Good morning, Dr. Malzberg.
Good morning.
I can't think of any good cold open today, can you?
I was talking to my friend and he was talking about how he asked his psychiatrist if he had ADHD and his psychiatrist said, you know, if we go down that route, that means that you have a lifelong condition that you'll need medications for the whole time. Are you sure you want to do that?
I don't know if I can agree with that. That's not a good approach either.
I didn't say it was a good approach. I just said that that's what I'm telling you a story, Dr. Fu.
Sure, sure, sure. I mean, I just want to categorically disapprove of that kind of thing. What are your thoughts on that?
It's better than the psychiatrist who just mindlessly does the ADHD screen and then hands out stimulants. I do think that ADHD is the kind of diagnosis that occurs in the context of the relationship. It's sometimes a decision because it's not a clear-cut decision. Oftentimes, it's not like there's a category of those who do and don't. It's a little bit murkier than that. You know, it's like if I think of executive dysfunction on a normal curve, every psychiatrist is going to have a completely different cutoff.
So like your cutoff might be the 30th percentile for executive dysfunction. Mine might be two percentile of executive dysfunction. There's no every single provider has to have their own cutoff.
Yeah, I guess that's the one thing I can approve of is that there's an attempt to warn, at least, about downsides. But it's exactly what you're talking about. We shouldn't misrepresent that diagnosis. is a process that has more accuracy or realism than it actually has. Because it's not a very realistic process. It's not like we reach into a body cavity and palpate the spleen Right. That's not what's happening.
And there are no set standards about when you call something or not. It's all clinical judgment. So, you know, diagnoses are not lifelong. Diagnoses can be hidden, obfuscated, you know, in many cases, unless you go into a civil litigation where there's a lot of discovery. You can live out diagnosis. You can revise a diagnosis. You should revise a diagnosis based on new information. But anyway, what are we talking about today?
You know, I said I wanted to do a podcast that we kind of get to that line, like where, what is the, you know, the most mild case of ADHD that you would call ADHD. And you gave me some pushback and said, let's just do a case. And I think that's representative of the problem at hand.
Yeah, I guess it's because I don't think we can draw a line. The line, if there is one, is very squiggly. It's probably closer to something like the boundary, the border between two countries, right? It's shaped by geography. It's never really a straight line. It might be drawn as a straight line on the map. But if you actually get down there to the surface of the Earth and walk that border, you're going to see that things get pretty murky and they don't correspond to the map.
You know, there's that saying in rationalist circles, the map is not the territory. We really need to understand that diagnosis and the diagnostic process is a map and not the territory. And so as a result of that, I think it's more useful rather than talking about a line to just talk over an example case, a sample faith case, and how you might think about it.
guess the issue i have with that analogy is you know like yes it's squiggly but i still know when i'm in new jersey and with these diagnoses there's so many patients that it's so blurry like i can push the lines wherever i want um and it's it's a lot less clear uh it's you know very rarely are we on that that you know that border case where i can push a line this way i can push a line that way it happens all the time
Yeah. But, you know, you're in New Jersey because I don't know what's the population, New Jersey.
I don't know.
Probably everyone in the world knowing the same facts as you do would agree that you're in New Jersey, except for people with psychotic disorders. Sorry, folks. But, you know, when it comes to diagnosis, most of the time we're dealing with a two person reality. Right. And that gets really a lot harder to determine. And that's why it's nice to have collateral, right, on records. Then you can expand the apprehension of reality to more subjects than just two people.
But anyway, getting a little philosophy.
You get very, very relational for someone who pushed so hard against relational psychoanalysis.
Very relational. My issue with relational psychoanalysis is due to a perception of how they practice, not the philosophy. The philosophy is sand. Okay.
So I'll present a completely made up case. Truly, this person's entirely made up. And then we can also like tweak it if it's like if we feel like some things are too far in one direction.
Yeah, we can say what if this detail was different? Then how would you approach it differently? I think that'll be helpful. And, you know, if you're going to probably recognize this case and it's because we're making an effort to pick a case that you might see frequently or at least would be relatively typical.
So chief complaint and the reason that they made the appointment is they can't focus in school and they want treatment for ADHD. So patient reports his academic and functional struggles. He reports they started in middle school, which coincided with a prolonged custody battle between his parents. He recalls his stepfather often accused him of adding stress to the household. He remembers one quote of saying, you're always making things harder than they need to be.
In college at a state university, his academic performance was poor. He frequently skipped class and was on academic probation for most of his time there and then eventually withdrew from his major. He said he never really enjoyed the major anyway. He later enrolled in a city college for graphic design. He likes the field a lot more. He still says he consistently underperforms as a result of what he thinks is ADHD and often goes on long stretches of online gaming.
He's now a graduate student and he describes his episodes of work as quote unquote shutdown. He completes tasks only when the deadlines are absolutely urgent and he feels like this pattern fuels intense frustration and criticism. On top of his current graduate school, he works 25 to 30 hours a week as a bartender. He volunteers at a community arts center two evenings per week. He's in a two-year relationship with his partner, complicated by an arrangement that he describes as semi-open that began after a difficult conversation about their unmet needs.
Following several months of tension, this sort of has started to calm down, but he does report that they've always fought a lot. He denies any trauma. He says he's got a good relationship with his mom, but he says his mom does get depressed. When you ask her about her depression, he says she'll have periods of being really manipulative. She'll bring up all these wild things he's done wrong that he's had no clue about.
And he remembers getting yelled at a lot as a child. He says he started therapy about two years ago with an LCSW. He really likes going. He goes about every two weeks. Not really sure of the modality. He says he's typically just catching the therapist up on the last two weeks, and sometimes she'll make a few links to the past. In regards to inattentive symptoms, he said—he reports inattentive symptoms.
He said they were less obvious in childhood because of strict expectations in his household. His stepfather was very strict surrounding school, and he said he felt he could really compensate and mask his problems, saying he's very smart and he underperforms in school. He remembers having difficulty sitting down in school and generally works under significant deadlines. Yeah. He says he often feels like he's trying to express too many ideas at once when he talks to people.
As a child, he says he often, it looks like he's listening, but he's not really paying attention. As a child, he paid much closer attention as a fear of consequences from his stepfather who he feared. He reports he's easily pulled off by tasks, by noises. He often loses things, he reports. As a child, he didn't lose things because he feared being reprimanded. He says multiple people have told him that he reacts quickly when he's irritated.
His sister once suggested he do anger management. He said his mood shifts a lot with stressors or relationship tension. He's got days where he feels energetic and he gets a lot done for a few days, never crossing into anything like hypomania or mania. Often we'll have a period for a week or two where he feels down and he kind of loses track of his hobbies and stops hanging out with his friends.
He becomes angry easily when he feels criticized or misunderstood. He recalls an incident at a bus stop where he confronted a stranger for several minutes and he started screaming at them. He identifies with an anxious attachment style that he learned from a podcast. He tends to overthink. He describes spiraling thoughts related to his partner's involvement with their semi-open relationship. He experiences strong imposter feelings in his graduate program.
When he falls short of personal expectations, he engages a lot of harsh self-talk and self-blame. he reports some obsessive compulsive traits saying, yeah, maybe I'm OCD. As a child, he organized his trading cards in strict color and number patterns. He'll occasionally do small little rituals like lining up his M&Ms in particular color before eating them. He uses grounding strategies such as pressing his palm into his legs whenever he feels overstimulated.
He says he sleeps about seven hours per night and feels well rested. He used to be a big marijuana smoker smoking every single day, but in the last three months has kind of cut back and now is smoking just on the weekends. when something's weighing heavily on him, he'll often lie awake for significant periods of time, replaying events or reimagining future scenarios, which can cause delayed sleep onset or cause him to wake up and not have a tough time falling asleep.
Wow. Well, that was a thorough case. I think you presented more information for the case than some psychiatrists will elicit, which is nice, though, because we're going to have a lot of information. So, uh, first thing I do is I globally consider the story. What story does this most closely resemble? And of course this is going to be, um, pretty controversial because, uh, unfortunately I don't think that every clinician, uh, weights, uh, all the diagnoses possible, even We all have a bias, and our bias is coming from the clinical population that we work with.
Ideally, that's the main bias we have, but we can even have bias based on personal ideological beliefs about whether or not certain diagnoses exist or even worse, making estimations as a clinician about whether certain diagnoses are under or over diagnosed. OK, which is impossible to tell. Right. That's impossible philosophically. What I think is important for a clinician to do is to have a real sense of what is the life course and disease course of people who most psychiatrists would agree has certain diagnoses.
Does this sound like major depressive disorder? Does this sound like bipolar disorder, schizophrenia, obsessive compulsive disorder, ADHD, personality disorder? What does this most sound like? and from hearing the history so far we're hearing about somebody who had onset of difficulties with a family system problem a divorce a cruel stepfather we're hearing about somebody whose difficulties across their adult life suggest problems in self-direction okay uh dropping out of school not pursuing the thing that he wanted to to begin with having a variety of different jobs and interests identity having a lot of self-recrimination cruelty to the self in terms of internal monologue um possibly intimacy right in terms of sort of the fraught relationship between him and the girlfriend uh and maybe even empathy, but that's something that we'd have to assess more for, right?
There is aggression at work here, and there's even fights with strangers, it sounds like. Of course, that may be wrapped up with But we're not hearing a lot of substances that would actually cause these problems. We're hearing about some cannabis, basically. But we want to consider that substances could be not disclosed, right? Not everybody wants to disclose the harder drugs, especially because it means they won't get a controlled substance from some people.
We also want to consider the family history. The mother's description, remember, it's biased by the patient, but we have to take it with some reality, some kind of possible depression, but also maybe manipulative or unusually dissociative behavior that can be attributed to personality and personality runs in families. Okay. So thoughts so far about what I'm saying or my approach?
Yeah. And the thing that is going to be tough is so I think just to put into different words, what you said, you approached it through the alternative model of personality, the DSM alternative model of personality by naming the, you know, the, the, the self and, and relationship with others. And the, I want to hear you keep going because you can do that with almost any single person in regards to assessing the level that personality is contributing to their presentation.
The two big questions is let's say you do have that formulation first. Then the big question is what do you do with that? And then the second thing is a reasonable psychiatrist could also fit all these things into ADHD symptoms. So I kind of want to just hear you kind of continue in regards to how you formulate this case and what you would do for next steps.
Yeah. By the way, when I say that this most resembles a personality problem, I'm not even saying that's a diagnosable personality disorder. And I'm also not saying that this person doesn't have ADHD. All I'm identifying is the most likely explanation for the course of trouble so far. Mm hmm. What is the stereotypical ADHD? Now, online people will have you believe that it is this. Okay. But that is a online cultural understanding that has evolved within the last five to 10 years.
Okay. The typical and complicated ADHD case. is someone who was very disruptive, but pretty much a good kid in elementary school. Okay. They either got treatment or didn't get treatment. And if they got treatment, everything was basically peachy keen until they were an adult and stopped treatment. Okay. Or they didn't get treatment and they continued to have basically being a untroubled kid, but having a lot of problems with school.
These problems of school and organization would have persisted across multiple settings in their life and would have continued through their college and graduate school years. You wouldn't see change-ups as much in terms of relationship problems or problems with picking a career or sticking with a career. It's more that they would pick a career, try to do it, and they would struggle of certain aspects but be pretty good at other aspects, especially the aspects that they're very interested in.
You know, you wouldn't hear indicators of relationship troubles to the degree that you would in a more personality weighted case. Right. What would be the stereotypical example of somebody presenting with inattention based on the mood disorder? You wouldn't hear really of any significant problems until at least adolescence. And the main problem that would come out would be episodic problems. of attention or persistent problems of attention that may resolve with treatment or may not resolve with treatment.
And you would basically hear of global concentration problems that correlate with other symptoms of a mood disorder, sleep problems, for example, rather than the ADHD picture, right? And similarly, substances and trauma, you would hear about a more stepwise down of functioning and attention at an identifiable time. And you may not even get the trauma with the initial story, or you may not get the disclosed substance use, but it's not gonna be early on and persistent.
It's gonna happen later in the life course. And then with more questioning, you're gonna be able to identify the incident, whether it's a TBI, a series of traumas or one trauma, or the onset of substance use that really made things worse.
Now, one thing I do want to push back a little bit on you is I think you described the slam dunk cases of ADHD. Like you described like pretty good kid who had inattentive symptoms. Yeah, that's the obvious. Those are the slam dunks. But the thing I want to push back on you is like pretty bad kids also are just as likely to have ADHD. Yeah. We've kind of talked about this earlier in that, like, yes, someone can have tons of personality problems.
They're actually more likely to have mood symptoms. They're more likely to have mood disorders. And I worry that your description you just provided is you looked at only the isolated, like, clear-cut ADHD and isolation cases. And so many patients are much more complicated than that. You see inattentiveness within other problems.
And this is what I'm going to emphasize. I'm not saying that this patient doesn't have ADHD, but we need to be complete in our formulation and diagnosis. And if you label ADHD as the primary problem, you will tunnel vision you and the patient to a lifetime of escalating stimulants. Patients with comorbid ADHD and access two and one issues, I think they're at much higher risk of getting really escalating doses of stimulants because they're not going to respond.
In the same way as the simple ADHD case, it's a risk benefit analysis. The simple ADHD case, I put them back in Vyvanse as an adult. We're done. OK, they're basically pretty much good. Sometimes I have to say, you know, you got to take this on weekends, too. Aren't you neglecting your chores? Oh, yeah. Yeah, that's true. And then they start taking out weekdays and then my job is done.
OK, it's pretty easy. All right. But then when you have all these other comorbidities, I think that the responsible psychiatrist must identify the comorbidities, even if they are subthreshold for a DSM diagnosis, communicate them to the patient, and give recommendations on how to manage that. What's an element of this case that stood out to me, that this is something that is behaviorally manageable? the dysfunction was better under a structured environment.
This is true of almost everybody with ADHD, by the way. This is why we see sometimes worsening in the college environment because it's a less structured environment. Am I saying that you should either hire someone or reconnect with a stepfather so you can be truly abused? And no, I'm saying that there needs to be more than a stimulant. There needs to be the patient's own self-regulation and executive function.
Because what probably happened if a patient like this had a less than ideal childhood and development is that they were not actually taught any self-regulation or skills, right? Instead, they just had to kind of live under the iron fist of somebody else. And so they didn't have the opportunity to develop what other kids of ADHD can develop if they're given the right circumstances.
I want to reiterate what you were saying is, as a result of social media and the general knowledge that's being output by ADHD, a lot of patients are coming in... thinking that all their problems are attributed to this one diagnosis, that ADHD can explain the emotional dysregulation, it can explain the conflicts I have in my relationships, it can explain the difficulties I have in work, it can explain that I wake up and I can't get out of bed.
And the job of the psychiatrist, even if a patient pressures you to only work up the one aspect of ADHD, you have to push back in some sense. And as you kind of say, I'm not saying you do or don't have ADHD. I'm saying it doesn't explain the whole picture. And the danger in terms of what we see more and more occur in today's climate is patients will come in and walk away with just the diagnosis of ADHD and just the treatment plan of stimulants.
And that's the really scary part is that... Yes, we might be capturing more and more ADHD, which is a great thing, and treating more and more ADHD. But are we doing it with a blind spot to all these other problems? You know, if you think about medical problems, like someone can have multiple different comorbidities. They can have diabetes. They can have hypertension. They can have cancer. You can't just say, oh, it's all the hypertension and ignore those other medical problems that are really contributing to their health, which is becoming more and more common.
Yeah. Yeah. So by the way, this is all thinking that I would be doing in my head before I actually gather history. Um, Let's pretend we have a clinic set up where this is all in a form that the patient fills out. I've worked at a clinic like that before. And once I've read this story, that's me making the differential diagnosis. And so my differential diagnosis for this case is, again, number one, personality and developmental issues.
Okay. Number two, ADHD. I actually am putting that in my top three because there is at least enough report of early childhood difficulties and ongoing difficulties that resemble ADHD at least reasonably. And then number three is probably substances. And then number four would be mood disorder. Those are going to be the main ones that I'm going to be sussing up. Now, here's the thing about ADHD. Being a neurodevelopmental disorder construct that is designed to be identified in children who don't have these comorbidities most of the time, the vast majority of the time, even in troubled situations, you know, you can't take the approach of going straight for the ADHD.
Instead, you have to essentially rule in and rule out the other comorbidities that you have evidence for. So then comes the questioning. First and most important thing I want to know is why now? Has this person been in treatment for the last few years other than talk therapy? Have they been in medications? Have they wanted to take medications? And why are they now presenting for the medications?
Well, actually, why? So I'm going to answer that. And then afterwards, can we do a role play that you just finished up the intake and I want you to communicate what you would communicate to a patient? So the answer for why now, I'll just answer quickly for this, for our little role play. only has ever done the therapy that I described. Why now? Because they're having so much trouble at work or at school and keeping up with assignments.
And they just, they're at risk of failing and they have finals coming up in like two months and they're just falling more and more behind.
Okay.
How old is this patient? 25.
Okay. Has this patient ever been treated with any prescription psychiatric medications, including the ones that he didn't take?
at one point the PCP when they were 20 recommended Zoloft and they tried it for a few days and it didn't really they didn't like it so that's a thread that we would
need to pull we would need to say what was going on then Why did the primary care doctor feel like he needed that? What kind of problems were you going through?
I'm going to pull that out.
I'm going to pull that out.
I'm pulling out the Zoloft. You don't want that? I don't want the Zoloft.
Okay, fine. But then if that was a detail, that's a clue, right? It's a clue of something and you need to get more details.
I'm pulling out the Zoloft.
We're taking it out. That's fine. How long has he been doing this grad school?
They're in their second semester.
How was the first semester?
um not great they were getting like you know b's and c's okay what happened this
semester what's been going on in your life anything new happening no nothing in
particular it's really just been that um the partially open relationship conflict has kind of caused a little bit more mind headspace but other than that that's like there's everything else is safe the workload's a little bit higher thing to me
is what i would confront immediately if someone was minimizing that right that's a pretty significant change as identifiable change in the life events of this patient um you know for some people any change in a relationship problem even if you can't identify it as a mental illness can be really significant and can be impairing as well so that's another thing i would think about um
I want to get to the role play. I want to jump.
I feel like the role play you want to do is like the entire end of the session thing. And this is really about sussing it out. But then there's one more thing. Why were you never referred to or received treatment as a minor? That's another question. This can be due to the parents. This can be due to the child. This can be due to the school. But we want to know why.
And so we're going to try to get the patient's best recollection about
So the patient reports like he is very smart and didn't really cause trouble at school. Like he just kind of couldn't really pay great attention to things. So it mostly was just that he's like really underperformed, like got B's and C's when he was probably capable of A's.
I thought you were getting up by your seat. What happened with that?
I'm making these details up as I go. Give me a break. Well, this isn't... Come on.
I'm showing you how we do this. I know, I know, I know. It's not about your questions.
I know, I'm being silly. Remove the hyperactivity.
The reason why I ask it that way is because... I think a lot of psychiatrists, a lot of clinicians are afraid to do what are essentially technical confrontations. They can detect certain things that don't exactly add up, but because of their human kindness, they don't want to question about it. They'll just kind of accept it. Okay, I guess that's true. But that's not a good process for a diagnosis.
You have to question things and get into details for diagnosis. You're not going to be able to just leave threads unpulled. If you're leaving threads like that unpulled, you are pretty much just not really doing differential diagnosis. You're just picking the most likely diagnosis in your head and just sticking with it. That's really, heuristically, what you're doing if you don't pull threads. So that was the point of me asking these follow-up questions.
I think you'll be surprised that when you do pull those threads, sometimes you'll get a completely... understandable answer it's it's actually like as i've gotten more and more confrontation not intentionally confrontational but as you said like confronting a discrepancy um oftentimes there's a very reasonable explanation um and as you said like it opens up different doors and i think of it as like if you're in a house of all these things you're kind of just opening up these doors and getting more and more information and getting more of that that history um as i said the analogy i like is i like to have like in this i like to close my eyes and have a picture of what's going on or a picture of what happened and whenever my brain can't make that picture that means that i need to open more doors like here as you said like yeah i can't quite get a picture of like you were jumping up out of your seat but also you didn't cause any problems um so you just kind of keep opening doors until you have that picture exactly exactly the
purpose of confrontation is twofold The first is basically in a information gathering sense to get more information. You're not trying to show the patient that you're right and they're wrong. You're trying to confirm or disconfirm an element of history that's been shown to you. The second point of a confrontation, especially in that therapeutic context, is to show the patient their own mind. The purpose is just people all the time.
This is normal. We'll say things, but that's the automatic process of thought that's happening. There's no self-reflection happening until you actively self-reflect. So by presenting the patient their own mind or discrepancies and things to say, you're giving patients an opportunity to actually reflect on what they have experienced or communicated. OK, this sounds stupid, but I really can't emphasize this enough. Self-reflection is not automatic, even for the most intelligent and self-reflective people.
When we are talking, we simply produce information. We need to step back, pull back and reflect in order to reflect and confrontations help with that.
Yeah, totally agree. Let's get the role play. So wrap it up appointment. Tell me what the plan is, Doc.
Well, you know, you've told me about a few of your problems, and I am concerned, as you sound like you are, about the school performance aspect. I think that that's a pretty concerning issue. You know, you're in your second semester here, you want to do well, and you're not performing the way you want to be anyway. I have to tell you, though, after just this one evaluation, I'm still not really exactly sure what you have.
OK, I am hearing some evidence of possible ADHD type symptoms, but I'm also hearing that there is some problems here in terms of how you manage your affairs in terms of organization. And that doesn't have to be ADHD. That can be something that you get. from not having a good support when you were growing up. And based on what you're telling me, it wasn't always the most supportive environment for you emotionally or intellectually at home.
You kind of have to do things because there is this big repercussion at the end of the road for you, right? Also, I'm hearing that even today, there are some things that could really be interfering with your attention. OK, something changed in last semester for you compared to the one before. You know, you were doing OK, I suppose, not ideal in the first semester. But the second semester, it seems to correspond with your relationship issues.
And I think, you know, you seem to be thinking it's not such a big deal but i wonder if this is a bigger deal that you're giving a credit for because that can really cause a lot of problems in terms of retention and also i'm hearing that you work as a bartender and i'm hearing that you use cannabis and i know that this kind of stuff is very common especially at your age but with the cannabis that can be a big contributor even on the weekends to your ability to perform at your top shape And I do wonder if there's any effect on your sleep quality that is involved with either the work itself of being a bartender, which often has late hours, or even some of the alcohol consumption, which insensitive people, people who already have problems of organization and attention, even a little bit of alcohol use can really throw you off.
So if it's okay with you, I would rather not give you medication today. But if you absolutely insist, we can think about something that will be relatively safe and simple. And we really need to meet again at least a couple more times for us to figure out what's going on with you and help you out in the long run.
I agree that the relationship stuff has caused problems, but it's actually really calmed down in the last two months. Yeah. So, yeah, it is a problem that I should be addressing, but it's not the main problem. Like, it doesn't explain everything. And I guess my concern is, like, I am having a really tough time focusing, and I got finals in, like, a month. You mentioned, like, we could talk about...
I hear what you're saying. I guess my big question is, like, so what do I do? Like, I... I just want to be able to perform better in school and be present in my relationships. So I guess you said we could talk about medications, but what are the next steps for me getting better?
Well, I think the first thing is I'd like you to identify a couple of small changes that you can make in your life to help with things. We'll probably focus on your sleep schedule and your sleep hygiene. And we're also going to focus on the substances.
I'd like you to try to cut those down. My sleep's not that bad. So I think I'm glad that you're being thoughtful, but I've been sleeping like seven, eight hours a night. Like I said, I was smoking weed every day.
Let's pause the role play. This element would be titrated based on the actual history we gathered and we weren't able to get enough history. So, you know, this is just kind of a boilerplate thing.
I know. I'm trying to just steer it.
It's not that. And then I would say, you know, I want you to work on your executive functioning through your behaviors and your planning, because that's the next thing I'm going to say. I have some workbooks for you if you're willing to work on that. And if you feel like you need more guidance than that, I'd like you to speak to an occupational therapist or another therapist who specializes in the treatment of ADHD.
And I'd like you to start doing some incorporating some regular things into your life. This can range in a lot of different ways for different people, right? This can be even just keeping a calendar and keeping a schedule, right? And sometimes it's going to be something more nuanced about what you do in the middle of a workday after you've sat down, right? But basically, I'm going to be advocating for non-pharmacological treatments as we wait for stuff.
And because, and I'm going to tell a patient, you know, there's no magic bullet here. Even if I gave you an Adderall today, this is just going to give you a boost of energy and you're going to feel like you're doing better. And I don't think that you're actually going to get better in the meantime. And even if we use that bandage in the next few weeks as finals are coming up, this is not something that's going to work for you long term.
OK, unfortunately, we're meeting here at the end of the semester and it's going to be a very stressful time and there's nothing that I can do to change what happened before this semester and during the semester. But my advice is that you continue to work with me or any other mental health profession to try to improve things in the long run rather than just in the next few weeks and months.
Yeah, and I'm curious. There's a bunch of doors now I want to open. In regards to workbooks, the one I like the best is Mastering Your Adult ADHD. And I made a video that I think is a little under... It hasn't done pretty well, but I think it's pretty good. It's like the top 10 ADHD intervention, like non-pharmacological interventions, and includes most of the ones from that book.
So I use that book to make it. Now... I like how you said thinking long term. I'm curious what workbooks and who do you refer to?
Well, you mentioned ones for executive functioning. Mastering adult ADHD is a good one. Executive functioning workbook for adults is a good one. But frankly, the best thing is if they work with someone, because what we really want to do is to get real examples individualized to the patient of when they are having problems with attention or organization. Because only getting to that really close to the event moment-to-moment detail are we going to actually identify what the problem is.
Is it that they have a tendency to respond to boredom with immediate gratification, things like scrolling TikTok? That's one of the possibilities. Is it because they get hyper focused on one element of the thing that they are working on and they begin to do that rather than focusing on the bigger picture? There are different solutions for different kinds of problems. And that's not my area of specific expertise, even though I will give basic advice and exercises for this kind of problem.
They should be working with a therapist who has worked with people that have ADHD.
Yeah, that's – so how do you bring up these things in monthly medication? I say medication management. I'm just saying that like essentially as your psychiatrist, you're meeting at probably at most monthly. So with this particular patient, like how you're bringing this stuff up once a month, like – You're referring to like, let's say you don't have a referral network for ADHD specific therapists, especially ones that are in network.
I'm thinking people do have the hurdle of like, okay, I don't know ADHD, a decent ADHD therapist that the patient can afford. I don't know how to implement what you're describing in monthly medication management. What would you say to those people?
This is not going to be popular. Unfortunately, I cannot in these 30 minute sessions once a month teach you wholesale about how to organize yourself in your life. And even if I could, this is not something that you're going to get from talking to me. This is something that you're going to get from trying out on your own and being consistent about it. so in the end we can talk about little things or one thing each visit that we can do and i'd like to do that with you but this is something that you have to direct yourself with and if you're finding yourself having problems of motivation and self-direction in terms of changing your life in this way that's something i want you to talk about the feelings and emotions that come up with it in your therapy now today what i'm hearing is that you have let's pretend um a tendency to work for about 40 minutes and then get bored and frustrated and then watch NBA games for the rest of the day.
Old NBA clips. Let's do this. I'd like you to schedule breaks. OK, I want you to work in 30 or 35 minute chunks and I want you to schedule another chunk with five or ten minutes. And I don't want you on TikTok or watching clips during that time. If you can, I'd like you to take a walk. All right. Take a walk for five minutes. After you've done this twice in a row, then consider scheduling in a 30 minute break to do whatever you'd like.
But don't exceed X, Y, Z amount of time based on what they're used to of working without taking a break. And I want you to get used to this. If this is too hard for you to do on an everyday basis, I want you to pick one day a week that you're going to start doing this. And then I'm also going to pay attention to their leisure time.
I want to know what they do with their time off. OK, are they socializing? Are they exercising? Are they doing something that is over stimulating, under stimulating? Are they lying around? I not only in the follow ups, I not only assess the problems they're having, but what's their functional life like otherwise. When you do that, it's not just about solving those specific problems. The process of questioning and investigating this will show you more about a patient, who they are and how they work and how they cope with stress.
personality, but also just who they are, right? And then that's going to help you get closer to a diagnosis as well. And if you begin to be convinced after a couple more meets that there is a underlying ADHD problem, well, prescribe. See what happens. But just be skeptical about your diagnosis. Don't be so sure that you've got the right diagnosis is what I'm saying. Mm-hmm.
And the technique that you described on the, you know, work for a certain amount of time and take a break, that is the Pomodoro method, which is tool number five in my top 10 ADHD tool video. But, yeah, so I want to talk about when... wanting to get to know the patient a little bit more, work with them a little bit more before considering medications. With a patient like this, when do you start considering medications?
Do you see a world where this patient describes their problems and you would prescribe a stimulant on the first treatment, second treatment, or first visit, second visit?
I do prescribe stimulants on the first or second visit, but I need medical evidence. I need enough evidence to say that the major problem that we're dealing with today is not mood disorder, not personality disorder, not self-regulation disorder, not a mismatch between the self and the environment, but a neurodevelopmental disorder, a neurodevelopmental disorder, you know. if there was a FDA-indicated, true FDA-indicated treatment that addressed autism, we'd probably do the same thing, okay?
We want evidence for a degree of dysfunction that is so different from normal functioning from an early age that we want to call it a mental disorder because neurodevelopmental disorders except for the specific learning disorders, are all extreme types of normal variation. Everyone has a level of intellectual functioning. Some people have a very high level of intellectual functioning. Some people have a very low level of intellectual functioning, but everyone has intellectual functioning.
Everyone has executive functioning. Some are high, some are low, et cetera, et cetera, right? And everyone has a degree of autistic or empathic systematizing or empathizing traits, right? It's normal. We don't want to just hyper pathologize people, especially if there are other contributors to their ongoing dysfunction that can be addressed and should be addressed through other means. At the same time, again, if I am convinced that this is a early onset, lifelong neurodevelopmental condition, especially if I see evidence for it in my exam, in the interaction I have, okay, in terms of distractibility, right?
You know, spaciness, if I'm hearing about dysfunction that is more attributable to ADHD rather than a personality, I'm going to, and especially if they have a history of treatment as a child and response, that's going to be a population that I'm more comfortable prescribing in the first couple of visits. OK, unfortunately, if you have a less certain case, you should not get certain treatments right away. OK, if we're not absolutely sure that your gallbladder needs to come out, we're not going to operate right away in a ideal and ethical scenario.
The same thing applies to medications.
So you mentioned you really want that neurodevelopmental thing, and you say you want future appointments to assess if you think there are those neurodevelopmental things. What sort of things are you looking for? What sort of questions are you asking? What sort of things are you hearing that points you in one direction or another?
Once I'm very sure about the history of episodic mood, major mood episodes, once I'm sure about the history of an ongoing problems with any kinds of trauma or developmental personality, issues then i think uh it is time to start doing something a little closer to the structured or semi-structured adhd assessments and this is not the uh scales okay this is not the self-report scales this is where you use questioning along the lines of the diva okay this is where you can interview collateral or you can review school records obviously if you have that stuff already available day one, then that's going to be what you're going to be starting with on day one.
But we're talking here about a undifferentiated patient who comes in with no history of childhood diagnosis or treatment, and you're basically going off of their word alone. Based on that, then I would begin to, in a yes or no fashion, get history from them. I want them to describe their experiences in school as a kid and as an adult. What happens and why? When do you struggle and why?
When do you have ease of functioning and when do you have difficulty functioning? History, history, history. And then if that begins to support primarily the ADHD syndrome as described in various places, then we can be more assured that that's going to be the primary problem.
One thing that I – so I think you described – when we went through the case, you spent that time saying you want to work on a few other things before moving ahead with medication. So working on workbooks, working on – yeah. Yeah. Now, I'm also imagining a few of my intakes when I have an hour and I'm doing this history taking and an hour is not enough to do the history taking, let alone discussion of treatment plan, let alone discussion of interventions.
So how do you fit all of this into an hour? Yeah.
That's the neat part. You don't. OK, you have to accept that if you're going to practice a, in my opinion, ethical and thorough version of psychiatry, the way that should be, you're going to need more time. It doesn't matter what the economy or the payer says. You cannot reach diagnosis without medical evidence. And so sometimes you can. Sometimes it's so obvious within 20 minutes that you have a diagnosis, but that's sometimes.
And for many cases, that's not the case. And I will say that if the patient is, generally speaking, dialed in uh to treatment treatment and proper assessment rather than a quick fix they will come along with you if you are a good assessor and a good communicator as a clinician and you make your case well and the patient will agree and if they don't agree that's the nice thing about the free market they can go find someone who will make that diagnosis and prescribe right away if that's the way they want to live their life or the way they want to run their treatment But you, the clinician, you get to decide what kind of psychiatry you're going to practice.
But to a certain extent, the DEA is already beginning to decide for you. So be careful.
All right. So let's say this patient, you kind of say what you want, and the patient goes like, I'm really hoping, I actually really want to start medications. What would you say?
Well, I've done this outside of ADHD. I'll say, I understand you really think that the medication is going to help you, but I don't really see any medical indication today. And so unfortunately, I'm not going to prescribe you anything. And I hope you don't feel too disappointed or let down about that. It's really because I want to be helping you. I don't want to be doing anything to harm you in the long run or to give you an impression that something helps you when it doesn't.
Please, I want to see you again at this time and date, and we're going to continue the assessment.
All right, let's keep this role play. And I'm going to be a good faith patient. So, you know, but, you know, you did mention I had those ADHD traits. I do have those finals coming up. And like, I understand you can't just, you know, send medications just to fix my finals. But even my therapist, like we did, my therapist really thinks I have ADHD. And, you know, I hear you.
There are all these other things going on in my life. But it does feel like there's this like one thing that kind of makes it all click together.
You know, I can't say yet if it's true or not. You know, your therapist knows you pretty well. At the same time, what we're talking about here is a medical diagnosis. And in terms of the process of medical diagnosis, I'm simply not finished yet. And we're going to need more evidence. You're not an easy case. So keep it in mind, you know, and if you get more information about what you're doing day to day comes up, that makes you pretty sure that you have ADHD.
That's something I want to hear about at future visits. But at the same time, it's my responsibility to check for the other explanations.
I don't mean to push you because I hear what you're saying, but like, what would you need to see for me to get started on what I thought was treatment for ADHD? Yeah.
I'm going to have to essentially find out that there are no other major contributors or sources that are causing you problems with your day to day functioning, because I don't want to ignore those. All right. Everyone basically feels better and more confident about what they're doing on a certain dose of stimulants. And it's not a medication without drawbacks. I've seen too many bad cases and fixed too many bad cases to be practicing that way.
And I know I might be more careful than the average psychiatrist about this, but that's simply the way I practice. So if you feel like that's a good match, I think we should really keep working together. But if it's not a good match, you could find a different psychiatrist. I won't be offended. I want you to try to work with somebody that you feel like understands you and that you're going the right direction with.
So I guess when can we meet next to kind of keep talking about this stuff?
Well, I usually have openings in four to six weeks. So let's figure out a time that works for both of us.
So I really like how you explain things. And I like how thoughtful you are. But I guess I am worried that like four to six weeks, like I... I don't know. My problems are going on. I have my stuff soon. I'm just worried.
You feel like there's a lot going on. It's a big problem. Things are getting worse. You want things to be better as soon as it can. I think anyone in your situation is going to feel that way. What I'm going to warn you is this, though. Generally speaking, even for the most biological mental disorders in psychiatry, treatment is something that really happens on the order of, at minimum, two or three months.
OK, if you get a major effect within a few weeks, most of the time, that's a drug, not a medication. A drug is something that when you take it, you get something. And when it's gone, it's gone. Treatment is whatever we do to try to get you on track in the long run to a better place.
Oh, that's fire. I've never heard you say that before.
I feel like I had something similar to it before. But anyway, the fact is a large proportion of patients will leave with this approach. And unfortunately, some practices don't want them. Some practices want to repeatedly see patients and, you know, have simple patients that you can see quickly with a quick script once a month. Right. But if you do this, I will tell you there are many, many patients out there who really just want their lives to be better and they want to understand themselves more.
But you, the clinician, you have to be able to get that information and discuss it with them in a way that the patient can understand. You have to be able to form a therapeutic alliance. And if you can do that, I think you're going to have a lot less headache and patients are going to get better or at minimum not be harmed the way they would be under a different treatment practice.
Mm hmm.
Yeah, and I really like, as you kind of say, you know, I always save the last like 15 minutes for discussing my case formulation. And patients at the end are like, oh, you're definitely not a reductionistic kind of doctor. And if what you say resonates with them, even if there's aspects that are disappointing, like they're not getting the medication they expected to, which... in good faith, they didn't, they didn't come like, you know, Oh, I want this to me.
Like they, they just want to feel better. Um, there will be aspects that disappointing, but if they feel that you understand that you're being thoughtful, um, they're, they're going to stick around.
Yeah. And again, uh, late people, listeners, the obvious and clear ADHD cases, they just get the stimulant. Yeah. Those don't even need to be discussed. They're just too obvious. Yeah.
Now, you did mention in your little thing, like you would consider some of the medications. So for a patient like this, would you consider prescribing one of the non-stimulants right off the get-go?
If I have a at least 60 to 70 percent belief that there is a neurodevelopmental ADHD type disorder at the same time, I'll go straight for the Stratera. I will. If I think that there is possible depressive and there's no bipolar and there is some ADHD stuff and they agree, I'll do a trial of Wellbutrin. um other than that uh most of the time if i'm going to give a medication it's only for things like sleep support for example that i'll especially strongly consider for someone who seems to have neurodevelopmental but not adhd uh like autistic traits uh often you see dysregulation the sleep-wake cycle i'm going to give something not habit forming you guys can look at the sleep episode that we did um to help with that that can actually help a lot of people um we have to remember You know, ADHD used to not be co-diagnosed with autism for a reason.
And it's possible that the executive dysfunction that you see in autism is actually a separate issue than the ADHD issue. It's just a real murky area. So, yeah, I'll do some kind of a targeted medication. But if I don't see any treatment target, any reasonable treatment target, no medications, we're going to use non-medication treatment. All right. Well, I don't know. That's enough ADHD for me. I would hate to have to do any kind of ADHD treatment episode, especially because, again, I don't claim any expertise in that.
Most of my patients either have a simple ADHD, and I've already been on treatment for years, and I continue it, and that's fine, or they really don't have ADHD. They have other problems, and then those are covered in the other episodes. But I guess we'll see what the listeners want.
So I guess we'll just see what happens.
All right. Well, until next time.
Later.