Shirah Vollmer MD

The Musings of Dr. Vollmer

Archive for January, 2010

Attention Spectrum Disorder

Posted by Dr. Vollmer on January 24, 2010

This blog is part of my series on psychopathology.

In my previous blog I spoke about how ADHD is both a cognitive issue and an ego or personality issue. Children with ADHD have a problem with inhibition and as such, they do not wait to hear what the other person has to say. In turn, friendships can be quite challenging. When severe, ADHD children can be very lonely and subsequently depressed. This clinical picture of the lonely, depressed ADHD child can resemble a child with Asperger’s Syndrome.

My six year old female patient who is highly intelligent, unable to focus, hyperactive, has poor frustration tolerance and has no friends. What is the diagnosis? As I have mentioned many times, all psychiatric diagnoses are clinical diagnoses and as such they are subjective. One doctor would call her Asperger’s, another would call her ADHD and a third would say she has both. What do I say? I say that her primary diagnosis is ADHD as she has trouble with focus, trouble controlling her body and trouble containing her frustration. If these problems could be addressed then she would be able to have friends.

Theory of mind is the ability to attribute mental states-beliefs, intents, desires, pretending, knowledge-to oneself and others and to understand that others have beliefs, desires and intentions are different from one’s own. It is typically assumed that others have minds by analogy with one’s own. Based on the reciprocal nature of social interaction, as observed in joint attention, the functional use of language and understanding of others’ emotions and actions. Having a theory of mind allows one to attribute thoughts, desires and intentions to others, to predict or explain their actions and to posit their intentions.

Joint attention is key to a theory of mind, such that a problem with attention will lead to problems in theories of mind. Hence, with my six year old patient, I say that her primary diagnosis is ADHD and not Asperger’s Syndrome. As such, I propose that the explosion in the diagnosis of autism spectrum disorders is in part a result of clinicians missing the diagnosis of ADHD. It seems to me that since clinicians think of ADHD as a series of cognitive deficits and they think of Asperger’s Syndrome as a series of social deficits, there is an artificial separation between these two diagnoses. I propose that we see ADHD as a spectrum disorder and as such, put children into the category of Attention Spectrum Disorder. Once again, I hear my critics worried about funding, since Autism Spectrum Disorders receive state and federal funding, whereas the diagnosis of ADHD does not, in our current system, warrant such funding. I do not want to take funding away from children who need it. At the same time, I do want to focus on having more accurate diagnoses so that we can better comprehend what we are dealing with. We need to give the child and his family greater insight into their struggles. Understanding is our first step.

Posted in ADHD, Musings, Psychopathology | 4 Comments »

ADHD: Is It A Thinking Problem or a Personality Problem?

Posted by Dr. Vollmer on January 24, 2010

This blog is part of my series on psychopathology.

When I was a child psychiatry fellow from 1989-91, I was taught by Dennis Cantwell MD, a world leader in ADHD, who stated that kids who have problems concentrating have different brains than other kids. As such, they have struggles that other children do not have. Typically, this means that an ADHD child cannot focus on things that he has no interest in, whereas another child of the same age, could force himself to focus on something, even if it bores him.

Karen Gilmore MD, as have child psychoanalysts before her, add that children with  ADHD,  also have problems regulating their ego. Personality is often defined by how one monitors themselves. The word ego, in this sense, is interchangeable with the word personality. Dr. Gilmore argues that the inconsistency and variability of the integrative, organizational and synthetic functions of personality are really the problem in ADHD. In other words, the child with ADHD suffers because he has a harder time forming relationships, in addition to suffering because he has a harder time learning.

Historically, at the turn of the last century in England, George Still (great name) observed a group of children in his practice who showed a pattern of aggressiveness, defiance, resistance to discipline, excessive emotionality, little “inhibitory volition,” “lawlessness,”  spitefulness and cruelty; these children were also notable for their impaired attention, over activity, and a “defect” in moral control” (Still 1902).This syndrome was attributed to an underlying neurological deficiency.

More recent research has taught us that ADHD has pointed us to areas of the brain which may be affected such as the frontal lobes, the inhibitory mechanism of the cortex, the limbic system and the reticular activating system. It has been said that 70% of the brain is there to inhibit the other 30% of the brain. It is possible that those with ADHD have a lower percentage of inhibition.

To meld these psychoanalytic ideas with the neurological notions, I have come to understand that ADHD children have a hard time with inhibition. As such, learning is difficult, particularly for tasks with low enjoyment, and relationships are difficult, particularly if they involve a reliance on verbal interchange. In general, school is hard for kids who do not feel rewarded by pleasing others. The same could be said for relationships. As such, it is easy to understand the child with ADHD in that he struggles in school and he may also suffer with friendships. Having said this, each child with ADHD is  unique, such that some will have more difficulties with school, others will have more difficulties with relationships, and the most severe cases will have difficulties with both.

As we look to Russell Barkley’s work, we derive the answer. Although attention may be a prominent part of ADHD, the most disabling symptom is the inability to control impulses. Without the ability to control impulses, no one will cut you slack: not your friends and not your teachers. If no one wants to help, then the child will have problems learning things which do not interest him, and he will have problems being patient with friends. Impulse control is an ego function. Impulse control is  a cognitive skill. Both are true. Dr. Cantwell, may he rest in peace, would agree.

Posted in ADHD, Musings, Psychopathology | 15 Comments »

Retired From Psychology Today: How am I Doing?

Posted by Dr. Vollmer on January 24, 2010

Friday, January 15, 2010 2:33 PM

Yesterday was a tough day for me. I received an email from my editor at Psychology Today which said “call me”. I knew this was bad news. I also knew that my most recent post was entitled “Betrayal”. This was my favorite post, but I also felt it to be risky. I received many comments, both positive and negative. Amongst the negative comments were statements which claimed that I was betraying my patient by blogging about him. I responded by saying “this is fiction”. By that I meant that I do not have a 24 year old male patient who was betrayed by his mother, but I do have many patients who have gone through that experience. I changed the details of my patient so as to describe my psychotherapeutic process. The details of the patient are not important. The key elements involve how one goes from pain to healing. I was trying to describe an instrument of change. Still, I had a funny feeling when I responded that that this was “fiction”.

I am caught in a bind. If I describe an actual patient after obtaining consent, then I still risk violating patient privacy since the client is entitled to change his mind later on, but by that time, the damage would have been done. On the other hand, if I make up a patient (based on actual patients), then I may lose credibility with my readers. To me, this was an easy choice. Patient privacy trumps everything else and as such, I needed to create an imaginary patient.

This conflict about patient privacy versus writing fiction made me pause. During my reflection on this issue, I called my editor and she told me that I was “retired”. The co-occurrence of my thinking about patient privacy and my termination seemed to me to go hand in hand. That is, although I do not have any clear reason for my cessation as a Psychology Today blogger, it is my hunch that my blogs, such as “Betrayal” in which I described the therapeutic process, created a liability issue for Psychology Today. Of course, I could be completely off the mark, but that is how I piece together this puzzle.

What about my feelings? Am I angry? Do I feel betrayed?  I loved blogging for Psychology Today and I feel disappointed. Psychology Today provided me an opportunity to try to take my ideas about psychiatry, psychotherapy and psychoanalysis to the public. I was excited to get comments, both good and bad. I was imagining developing my writing  into articles and then maybe even a book.  I thought that this venue was my first step. I do not feel angry or betrayed since I understood from the beginning that there had to be mutuality. I was giving them content and in return they were giving me public access. When my content presented a dilemma for them, I was done. I knew that. Disappointment prevailed.

Where do I go from here? I am going to continue on this blog, but I am considering working on my graphics to make it more appealing. Some of my readers have suggested that I try, and so I will do that. Perhaps that will be my new venue. I am going to talk to people to get some ideas about my next step. However, in the immediate future, I plan to just breathe in and breathe out. It is time for yoga.

Posted in Musings | 4 Comments »


Posted by Dr. Vollmer on January 24, 2010

Thursday, January 14, 2010 10:01 AM

Psychology Today has “retired” me. No reason was given. Sigh!

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Non-player Character

Posted by Dr. Vollmer on January 24, 2010

This blog is part of my series on psychotherapy.

An 18 year old patient whom I have known since she was twelve, an avid video game player, explains to me that she feels like an NPC. I said “what?” She explained that an NPC is a non-player character in video games. This is a character, unlike a player character (PC) which is part of the computer program and not controlled by a human. I do not play video games, but I understood her to be saying that she felt that she was not part of life, but rather she felt that she was going through the motions, as if she was the result of some mysterious computer program.

I felt so sad for her. Life feels good when we feel like we have an impact. In a poetic way, she was telling me that she had no sense of agency; she had no sense of power in her universe. I imagined that had she not been a gamer, she would have said to me that she felt like the little girl behind the window watching other children play, and not understanding why she is not playing with them.  She was trying to tell me that she was not engaged with life and she wished she could be. She drew upon her hobby to describe to me her experience. As she was referencing an arena that I was not familiar with, she  was drawing me into her world. As such, she stimulated my curiosity about a non-player character. In so doing, she made me more curious about her life in the video game world.  At the end of the session, she seemed slightly less depressed. My hope was that this interchange, albeit painful, ultimately led to a feeling of connection and a feeling of hope. She shared her pain. I was interested and moved. She appeared to get some relief.

As I researched non-player characters, I learned that most NPCs do not have any details. That is, the characters are purposely vague. Further, NPC behavior in computer games is usually scripted and automatic. My young lady was conveying not just a sense of loneliness and ineffectiveness, but she was also letting me know that she felt herself to be vaguely defined. That is, as I reflected on her comment, I understood that she was saying that she did not really know herself.

At twelve, this young woman made poor eye contact, had no friends, and was constantly ridiculed. Many professionals thought she had Asperger’s Syndrome, but I was not sure. I thought that perhaps she was very anxious. As the years have gone on, her diagnosis is still not clear. Her eye contact has improved. She has a few friends. She is progressing in school. A few years ago, she could not put her internal experience into words. Now, she can describe to me her pain. With the long view, the work is hopeful. She wove her gaming world into her psychotherapy world. She was reflecting. I was reflecting. Maybe one day she will be a PC.

Posted in Musings, Psychotherapy | 4 Comments »

Most Popular, Finally!

Posted by Dr. Vollmer on January 24, 2010

Thursday, January 14, 2010 7:23 AM

Betrayal is popular. Who knew?

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Posted by Dr. Vollmer on January 24, 2010

This blog is part of my series on psychotherapy.

“I feel like I was thrown under the bus” says my 24 year old patient who experiences his mother as having a great deal more love for his half siblings. The word betrayal immediately came to my mind. Betrayal is the violation of a presumptive social contract that produces moral and psychological conflict within a relationship. In all of my years of psychoanalytic education, I am not familiar with any literature on betrayal. Yet, the theme comes up over and over again in my office. Adultery is the most common type of betrayal, but any type of relationship can end in betrayal. In the case of this patient, he trusted his mom to always treat him like he was very very important to her, but in point of fact, he feels that he is significantly less important than her children from her current marriage. This is a betrayal because the social contract implies that parents make all of their children equally important. I begin to wonder about this social contract. Perhaps growing up means understanding that parents have preferences and as such, children are not treated equally or fairly. Perhaps this is not a betrayal in that the social contract is in fact a myth. Although it may be true that the social contract is a myth, it is also true that children believe this contract and as such, growing up and finding out that the feelings do not correspond with the alleged contract, means that the budding adult experiences betrayal.

In my way of thinking, betrayal is one of the worst human experiences. I say this because betrayal involves shock, disappointment and re-evaluation of one’s belief system. Almost every betrayal makes the victim look back over their past to try to determine what caused it. This reflection almost inevitably leads to self-blame and guilt. Although my patient may express anger at not being treated well, underneath this anger is a sense that he must be unworthy of his mother’s love. This linear path between betrayal and unworthiness is how deception causes so much damage. That is, since betrayal causes the victim to feel bad about himself, the victim is hit twice. First, his social contract has been broken. Second, he thinks poorly of himself.

Betrayal leads to an utter sense of helplessness. The victim feels like there is no way they can fix the situation since the damage has already been done. Helplessness leads to profound and paralyzing depression. Sometimes, the desired solution is revenge, in order to restore a feeling of potency. The movie Inglorious Basterds demonstrates this fantasy. As Daniel Mendelsohn says “Tarantino indulges this taste for vengeful violence by-well, by turning Jews into Nazis.” In this area, psychoanalysis does help us to understand the revenge fantasy. Being passive is so painful that we often want to turn passive into active. The victim becomes the perpetrator.

Generally speaking, the greater the trust that one puts in another person, the greater the impact the betrayal has. In the case of my client feeling betrayed by his mom, the impact is enormous. This impact results in anger, despair and fear. The patient will likely fear that he cannot trust anyone. After all, if your mom lets you down, how can one believe that anyone will really be there for them. So, in addition to having low self-esteem, my patient suffers from relationship problems where it is hard for him to allow himself to become vulnerable to trust anyone.

I imagine my patient being thrown under the bus. I imagine him screaming for help. I feel his pain. I want to help, but I am not sure he is still alive. Worse yet, I imagine that he believes his mother put him there. Then, I think that maybe, just maybe, the bus has high clearance and so rides right over him. I see a near-miss, like the story of the man who jumped into a New York subway to push a young gentleman having a seizure down into the hole so that the subway went right over the two of them, causing no damage. I see a story with such a happy ending that I cry every time I think about it. Still, the fragility of life, both physical and emotional,  is all too present.

I trust that we can keep working. The opposite of betrayal is loyalty. Both exist. My client and I need to remember that. Sometimes, many times, when the pain is great, it is hard to keep that in mind. As I said before, we have work to do. Our work involves loyalty to each other. Perhaps in that loyalty, trust will develop, and maybe this newly made trust will layer over the betrayal he has felt.  A layer of trust will help him, but make no mistake, it will not take away his pain. My hope is that this new layer will help him manage his feelings so that his world is now a mosaic of trust and betrayal.

Disclaimer: Details have been changed in order to maintain privacy. This blog is for illustrative purposes only.

Posted in Musings, Psychotherapy | 4 Comments »

Mom’s Birthday

Posted by Dr. Vollmer on January 24, 2010

b: January 12, 1925..

Today is my mom’s birthday. It is hard to think about a birthday when the person who was born is no longer with us. Normally, I would wake up and call my mom and I would wish her a happy birthday and for many years she would say “well, it is better than the alternative”. Even though my mom passed away in 2008, I am still thinking about calling her.

My mom was born in 1925. She often told me that she was a depression baby. By that she meant that she grew up in the Great Depression. As we all know, the Great Depression was a severe worldwide economic depression in the decade preceding World War II. In most countries it started in about 1929 and lasted until the late 1930s or early 1940s. In 1933 the unemployment in the United States rose to 25% and in some countries rose as high as 33%.  The depression originated in the United States, starting with the stock market crash of October 29, 1929, but then spread to almost every country in the world. In today’s terms, we would say “it went global”.

The cause of the Great Depression is not clear, but two economists of the 1920s, Waddill Catchings and William Trufant stated that since the economy produced more than it consumed, there was an unequal distribution of wealth throughout the 1920s, causing the Great Depression. The end of this economic downturn seems more straight forward. Most people think that the Great Depression ended with the advent of World War II. America’s late entry into the war in 1941, when my mom was 16, finally eliminated the last effects from the Great Depression. Unemployment rate went below 10%.

For years, when my mom described herself as a “depression baby” I had no idea what she meant. I knew that she grew up in poverty. I knew that when I went to visit my grandparents, her parents, I slept at night with my hands over my ears so that I would not hear the gunshots in the neighborhood. I understood that her childhood was rough. I also understood that she attributed her challenges to the economic conditions of the country. However, what I did not understand is whether other people, born in her era, saw themselves in the same way.

My dad, born in 1927 into a poor family, had a very different outlook. He saw himself as a very lucky young man. He served in World War II, went to college on the GI Bill, and poof, his life changed. My dad’s focus has been, and continues to this day, to be on how fortunate he was to be able to take advantage of this government program. My father often tells me how college was amongst the best years of his life.

So, as a psychiatrist I wonder how two people, born into similar economic circumstances, grew up to review their early years so differently. Clearly, there are many many factors which determine one’s formative experiences. My question though is why my mom attributed her challenges to the economy. My mom spoke about how poor people suffer in ways that affluent people do not understand. It is not that rich people do not have their challenges, it is only that people in different economic classes cannot really understand each other, even if they think they can.

I remember when I was little and the Pritikin diet had just hit the public’s eye. The diet promoted grains, with some, but not much protein. My mom laughed, saying that when the food is associated with poverty, no one wants any part of it, but now that some fancy doctor is saying it is good for you, everyone wants to eat like poor people.

My mom never wanted any presents for her birthday, but she did want me to call her. She wanted me to remind her that I was happy she was still here. At the same time, even though in her adult years, her economic life was characterized by booms and busts, her birthday seemed to be a painful reminder of her adversities. She understood that her childhood was challenging on many levels. Eventually, I began to understand that when she said she was a “depression baby” she was saying that the challenges of the country were woven together with her personal challenges of her family dynamics. I came to appreciate the wonders of the double meaning of depression: psychological and economic. This is no coincidence.

My mom taught me a lot. Today I appreciate her wisdom. In particular, I embrace her point that people in different economic circumstances do not really understand each other. The longer I live, and the longer I work with people who are suffering, the more I understand that she was right. Happy birthday mom.

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Mosaic Mentoring

Posted by Dr. Vollmer on January 24, 2010

Mentoring refers to a personal developmental relationship in which a more experienced person helps a less experienced person. The receiver of mentorship was referred to as a protege, but more recently the word “mentee” was invented. Mentoring involves informal communication, usually face-to-face and during a sustained period of time. The word mentor was inspired by the character of Mentor in Homer’s Odyssey. Though the actual Mentor in the story is a somewhat ineffective old man, the goddess Athena takes on his appearance in order to guide young Telmachus in his time of difficulty.

Historically significant systems of mentorship include traditional Greek pederasty, the guru, Elders, the discipleship system practiced by Rabbinical Judaism and the Christian church, and apprenticing under the medieval guild system. A mentor focuses in issues pertaining to both life and career. Potentially, mentoring can promote spiritual development.

Robert Davis and Patrician Garrison undertook to study successful leaders. They wrote a master thesis describing many roles for mentors. Their research presented evidence for the roles of: cheerleader, coach, confidant, counselor, developer of talent, guardian, guru, inspiration, master, “opener of doors”, patron, role model, pioneer, “seminal source”, “successful leader” and teacher. Subsequently, the name “mosaic mentoring” has been coined to describe this kind of mentoring. Mosaic mentoring implies that almost everyone can perform one function well for someone else.

My own experience of being a mentee has fit with the mosaic model. For the most part, my psychoanalytic teachers have served as an inspiration. My psychiatry professors have been great teachers. My Family Medicine colleagues have been inspiring. For many years, I was deeply disappointed that I did not consider any one person to be my mentor. I thought that this was a personal failing. However, when I reflect on my need for mentorship, I now embrace this mosaic model. In fact, the mosaic model of mentoring seems to fit many aspects of my life, where if I look to one person to meet all of my needs, I feel disappointment, but when I see my network of people fulfilling individual needs, then I feel fulfilled. I am not saying that all of my relationships are uni-dimensional where each person serves one function, but I am saying that taking the positive part out of each relationship and then putting together the mosaic changes my mindset from disappointment to contentment.

Posted in Musings, Professional Development | Leave a Comment »

Henry VIII: A Tale for Our Time

Posted by Dr. Vollmer on January 24, 2010

As I read Wolf Hall (2009) by Hilary Mantel for my book club, I am struck by the story of Henry VIII. He is popularly known for his role in the separation of the Church of England from the Roman Catholic Church. Henry’s struggles with Rome ultimately led to the separation of the Church of England from papal authority, the dissolution of the Monasteries, and establishing himself as the Supreme Head of the Church of England. Apparently, Henry’s motivation for stirring this change was his desire for a male heir. Anne was charismatic, although she resisted Henry’s attempts to seduce her. She said “I beseech your highness most earnestly to desist, and to this my answer in good part. I would rather lose my life than my honesty.” This refusal made Henry even more attracted, and he pursued her relentlessly. As we all know, Anne’s story ends with execution.

Henry VIII seized economic and political power from the Church by the aristocracy, chiefly though the acquisition of monastic lands and assets. Henry worked with some success to make England once again a major player on the European scene. Henry’s break with Rome incurred the threat of a large-scale French or Spanish invasion. To guard against this he strengthened existing coastal defense fortresses. He also built a chain of new castles along Britain’s southern and eastern coasts.

To me, this is a tale of power, of seduction, of charisma and disloyalty. I see this story as a story that every family and every organization can tell. Henry VIII was focused on his legacy. He would do anything to engineer a male heir. This drive for power, even after his death, made him so focused that nothing else and no one else mattered. As far as I can tell Catherine of Aragon was a victim.  She was persecuted for not having a male heir who survived. Anne was an opportunist. She was clever and charming. That started out well, but ended poorly.

I like thinking about Henry VIII because I am reminded that the world is a complicated place. Love does not always prevail. Good people do not always have happy endings. There are victims and persecutors. Power is powerful. Charm and charisma go a long way, at least initially. The 16th century is no different than the 21st century. These themes will always be true. For short periods we try to escape these powerful forces of human nature, but over time, we see these stories again and again. Some people will accuse me of being a pessimist. To them, I suggest that they look at history, both family histories and corporate histories. I suggest that almost every family and almost every corporation has a story of greed, power, and betrayal. There are also stories of love, devotion and altruism, but to look at one side without the other is to miss the big picture. There is the good and bad of human nature. We need to keep both in mind.

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