Pri-Med West: Shameless Self Promotion

West Annual Conference

Anaheim, CA | April 27-30, 2016

Anaheim Convention Center

 

Adult ADHD: How To’s for Diagnosis, Management and Remission

Shirah Vollmer MD

• Friday, April 29

Description

This session will illustrate how ADHD manifests in adulthood. Assessment and management tools will be explored. The complicated interface between stimulant treatment and addiction will be discussed. Both old and new stimulants will be presented, along with behavioral interventions. Mindfulness as a tool for ADHD will also be discussed.

Learning Objectives

Discuss diagnosing ADHD in adulthood

Review treatment options for ADHD in adulthood

Discuss treating the adult ADHD patient who is also an addict

Learn non-pharmacological interventions for adult ADHD

Is Psychiatry Turning Into Neurology?

I went to a Psychiatry Grand Rounds yesterday where the topic was “Post-stroke Apathy,” presented by a neurologist, describing the brain mechanisms of personality change. Suddenly, the obvious hit me. “Do you think that the future of psychiatry is that it will be folded into neurology and the psychiatry field, as we know it, will simply die?” I asked my friend and colleague sitting next to me, hoping she would protest the notion, but instead, she looked at me with a clear expression of “duh”. Oh my, it is that clear, and oh my, I have been in denial, and oh my, I really am a dinosaur. Psychiatry is trying to understand the brain, not the mind, and as such, it has more in common with  neurology than psychology, and so there you have it. Neurobehaviorists, will perhaps be the new name for Psychiatrists. Therapy will, in the future, be done by mostly non-MDs, since very few MDs are getting psychotherapy training, and the little they do get, is not enough to sustain a career of deep thinking about human motivation. Landscapes change, and so it is.

Transference

“Psychoanalytic treatment does not create transference, it merely brings them to light like so many other hidden psychical factors.” Freud, 1905

 

“I am just not comfortable with your shoes,” a fictional patient, Trey, sixty-one tells me, to my astonishment. “What do you mean you are not comfortable?” I ask, feeling clueless about his comment. “I mean, they do not suit your outfit and they just make me uncomfortable, ” he protests. “Tell me more about this feeling of discomfort,” I ask, hoping for clarity, which never seems to come. “I know this sounds silly, ” he continues, “but I trust you more when I like what you are wearing.” Again, I am confused, but aware that this discussion is about his pre-conceived notions of authority. I sense that to him, being in power is strongly associated with a professional look, and as such, he was raised to associate appearance with wisdom. This superficial connection, as I suspect, has caused him great difficulty in his life, as he is a sucker for the polish without the substance. He never grew to appreciate the inner workings of relationship which involve loyalty and dedication because in his background, appearance trumped sincerity. As he focuses on my shoes, I am reminded of his traumatic beginnings where there was a confusion as people he was told to trust turned out to be disloyal, leading him to feel anxious and unhappy in his close relationships. He repeats these poor judgments by commenting on my shoes. He opens the window into his childhood in which I can now appreciate that the trappings of wealth were of such high value in his family that he became blind to the bonds of good relationship which depend on honesty and reliability. If I did not understand transference, I will tell my students, I would be completely taken aback by his focus on my clothing. With understanding this phenomena, I am still confused, but I know I am in a transference confusion and that is the area I need to pursue. Freud, once again, has guided my thinking so that although the path to helping Trey is not linear, I do have tools to help me.

Growth Vs. Anxiety

Anxiety is often a stimulus for growth, but when it becomes paralyzing, it is termed a “disorder”. On the other hand, no anxiety can mean mental “deadness” and that may represent developmental stagnation. The sweet spot of anxiety is the discomfort on the journey to new challenges, and yet to get to this “sweet spot” is a non-linear path. Medicating anxiety is often helpful, but at the same time, it side-steps the notion that anxiety which is overwhelming is often more a reflection of self-esteem than a problem with “anxiety”. Psychic withdrawals often produce calm states of mind, but at the price of developmental growth. Similarly, addiction is a form of psychic withdrawal, which temporarily relieves anxiety, but long-term causes immaturity and bodily destruction. With this conundrum I am left wondering about our diagnostic system which classifies “Anxiety Disorders” as a condition warranting treatment, as opposed to an “immaturity disorder” which is a condition warranting psychic growth. It is politically incorrect to term those with “Anxiety Disorders” immature, and yet, for the moment, I would like to entertain that notion. Perhaps maturity means a certain calmness in handling life’s irregularities. Perhaps anxiety is a signal to promote growth and development, to help the patient “grow up” and manage life. Perhaps it is wrong to give these folks a medical diagnosis which promotes the sick role, as opposed to a psychological diagnosis which mandates them to develop coping skills.

Chad, fifty-four year old male, comes to mind. He quit his executive job because he was having panic attacks. He now stays home and reads books, while his wife and three children leave the house to go to work and school. He says he is “disabled” by his anxiety, and that “no one” can help him. His “panic disorder” qualifies him for disability, so he receives a monthly check. I wonder what would happen if his panic attacks did not qualify him for disability. I wonder if he would then feel the need to re-boot his life to a job that gave him more satisfaction. Chad is not anxious now and he is not on medication, but then again, he hardly leaves his house on weekdays and his weekends are spent driving his kids around. Is Chad immature by my account? Yes and no. Chad had a good job for many years but when he was passed over for a promotion he felt humiliated and started having panic attacks. He left his job and his symptoms immediately went away. Chad needs to take this humiliation as a step towards finding a new way to be in the world, rather than retreating to a safe, but stifling existence. We, as physicians, should not encourage him to take on the sick-role, but rather we should facilitate him in finding his next career move, by exploring different areas of satisfaction for him. A more positive psychology, one based on the notion that humans want to live in deeper and more meaningful way, would be far superior to a medical model which promotes disability and stagnation.

To Understand Or To Ameliorate?

How does the mind work? More specifically, how does your mind work? That is what I am curious about. Does that mean I do not care about my patients and that I am only on a journey of understanding? Of course not. This struggle between the therapeutic basis of the relationship versus the need to understand unconscious motivations seems to be a weak fight in that they are complimentary. The central question is what is the agent of change. Is it the bond the patient forms with his therapist or is it the patient  “learning” the secrets and lies which underlie his “analytic surface”?  How about, both are true? Or, why do we care as long as the patient gets better? We care because we aim to help people and we aim to teach new therapists how to help people. If the relationship heals then the content of the therapy is not relevant. On the other hand, if the understanding is key, then maybe we won’t wish the patient a happy birthday. I find this discussion tiresome and yet my job tonight is to review these ideas with bright and eager students. I will take the unpopular stance and say that we do not know the agent of change, ever. In fact, it is a surprise when patients get better, not because we don’t have a lot of training or experience, but because the one thing that seems certain is that patient, no matter how much they consciously express a desire to change their way of being in the world, the pull towards sameness is very strong. Hence, when a person grows and sees himself as a third person in order to understand his own struggles, the work is both rewarding and astonishing. What distinguishes psychoanalytically trained therapists from cognitively oriented therapists is that we accept that change is not going to come easily, if at all. Through this understanding we have joined the patient in his rigidity and we propose an opportunity to loosen up the joints in that box the patient has put himself into. Like Houdini’s work, the escape is crafty and creative, and not linear or easy to see. Knowing the dark halls of interior mental life, we tread slowly and gently, with great respect for what is around the next corner. We take time and patience as we are wary of what we will uncover with even gentle probing. We imagine the challenges their life presented to them and this helps the patient feel less alone, but it may not help the patient cope with his circumstances. Coping skills developed over many years. Adding new coping skills and/or getting rid of old ones is not a linear process. So, what is the technique? I imagine a student will ask. To which I will respond, you imagine the life of your patient, both past and present, and from there, the narrative begins.

Understanding One’s Own Mind: The Work Of Mental Well-Being

The mind both inhibits and punishes. To quote Fred Busch http://drfredbusch.com/ “unless the analyst is willing to make some attempt to understand the patient’s mind, and comes reasonably close to doing so (especially with regard to those ways of thinking that brought the person into treatment), a primary component of what has led to the patient’s unhappiness will be ignored.” To continue, “Within the areas of conflict that bring the patient to treatment we see an ego frozen into rigid, repetitious ways of seeing and living within the world based on ancient but still active fears.” The goal then of treatment is an expansion, or de-icing of the ego, rather than  symptom relief, which is the goal of third-party reimbursement. With the expansion of the ego there is reflection instead of action. With reflection comes compassion and peace.

My “Technique” class begins this week and so I will start the discussion about what happens in the office? What does it mean to think “analytically”? What are the tools of our trade? Bianca, fifty-four, will be my imaginative case example. She is a successful attorney. She likes her job. Happily married, she is  the mother of adult children, who are doing well, by her report. Yet, Bianca constantly thinks about how pointless life is. She is not suicidal, but nor does she embrace life. She denies feeling depressed in that she says “I don’t feel anything but anger.” With time, Bianca has come to understand that her “anger” follows the path of her mother’s anger, in that her mother raised five children with a husband who was often gone and not available. Bianca being the oldest child felt her mother’s anger and felt helpless in that she could not make her mother happy. Bianca identified with her mother’s anger such that all these years later Bianca still carries the negative feelings which she says are often directed to my husband, which “sometimes he deserves, but most of the time, I am being unfair and then I feel horribly guilty.” In helping Bianca to see how her mind is still punishing her for not being able to make her mom happy she can reflect on how her past is influencing her present. This reflection replaces the tantrums she used to throw when her husband did not put his socks in the hamper. Her ego expands. Her coping skills improve not because we talk about coping skills, but because she can see that the intensity of her disappointment with her husband stems from her mother’s disappointment in her life. From the “analytic surface” of “persistent anger,” together, Bianca and I can explore the repetitions in her life which leave her feeling either dead or guilty inside. Her ego does not have to punish her.