a heroin overdose and of finding him with a needle still in his arm have been shocking. Yet heroin deaths are a common, daily and painful occurrence: about 100 people die across the country from heroin every day. They are not celebrities but mostly middle-class, suburban and young (some as young as 12). Heroin slows down the respiratory drive and can some times cause addicts to stop breathing and turn blue (cyanosis) almost immediately. Although technically a suicide, in reality those who OD hardly ever do so intentionally. In fact, only 10% of heroin ODs end up in death. Users are simply unable to factor in the purity and strength of what they are shooting, or may not be fully aware if heroin was cut with something else that also shuts down the respiratory brain center. Police and EMS workers frequently encounter these situations and can save lives by promptly administering an antidote, naloxone . Heroin kills in many ways, both in the short and in the long run (think of hepatitis, HIV and endocarditis). None is more dramatic and unexpected than the almost instantaneous shut down of the respiratory drive.
Most street heroin is cut (mixed) with an adulterant. The adulterant is cheaper, allowing the dealer to maximize profit. The internet is full of websites where addicts (using the acronym SWIM, Someone Who Isn't Me, to avoid self-incrimination) comment on how to spot how much has heroin been cut, and with what adulterant. St Louis SWIMs report that local street heroin is routinely cut 50:50 with over the counter diphenhydramine, sold under the brand name Dormin. Finding Dormin capsules in your child's room is a strong indicator that they may be dealing heroin. SWIMs are extremely adept at spotting overly adulterated heroin since it burns, looks, smells and dilutes differently. For example, Dormin's capsules are pink, and heroin cut in a blender with them will have pink freckles. Too many freckles means the drug was cut with more than the customary 50% of Dormin. Other adulterants include sugar, coffee and quinine (used for this purpose for more than a century).
Some addicts claim that using Dormin saves them money, since they can get a longer-lasting high with less heroin. Tragically, heroin can also be cut with stronger psychoactive drugs (pain killers) to maximize and prolong the high. This makes the mix even more dangerous, since these added agents are also strong respiratory depressants. We are currently experiencing an epidemic of ODs (many lethal) with the widespread use of heroin cut with Fentanyl. It is extremely difficult for addicts to evaluate the potential lethality of this combination.SAMHSA (The Substance Abuse and Mental Health Services Administration) alerted this week that a dangerous increase in heroin+Fentanyl ODs are being reported. In a 2-week period, 17 such deaths were seen in Pittsburgh, and 22 in Rhode island. Additional deaths are being reported in New Jersey and Vermont, and the problem is likely to expand across the nation rapidly. You can find free copies of SAMHSA's Opioid Overdose Toolkit here .
What differentiates heavy drinkers from alcoholics? The answer is not necessarily based on the frequency or the amounts drunk. The essential features of alcoholism include an inability to abstain and, once drinking starts, an inability to stop.
One of the most reliable ways of finding out if someone is an alcoholic ( Alcohol Dependence , in previous psychiatric nomenclature) is verifying their inability to stay sober despite numerous efforts to do so. Alcoholics are often remorseful and apologetic after getting drunk and in trouble, and will make promises never to start again. Yet, they will invariably find a rationalization or justification for drinking, no matter how severe or devastating the consequences. A heavy drinker (or Alcohol Abuser ) on the other hand, is able to abstain in the presence of powerful reasons to do so. Alcoholics see their lives spin out of control in front of their eyes, yet they invariably hit the bottle again and again. Some heavy drinkers could conceivably end up drinking larger amounts and/or more often than certain alcoholics. What sets them apart is not the amount or frequency of their alcohol use, but the seemingly hopeless inability of the real alcoholic to stay sober.
A second telling sign of alcoholism is the inability to stop once drinking has started. The powerful effects of the first drinks trigger strong cravings to continue. Stopping becomes impossible: " one drink is too many and ten are not enough ". Alcoholics will constantly try to drink in moderation ("normal drinking") only to find out, over and over again, that once the first few drinks are consumed they have no control over how much they will drink, or over when will they stop. The delusion of every alcoholic is that, some day, somehow, they will be able to drink in moderation.
An alcohol abuser drinks despite negative consequences (such as DWIs, problems at work or home, etc) but, unlike real alcoholics, is able to sober up if compelling reasons appear (severe medical problems, impending divorce, etc). Binge, sporadic drinkers may or may not progress to full-blown alcoholism, although most alcoholics were first alcohol abusers or binge drinkers. The current psychiatric classification ( DSM-V ) no longer separates Alcohol Abuse from Alcohol Dependence. It simply diagnoses "Alcohol Use Disorders" as mild, moderate or severe. In practice, two simple questions: "Have you tried repeatedly and unsuccessfully to stay sober?" and "Do you lose control of your drinking once you start?" often suffice to establish a strong suspicion of alcoholism.
For a folksy, clever, insightful, engaging and at times hilarious description of the alcoholic mind, alcoholism and AA, download for $2.99 J oe and Charlie's talks at the itunes store. Charlie P. and Joe McQ. gave numerous workshops around the country for 30 years, presenting in an accessible way the teachings of the Big Book of AA. "People often say that it took Bill and Bob to write the Big Book but it took Joe and Charlie to explain it".
It is now possible to get an early diagnosis of Alzheimer's Disease (AD). Scientific advances allow us to tell if, at some point, the "senior moments" we notice in ourselves or our loved ones will develop into full-blown AD. However, these exciting advances have not been followed by equally significant breakthroughs in AD's treatment. Do we want to know that we will get AD, if there is not much we can do about it?
About 13% of those 65 and older, and 45% of those 85 and older, will experience memory problems suggestive of AD. Answering "yes" to 2 or more of the AD 8 questionnaire (the Washington University Eight-item interview to differentiate aging and dementia) suggests the presence of dementia and warrants further assessment. The AD 8 is especially sensitive when answered by an informant on behalf of the patient.
It used to be that AD could only be diagnosed unequivocally after death (by autopsy). Since the late 80s, a few familial cases can be diagnosed at any time in at-risk individuals by finding mutations in specific genes. These genetic cases represent a tiny fraction of all cases of AD. Cases of AD due to a single gene mutation tend to have very early onset, with some families showing cases of dementia in their 30s and 40s. In a majority of cases, AD is not caused by a single gene mutation, although certain genes (like Apo E4) can increase our risk of developing AD while Apo E2 may provide protection against it .
Exciting research developments allow now for an early diagnosis of AD by using biomarkers . These biomarkers measure the presence of amyloid in the brain (a substance that accumulates in the AD brain). They also measure evidence of brain cell's injury and degeneration both in blood and in cerebrospinal fluid. Sadly, all these reserach breakthroughs have not yet improved our ability to reverse, stop or significantly slow down the progression of the disease.
Who benefits from early diagnosis? The answer is still unclear (read this ). Do we really want to find out if we'll develop Alzheimer's at a certain unknown point in the future, if there really is no proven way of significantly changing the course of the disease? We need to answer this individually . For some, the opportunity of joining a clinical trail to test a new drug is both a personal and an altruistic incentive that favors knowing. For others, it's best to live in the present and enjoy every day: why worry about something we can't control?
We are all familiar with the terms Anorexia Nervosa and Bulimia Nervosa. How much do you know about Orthorexia Nervosa?
Anorexia Nervosa and Bulimia Nervosa are well defined psychiatric disorders. Patients with these conditions focus obsessively on food quantity . Orthorexia Nervosa , on the other hand, is a disorder (not yet included in the official psychiatric classification) where patients are obsessed with food quality . They have an extreme preoccupation with avoiding certain foods that are perceived (often mistakenly) as unhealthy.
Every orthorexic has his or her own unique, individual and idiosyncratic set of rules regarding which foods are allowed to be consumed, and which foods are to be avoided. As a result, their diets can become quite restricted, and large amounts of time are spent preparing their "OK foods". Eating out is almost never an option for orthorexics, and they routinely avoid socializing and family events centered on food.
Frequently, orthorexics will obsess about healthy foods and go to extremes to avoid those containing additives or preservatives of any type. They may fixate on avoiding any kind of fat, or any animal products. Restrictive diets often lead to emaciation and malnutrition. The orthorexic patient, however, persists on his or her obsessive fixation with what is perceived as healthy eating and will reject any suggestions to do otherwise. Soon, patient's rules become arbitrary, unpredictable and illogical. A patient may refuse to eat chicken livers but may eat other organs from the same animal, citing obscure references about liver metabolism that do not fly in the face of evidence.
Orthorexics can become extremely thin. However, unlike anorexics, they do not wish to lose weight and do not see themselves as overweight. Their obsession is with eating and staying pure, uncontaminated and healthy. To learn more about orthorexia, rawfoodism , paleolithic diet, fruitarianism, anopsology and other interesting edible topics, visit BeyondVeg .
Stigma derives from a Greek word that means "sign", "point" or "branding mark". It originally referred to a type of marking or tattoo that was cut or burned into the skin of criminals, slaves or traitors in order to easily identify them as blemished or morally corrupt. Stigmatized individuals were to be avoided and shunned.
It is a common experience among those struggling with mental illness. Stigma can be obvious and direct (someone making a negative comment about mental illness or its treatment) or subtle (when it is assumed that someone with mental illness is dangerous, unstable or violent). Patients may even judge themselves ( self-stigma ), wrongly assuming there are certain goals they can't accomplish, or that they won't get better. Stigma leads to prejudice, discrimination, avoidance and rejection. Those who experience it go through shame, blame, secrecy, isolation and social exclusion.
When properly treated, people with mental illness are no more dangerous than anyone else. In fact, they are far more likely to be the victims of violence rather than the perpetrators. The media often reports distorted and inaccurate representations of the mentally ill, inviting unwarranted generalizations and widespread prejudice. Every year, there are over 16,000 murders in the US, yet the few involving the mentally ill get disproportionate front-page coverage. Astonishingly, after the Sandy Hook tragedy, louder voices advocated for arming school guards than for education and early detection of mental illness. The shortage of mental health services have turned jails and prisons into the new psychiatric hospitals. Correctional psychiatry is, sadly, among the fastest-growing mental health specialties. A person with mental illness has much easier access to guns than to mental health. That is an ongoing tragedy.
Several public figures are giving their names to the cause of fighting stigma. Former congressman Patrick Kennedy and actress Glenn Close are among the most vocal ones. Legal efforts to support parity in mental health insurance coverage have also contributed to leveling the playing field between physical and mental illness. The National Alliance on Mental Illness conducts an active StigmaBusters campaign to challenge stereotypes portrayed in the media.
What can we do? Prejudice arises from ignorance. People tend to distrust and fear what they don't know or don't understand. Stigma decreases when people meet those afflicted by mental illness who are able to live as good neighbors in their communities. Strategies that include educational interventions and promote inclusiveness of the mentally ill contribute to a better understanding. It is said that the greatness of a society is measured by the way it treats its most vulnerable members: how well are we doing with the mentally ill?
Hans Asperger (1906-1980) was a Viennese physician who published the first definition of Asperger's syndrome in 1944. He identified a pattern of behavior and abilities that included "a lack of empathy, little ability to form friendships, one-sided conversation, intense absorption in a special interest, and clumsy movements." Asperger called children with AS "little professors" because of their ability to talk about their favorite subject in great detail. Asperger was convinced that many of the children he identified as having autistic symptoms would use their special talents in adulthood. He followed one child, Fritz V., into adulthood. Fritz V. became a professor of astronomy and solved an error in Newton’s work he originally noticed as a child.
Asperger died before his identification of this pattern of behavior became widely recognized, because his work was mostly in German and barely translated. The term "Asperger's syndrome" was popularized in a 1981 paper by British researcher Lorna Wing, MD, who had an autistic daughter and became involved in researching developmental disorders.
Interestingly, as a child, Hans Asperger appears to have exhibited features of the very condition named after him. He was described as a remote and lonely child, who had difficulty making friends. He was talented in language; he was interested in the Austrian poet Franz Grillparzer, whose poetry he would frequently quote to his uninterested classmates. He also liked to quote himself and often referred to himself from a third-person perspective, typical symptoms of what we now call Asperger's syndrome.
There are many resources to help patients and families better understand this condition. The australian psychologist Tony Attwood has one of the more comprehensive websites ( www.tonyattwood.com.au ). His philosophy (very much like the one supported by Hans Asperger) is to view the patients as differentially abled rather than disabled. A thorough inventory of strengths and weaknesess can help patients become active members of society. Many AS patients have great computer skills and, not surprisingly, a vibrant virtual community exists (for an interesting perspective from patients, visit www.aspiesforfreedom.com ). You may also want to learn about the www.aspiequiz.com or the autism spectrum quotient ( aq.server8.org ).
Overall, kids on the autism spectrum have wonderful potentials and should be given every opportunity to succeed. They often have a unique way of viewing the world, which can be surprisingly insightful. They are capable of great accomplishments. Temple Grandin, PhD, is one of the best examples of success within the spectrum. She didn't talk until she was three and a half years old, communicating her frustration instead by screaming, peeping and humming. In 1950, she was labeled "autistic," and her parents were told she should be institutionalized. She tells her story in her book Emergence: Labeled Autistic , a book which stunned the world because, until its publication, most professionals and parents assumed being diagnosed "autistic" was virtually a death sentence to achievement or productivity in life.
Ever since its beginnings, AA has struggled with the issue of God and a Higher Power. Bill Wilson, the iconic AA founder (and one of TIME magazine's 100 most influential people of the 20th century) was himself an agnostic and an atheist at various points in his life. Those struggling with alcoholism who refuse to attend AA because "it's too religious" may be missing the point.....
Bill W. and Dr. Bob started what is now known as AA in 1935 in Akron, Ohio. Shortly thereafter, Bill W. wrote (with the input of AA's first 100 members) the Big Book of Alcoholics Anonymous, introducing for the first time the Twelve Steps model of recovery. Chapter 4 of the Big Book is titled "We agnostics" and explores the meaning of a Higher Power. In this chapter, Bill W. explains the famously italicized statement that follows the word God in Steps 3 and 11 of the Twelve Steps: "God as we understood him" . It is clear that the AA fellowship knew since its beginnings that non-believers could also get sober in their program.
Jim Burwell ("Jimmy the atheist") was one of AA's first members. He wrote his personal story, "The Vicious Cycle", for the 2nd edition of the Big Book. He took his last drink on June 16th, 1938. After months of lively discussions with other AA founders on the issue of God, he was the first to conceptualize the AA group as his own Higher Power. "Those who honestly try to find a Power greater than themselves", he wrote, "were much more composed and contended than I have ever been, and they seemed to have a degree of happiness which I have never known." In his article "Thirty Years Sober" published in 1968 he elaborated on the concept of how the Good all human beings have, deep in their hearts, could serve him perfectly well as his Higher Power. "By meditating and trying to tune in on my better self for guidance and answers, I became more comfortable and steady."
Beyond Belief (BB) is a secular spinoff of AA started by non-believers who didn't feel comfortable in certain AA groups where religious beliefs played a significant role. In their website they list several secular versions of the Twelve Steps. Overall, they fully endorse the principles of AA but try to offer a friendlier environment to those firmly rooted in atheism or agnosticism. Quad A (AAAA, AA for Agnostics and Atheists) started in Chicago in 1972. Both of these groups' understanding of the Twelve Steps follow "Ed the atheist": God as a Higher Power is replaced by AA and its members.
Those fulfilling AA's only requirement for membership ( a sincere desire to stop drinking) should have no problems accommodating their religious beliefs to AA, including lack of any religious beliefs. AA (or BB or Quad A) will certainly accommodate them. To date, one of the most successful, consistent and effective long-term ways of staying sober is to embrace both the fellowship of AA (becoming a friend of Bill W. ) and to diligently work the Twelve Steps.... one day at a time.
We all hold (sometimes secretly) certain fears or phobias. For these to be of clinical significance, they need to be severe enough to cause impairment in functioning. Clinically, a phobia is a persistent fear of an object or situation in which the sufferer commits to great lengths in avoiding. The fear is typically disproportional to the actual danger posed, and is often recognized as irrational. In the event the phobia cannot be avoided entirely, the sufferer will endure the situation or object with marked distress and significant interference in social or occupational activities
Coulrophobia is the fear of clowns. Astraphobia is the fear of thunder and lightning. Taphophobia is the fear of being placed in a grave while still alive. Xanthophobia is the fear of the color yellow (in chinese tradition, if a general lost a battle, the Emperor would send him a yellow scarf, an imperial order to commit suicide). Triskaidekaphobia is the fear of the number 13. The term nomophobia was recently coined to describe the fear of being out of mobile phone contact
Homophobia or Xenophobia are not real phobias. These terms refer to attitudes and prejudices that involve hate rather than fear. A more proper way of describing hateful beliefs is to use the suffix misia instead of phobia. Homomisia, then, correctly describes the irrational hatred of homosexuality. Iatromisia is, by the way, the intense dislike and hatred of medical doctors and the medical profession.
Phobias can end up being mostly an inconvenience. For example, fear of flying may result in very long car rides. However, they can also be truly debilitating, like social phobia. They are treatable. Often, the best treatment results are obtained with a combination of CBT (Cognitive Behavioral Therapy) and SSRIs (Serotonin-Specific Reuptake Inhibitors: Prozac, Paxil, Zoloft, Lexapro, etc). CBT should be a first-line treatment: after all, fears are often nothing more than stories we tell ourselves.
Fewer people know of the “Rat Park” study of drug self-administration. In that and related studies, researchers hypothesized that the social environment plays a big role in the rats’ willingness to self-administer addictive drugs. Rat Park was Disneyland for rats—lots of food, lots of tunnels and things to do and play with, as well as other rats to play and mate with. The rats were given a choice of two fluid dispensers: one contained a morphine solution and the other plain tap water. The rats in Rat Park repeatedly selected the plain tap water by substantial margins. Even rats that were made dependent on morphine and then detoxified chose to avoid morphine self-administration when they were in Rat Park and had opportunities for social interaction. The isolated rats, on the other hand, continued to use morphine when given the opportunity.
So what does Rat Park tell us about human addiction? We know that addictive substances and behaviors are extremely rewarding. But people who achieve recovery don’t just stop using drugs; they find security and connection in healthy, supportive social relationships. Successful treatment must accommodate this social need. When we help patients overcome social anxiety, depression, trauma, grief, family dysfunction and other obstacles to develop and maintain human connection, we help them achieve health and recovery. Addiction is a disease of isolation as well as a disorder of brain function. Recovery necessarily involves social support and connection.
Panic attacks are common and often debilitating episodes of sudden onset that include a number of symptoms such as palpitations, shortness of breath, a choking sensation, chest pain, sweating, shaking, nausea, dizziness and fear of losing control or dying. Other less common symptoms include derealization (an alteration of the way we see the world so that it seems unreal) or depersonalization (the feeling of watching ourselves act without having control of the situation). In severe cases, many activities of daily living are associated with attacks, and as a result patients become homebound ( agoraphobic ).
Anxious patients tend to monitor (scan) their bodies for trivial background sensations. They fixate on them, magnify their intensity and catastrophize their meaning. We all have occasional "body noises": aches, pains, itches, mild dizziness, etc. The anxious patient will monitor, focus, amplify and catastrophize these feelings. Consulting "Dr. Google" tends to worsen the problem since it often gives more ammunition to the anxious mind to wrongly conclude that a serious health problem is taking place.
Medications and/or Cognitive Behavioral Therapy (CBT) are excellent treatment modalities for this debilitating disorder. The benzodiazepines (Xanax, Ativan, Klonopin, etc) are effective in aborting an attack and turning off the symptoms once they appear. The SSRIs (Prozac, Paxil, Zoloft, Celexa, Lexapro, etc) and the SNRIs (Cymbalta and Effexor) are very successful in preventing panic attacks from occurring. Often, patients need to combine a benzodiazepine with an SSRI/SNRI at the onset of treatment, since the latter will take a few weeks to work. Once attacks no longer occur, benzodiazepines are rarely necessary and may be used only "as needed" for high-risk situations, like flying on airplanes.
A cognitive approach to panic teaches the patient to recognize its symptoms as inconsequential and not as evidence of a serious disease, such as a heart attack. This workbook is a good source of information on how to de-escalate the anxiety that a patient feels upon the onset of symptoms. If, soon after the appearance of the first panic symptoms, a patient's anxiety escalates, the patient becomes convinced that a serious health problem is taking place, and a full attack ensues (hence, a self-fulfilling prophecy). Panic symptoms are mostly the appropriate response we have to a dangerous situation...but they happen when no real danger exists!