Good morning, Dr. Malsberg.
What's going on?
I'm tired today. Are you tired?
I think we're tired every day, but why are you especially tired today?
You know, I've gotten a sense recently that many clinicians out there in psychiatry are tired. They're burnt out, and especially an outpatient, they're starting to see the same thing over and over.
over and over and over and i think i know what you're talking about can you tell us about your experiences with it well first off i'm curious dr food do you think i have adhd If I'm if I'm experiencing this, if I'm experiencing this burnout.
It's possible. There are two major community solutions to that. I will immediately give you stimulants or I will drag my feet and evaluate you over the course of eight visits. There is no in between.
Yeah, we're in an unfortunate state of affairs. And, you know, I think our initial, you know, your initial first few things in the podcast was always integrating. And I find that very helpful in that I don't need to fall into the camp that all these kids don't have ADHD or the camp of like everyone needs stimulants. We need to integrate all the different things that are going on.
Yeah. So how about your experiences? How's it been for you in your outpatient world?
Um, you know, you kind of, I'll have days where I have five intakes and all five of them are, do I have ADHD? Um, so that's the thing is I think on the patient forums, they're like, they don't, it's, it's both an inability to see the other person's side and that like, The clinician, it's like I have five people who have varied motives in terms of what they're coming for the appointment.
So you really need to stay grounded. I think we've been talking about this. I don't get frustrated. I assume they're acting in good faith and they're coming to me wanting help with the problem. But it's tough when the fourth patient in a row goes, I think I have ADHD and I want to get started on stimulants. It's not how I trained. I didn't train to gatekeep a medication.
give or not give stimulants you know it's a very so it's a frustrating thing yeah
it's i think people don't appreciate how artificial it is uh from the standpoint of the clinician and i don't think they appreciate that especially for the experienced clinician this is a marked change from even just a few years ago this is completely new and it is not normal That being said, exactly what you say, it's very important to understand that the vast majority of people coming in are not med-seeking.
Even if they would like a stimulant, who wouldn't like a stimulant? I'd like a stimulant. Kind of joking, not joking. But even if they would like a stimulant, most people are making an effort to come in because they have some genuine problem in their lives. And culturally in the US, they happen to be more inclined to consider that to be quote-unquote ADHD. But I think this is a failure of...
of course, common discourse and the profession to really educate the public on what are all the different causes of inattention for concentration. Because the reality is it's a symptom that's kind of like a cough, right? If you have a cough, you don't have cough disorder. Right. But if everyone started calling everything cough disorder, the moment you develop a cough, you'd be saying, oh, I have cough disorder.
I'd like to be evaluated for cough disorder. But it's really a symptom that can be produced by a huge variety of different underlying conditions.
Yeah, I think you nailed it with the cough disorder in regards to looking at just one symptom and not considering the underlying thing. And the thing that I try to get across to clinicians, because you're talking about what do I see? Oftentimes, I'll see patients that I say at the end of the appointment, I'm not quite sure what we have. Let's take some time. Let's think about it.
Or I'll say, I think this is maybe more of a depression or anxiety, and we should work on treating that. And then they don't follow up next month. And it would be easy to develop a frustration of like, oh, I have to give stimulants to make these patients happy. And the truth is, you have to be okay with losing a few patients. And the way I formulated it, I was being considerate.
It's not that I missed the diagnosis or I made a mistake. I wanted to make sure that I had the right diagnosis and I didn't just give a treatment to make it so that the patient kept with me. Um, so step one of releasing those frustrations is being okay with a patient, not following up or disappointing a patient.
Right. You, you can't work too hard. This is one of the best pieces of advice that I ever got from a senior resident. I was an intern and, uh, I don't know, I guess I was presenting the case or something. And then one of the chief residents just kind of looked at me and said, don't work too hard. Don't work too hard.
We're going to get crushed. Okay, just for a little bit of history for this podcast. Well, okay. No, I'm going to keep going. We have to talk about this.
Working too hard is relative, okay? So obviously, if a practitioner works too little, they need to work harder. But some people do work too hard. And if you invest too much of yourself into every intake, if you grip... clinical change and clinical success too firmly in your heart as a clinician, I think the patients will suffer for it because you're going to burn out. You're not going to be able to do that forever.
And having a death grip on the outcome keeps you from focusing on doing the process correctly, the process of treatment. Anyway, what were you going to say?
So what I would say is just a little bit of history of this podcast. We did when I think we were getting probably one of our first podcasts was on ADHD. It probably got like 60 views total. Like we're talking half of the views are my mom and sister. Someone on the Reddit ADHD posted like these doctors are minimizing. They say ADHD isn't real. And they like...
unvalidated me, all these crazy things. There was like 400 comments. It was like the top of the thing of like, revoke these doctor's licenses. These are disgusting human beings. I commented and was like, hey, just a heads up. I'm not sure if anyone listened to the podcast like this. The post doesn't represent us. I actually cite like Russell Barkley and a lot of like the main ADHD researchers that people with ADHD really appreciate.
And then the post just got taken down and everyone forgot about it. And fortunately, there were like 100 comments of like report these guys licenses like one star this. Fortunately, I don't. To my knowledge, I didn't get any.
I don't think controversy actually gets more popularity. You know, we didn't get any.
We didn't get any spike of views.
I want to comfort myself and say that we're not popular because we're not controversial enough. But, you know.
So one thing that was funny is we had there was like 150 comments about how terrible of doctors we were. And we had less views than the number of comments about how awful we were.
I'm sure the comments help us on the algorithm. Okay. We shouldn't get too meta. I think we should move on to the topic.
All right. All right. So what I want to talk about today is I want to talk about the differential for inattention or a patient presenting with an ADHD focus. Things I want to review. First, why does everyone think they have ADHD? Then I want to talk through the differential. Hopefully we get to how we combat all the misinformation as to why everyone thinks they have ADHD. And then I want to really hammer down, you know, the patient coming in good faith with mild symptoms.
What's the line for making the diagnosis? What do we communicate to the patient about what they're experiencing, depending on what you think is going on? So maybe to get started, why does everyone think they have ADHD? So first, ADHD is a disorder of attention. So the central concept is disordered attention. It doesn't mean like you can't keep attention. It means it can be maybe you can't let go of an activity.
You can't change focus when necessary. You can't. It's hard to keep your mind focused to sit still. And one of the big things that's happening is media has created a war on attention. This will sound like I'm an old man shaking their fist. But the truth is we've seen primary media over the last 100 years go from reading the newspaper to listening to the radio to 30-minute shows with commercials to now you either binge five hours of Netflix on a show or you watch a five-minute YouTube video that is visually the most appealing thing in the world.
So algorithms and research have gone into millions of dollars, billions of dollars have been spent into getting and distracting your attention.
Yeah, I mean, now that we have TikTok and Reels and whatnot, YouTube Shorts, I think five minutes is even too long, right? Five minutes is long now. Maybe five seconds is on the order of what we're used to paying attention to.
We're getting sugar candy in every single thing. Our eyes are getting sugar candy. Our food is sugar candy. Just everything is the most attention-grabbing thing in the world. So we see a dramatic explosion in choice options. So concepts like choice overload, decision fatigue. Whenever I'm watching something, there are a bazillion other things I could be watching that are probably better. And it makes it so it's hard for me to fully invest in being in something.
Yeah. So I just say all this to acknowledge that it makes more sense that people are vulnerable to losing their attention and having difficulty concentrating be a part of their life as a result of the ways that we've been living our life and the culture that we live in. So the big takeaway.
I think there's an important point related to that. Yeah. It's that every mental condition, including the serious mental illnesses, disorders of biological origin, the ones that are obligated to be treated with medications, every single one is responsive to some level to psychosocial interventions. That is habits, skills, training, changes of thinking, changes of habit. will improve or worsen almost every single mental condition, including schizophrenia, bipolar disorders, and yes, of course, ADHD.
ADHD is a neurodevelopmental disorder. Yes, at some level, there is going to be something that you can't overcome with training. But we've gone so far in the direction of using just medication for this condition that most many patients are really neglecting a lot of the things that they could be doing to improve their symptoms and their dysfunction. And I suspect that just as you're saying, the ordinary course of life events, what we do day to day, what we do or do not pay attention to, how we train in school and out of school is really impacting everybody's basic attention and concentration, task sequencing, executive function.
Yeah, you bring up an awesome point. And I have seen like in terms of how people view mental illness, like the expected over the last like 15 years, the expected view that people think mental health providers have is like, you know, for a long time when people were depressed or had mental illness, we told them just suck it up. You know, just pull yourself up by your bootstraps.
And the conversation in some regards has gone too far in that now people aren't willing to listen to being told that there are other things that they need to do. And the language has become like, you should understand mental illness and that I'm not capable of doing these things. And hearing the vocabulary people use to speak about themselves, saying like, I can't do this. I can't go to this thing because of my, you know, whatever, insert mental illness.
It's a very, very, very dangerous, self-fulfilling prophecy. And providers sometimes... are expected to have that view of like, you just don't understand mental illness if you think that you tell a depressed person they should be waking up and trying to start their day. A big message of this podcast is the best way to... Sometimes the best way to start is to act like you're not mentally ill.
And there's going to be hiccups and there's going to be things that you need to understand and forgive yourself about. And part of mental illness can be being too strict and trying to get those things done. But you still need to do things that help you out.
Yeah. I guess in the end, be aware of ideas that come from... the internet rather than an actual reputable clinical source. You know, I know it sounds very basic, but it's just a bigger and bigger problem every year.
Yeah, and I get it. The TikToks and the Instagrams about ADHD are funny. They're enjoyable. But there's a cost to consuming this kind of thing. And there's a cost to developing ideas like, I can't do this. I can't listen. I can't motivate. And I do want to talk maybe a little bit later about the difference between a person with an internal locus of control versus external locus of control and how they understand their disorder.
But... Let's stay focused on it.
Know well what leads you forward and what holds you back. Shall we get into differential?
Let's get into it.
So I guess we should list them. What would you say in descending order of frequency is other major explanations for someone coming in to an outpatient psychiatry clinic with the chief complaint of, I think I have ADHD.
In descending order, the biggest one I see is depression slash adjustment disorder. Mood symptoms that are making it difficult to concentrate. I'll throw anxiety in there and that people are really anxious and that makes it so that they're using a lot of avoidance for tasks. Another thing is a big mismatch of... work to the individual or just the individual's expectations. All of a sudden, someone's come in and say, I'm a CEO.
I'm a mom to five different kids. I run 10 different meetings, extracurricular activities. I'm and what's the the school board and i can't focus and it's like those are six i can't do one of those things well um so so just a mismatch of expectations to the individual um other ones uh people not i mean these aren't necessarily disorders but lifestyle things people not sleeping enough um people over reliance on substances um And just general like lifestyle things like that, which can also be disorders, but sometimes it's not on a full blown disorder.
I think it should be emphasized that your individual clinics top differential in terms of order of likelihood is going to depend on your individual clinic and the patient population that you see. Right. So we should keep that in mind. And even studies for general population prevalence of different disorders may not necessarily reflect your own clinical population. So you got to get to know your clinical population and do proper diagnosis and evaluation.
But my prepared list in terms of my own experiences about what is probably the most common explainers is depressive disorders, anxiety disorders, trauma disorders. That's a big one. I put OCD here not because it's frequent, but I think it's important. I want to mention OCD specifically, especially for the college age people, sleep problems and sleep disorders, problems related to substance use or other medications or other medical conditions, including those that are related to another psychiatric condition, for example, an eating disorder.
You know, if you've got a serious ARFID or anorexia, that's going to mess up your concentration. Trust me. As you mentioned, the mismatch of work or task to the individual for any reason that can be internal or external. Personality and personality disorders is an important differential that people really don't understand. emphasize or consider enough. And finally, plain old psychosis. I see that a lot, actually, but I know that's going to be too uncommon for most practitioners.
So I'm putting that at the end. And it's also worth mentioning that a specific learning disorder, another type of neurodevelopmental disorder, essentially can also explain the issue and it's not going to respond as well to a stimulant.
Mm hmm. And before we dive into each one, should I talk a little bit about the diagnostic hierarchy? Let's do it. The diagnostic hierarchy is such a core concept that a lot of people aren't taught. And I see it's a very simple concept that can clear up a lot of people's problems of like, what is this? This patient has all these presenting things. What is their diagnosis?
And We've talked about this a lot that like you can't talk to someone for an hour and know exactly what their problems are. So the diagnostic hierarchy is that you should be treating certain disorders first before considering disorders lower on the hierarchy. So if something's at the top of the hierarchy, you need to address it first before moving on to the next rung on the hierarchy for what you're diagnosing.
So if we can pause a moment, I want to emphasize it doesn't mean that you assume the one at the top of the hierarchy is there. It's that if you have evidence for both, you must treat the one on top of the hierarchy before the lower one, if you have evidence for both. Anyway, please continue.
Great point. And that you should be doing an assessment to rule out those other things or ask enough questions that you think that that rung in the hierarchy isn't the case. Everyone, there's not a... absolutely perfect hierarchy i think everyone kind of has a different one i think the top is organic disorders um so we're talking about any sort of medical conditions biological conditions um depending on the disorder you're going to be looking for i think brain problems thyroid problems cortisol all that good stuff substance so sub so that i put substances yeah you can include substances they are put next um so what Organic biological things, then substances, then psychotic disorders and bipolar.
Then below that, I put depression. Below that, I start thinking anxiety, trauma, eating disorders. Below that is personality factors. And in my opinion, ADHD is at the bottom in that you need to rule out all those other things and treat all those other things before considering treating ADHD. Yeah.
Oh, and true OCD, not just obsessive traits. True OCD, I would file that between the schizophrenia bipolar level and the level that you had below that, which was what? Depression? Depression, yeah. And sometimes OCD is severe and biological enough to really be on the same level as the psychosis and bipolar section.
And so, yeah, I think you made a great point that, like, I can still make ADHD as a diagnosis in an intake. But I'm making sure, again, when we do the order, I'm making sure there's no biological things going on. I'm making sure that substance use isn't the main problem. I'm making sure that psychosis or bipolarity isn't causing a lot of the symptoms. And then depression. Then anxiety, trauma, eating disorders, and then looking for personality factors.
And once I feel like all those things, I don't see major contributors in those areas, then I consider ADHD in treatment.
Yeah. And then this is a real thing that you have to wrangle with. Uh, I've had several patients where, uh, they had the childhood diagnosis of ADHD and yes, they began to develop a bipolar disorder in their early twenties. And, you know, if you're coming in and the only solution that you're aware of that anyone has told you about is a stimulant, that's going to be making things worse.
It's not going to be possible to improve your core functioning and your long-term trajectory. If you have a bipolar disorder, if you're hypomanic or manic or depressed all the time, uh, You know, there's nothing you can do to really touch the executive functioning related to the ADHD when you have a more severe problem at work there. I also want to say there, you know, in talking about coming back to social media and Reddit comments and YouTube comments, I bet there's a nonzero chance when you get that one child psychiatrist who thinks everything is caused by ADHD.
uh in the comments maybe and here's the problem uh you said you're on your diagnostic hierarchy you put adhd last i think the problem is that many child psychiatrists rightfully put adhd much higher in their diagnostic hierarchy because the fact is before the age of 17 all the other conditions that we just mentioned are way more rare okay even in somebody with the genetics who is eventually going to develop a schizophrenia bipolar disorder a trauma disorder something uh anxiety disorder even many of those conditions are not yet present early on in life course so naturally if all you treat is young children you're going to be considering neurodevelopmental disorders at the top of your pyramid right it's a skewed view of psychopathology you need to frequently treat especially the range between 18 and 35 in severe mental illness to really respect how many different types of psychopathology blossom out And start causing a lot of problems in the 20s, especially mid to late 20s.
And to your point, the childhood diagnoses, if you ever look at the Venn diagram overlap, it's very clear that they're not getting at something specific. And they're not nailing the underlying thing going on. If you ever looked, there's like ADHD, DMDD, ODD. The circle overlap is crazy. And if you ever are in an inpatient hospital, every single patient is like eight-year-old with... with dmdd adhd ocd or um odd occupational defined disorder um so they're really not getting at something specific it's really just capturing that this this kid is behaviorally dysregulated um all right so should we go one by one um sure through the differential
Yeah. So, you know, with depressive disorders and genuinely, I mean, almost any depressive disorder here, all the way from dysthymia to major depressive disorder, psychotic features, any of these can cause problems with concentration and staying on task. It's in the core criteria. Right. Four concentrations, one of the core criteria for major depressive episodes. And I believe it is one of the criteria as well for your dysthymia, your persistent depressive disorder.
And it's even in PMDD, premenstrual dysphoric disorder. It is a core aspect of depression. And if you are not fully free from depression, you know, I'm not going to have a great prognosis for your ability to concentrate compared to how you were before you were before you were depressed. It's a very important consideration that depression needs to be appropriately treated.
And this is the one that I see all the time. And the patient's coming in good faith saying, like, I think I might have ADHD. Basically, I am zoned out at work and then I get home and my partner wants to watch television and I'm half zoned out. So I really can't concentrate on anything. And what you're really seeing is those depressive symptoms, is that withdrawal, is that shutdown of the seeking and go out and enjoy enjoyment and activities.
And you don't hear in the longitudinal history, which I think we should talk in terms of like what we are looking for in ADHD later, you don't hear that longitudinal history of difficulty with attention resulting in all these different range of problems in different areas.
Yeah, you see much more parent-adult onset for this group, though, of course, depressive disorders can come in for severe cases in adolescence, and that can make things pretty murky diagnostically. But just remember, it's part of the psychopathology. Not only can your attention be distracted by persistent negative thoughts, people can have psychomotor and cognitive slowing. Right. Slow thinking, talking, moving. They can have psychomotor agitation. Right. A level of anxious distress, anxiety, crowding of thoughts that keeps you from being able to concentrate.
This is in addition to what you already mentioned in terms of the kind of motivational system based issues. And, you know, this kind of brings us to anxiety, too. Right. generalized anxiety disorder, pure anxiety disorder is very related to unipolar depressions. And it's a similar thing. If your mind is so crowded by different thoughts and by different fears and that you can't regulate your emotional level because it's so at threat all the time, you are not going to be in a place where you can focus attention, switch tasks, organize things.
There's a lot of energy being dedicated to the stuff going on in your mind.
And this is why we go back and listen to the intake episode. I think it's so important to get a longitudinal history, not just of symptoms, but of the person's life. Because when it comes to anxiety, depression, or group adjustment disorders into there, you'll hear things that make it clear that Things were going really well. I did great at college. It's really just been the last year or so since I've been having these symptoms.
And then you look and it's like, oh, about a year ago, you moved from California to New York City. And you lost your social network. You're at a job that you hate. And you go home and for the first few months, you were looking for things to do. Maybe you were dating, but then you hated dating. And you hear this thing of like, oh, there's a clear, even if it's not the time perfectly matches for adjustment disorder.
This is representative of someone moving from somewhere else and not... having gone through the adjustment period of going through those things. So these symptoms aren't a lifelong neurodevelopmental issue. It's much easier if you get the full history and idea of a person's life to kind of hone in and see the problems that are causing the symptoms.
Yeah. And trauma and stressors, right? Those kinds of issues, they can trigger, they can exacerbate existing depression and anxiety. They can seem to correspond with new onset or first onset depression and anxiety problems. Right. And of course, they can be their own thing. And I think we really need to account for how true trauma disorders and, of course, adjustment disorders can cause a lot of problems in concentration.
Here we are again, where in PTSD, the problems of concentration is a core diagnostic criteria. It is part of the symptom set. You see it all the time. And again, the body and the mind in trauma disorder is at a high level of threat. You're constantly engaged in a process of trying to essentially keep the intrusive memories, reminders, fear reactions and nightmares away. Right. Sleep is highly dysregulated.
Forgot to mention that, too. Sleep problems are part of anxiety and depression, too. But if you're not sleeping, you're not concentrating well as well. So if your energies are being spent all the time on trying to grapple with or dissociate from trauma, that is really going to disrupt your ability to do tasks day to day, focus on things, concentrate, et cetera, et cetera. So, you know, trauma disorders really need to be considered in the top areas of explainers.
for why people are seeing a downtrend in their ability to function. And if you don't get a good trauma screen, like a CAPS-5 style trauma screen of a patient, it is very, very, very easy to miss trauma. People don't want to talk about their traumas. It's upsetting. It's dysregulating to talk about traumas. Even when I do a formal trauma screen, we will miss traumas. The patient is not hiding the trauma.
It's disassociated. Right. So this is an important area that I think is really neglected because the treatment process is quite different than the other ones. And you need to be able to recognize it to be able to advise patients on how to get better.
Yeah. And for these patients, it's helpful. I mean, my little spiel is like, you know, I hear that you're having trouble concentrating. So it makes sense that you think it's ADHD, given that so many people are thinking that, you know, everything that is makes it so it's hard to pay attention. But we're really seeing a bunch of other symptoms that that suggest a different disorder. So for trauma specifically, I pull up the criteria.
And I say, let me just read some things and see if these are things that you resonate with. So I'm looking at criterion E. And I do that because I think it's helpful for the person to think like, this isn't just me saying like, oh, you can't concentrate. That's probably trauma. But hearing that these are very specific criteria and the other symptoms that go along with it makes it feel like, oh, this person is capturing more in a scientific sense what's going on.
It's not that they just don't want to... diagnosed with ADHD. So I say criterion E, which has to do with changes in arousal. Let me just read a few of the things, some of the criteria in there. So sleep disturbances, problems with concentration, hypervigilance, recklessness. So a lot of these things that you're describing as thinking that they stem from ADHD, I'm wondering if we look into the other aspects and the other criterions, you'll actually find that it fits more into that picture.
I find it great to actually read out the criteria because you're like, oh, this captures exactly their experience much better than if I were to read the ADHD thing and read the hyperactivity and some of the other inattentive symptoms.
Yeah. Touching on the whole therapeutic alliance thing, that's a great approach because a lot of the problems here is a mismatch in conceptualization and understanding. And if you're starting between the clinician and patient with a mismatch in conceptualization and understanding, then you'll have to get to a shared understanding of it more directly and specifically. And that's one great way to do it. But really, you have to inquire and discuss about it directly.
You'll have to usually pause proceedings and how you usually do things to address that you and the patient have very different ideas about how to conceptualize a problem.
Yeah, and I, you know, the other thing I like about this is what you're saying is a lot of people come in with like TikTok phrases of like, I have rejection, sensitivity, dysphoria, I can't concentrate. And if you walk through, if you pull up the DSM criteria, The way they word it matches the experience a lot more than the ADHD criteria. So I say like if we look at criterion D, which is the negative cognition and mood, you're reporting feeling down all the time.
Maybe that's that persistent negative emotional state, the markedly diminished interest in significant activities. This seems like it's more stemming from the trauma component than some sort of neurodevelopmental issue. Yeah.
Yeah. Broadly speaking, a lot of what is popularly referred to as symptoms of ADHD on social media, while, yes, present in many people with true ADHD, generally speaking, what they're talking about, that symptom cluster is better attributed to depressive disorders, trauma disorders and personality. OK, I'm sorry. That's just basically how it goes. But of course, that's something we can get into an academic debate about. So we'll we'll move on.
I want to do a special shout out here for OCD. OK, having treated many people in the college age transition, when you move from high school to the college period, the setting is very different. You're suddenly expected to do things in a self-directed way that you may not have been expected to do in high school. And it's also the time period where many people have their first onset of a more biologically rooted psychiatric issue, bipolar disorders, schizophrenia and OCD.
And for OCD, that's an easy one for somebody to experience as ADHD. Why? Because they begin to notice that they are spending a lot more time and hyper-focusing on certain tasks in their school setting compared to their peers, especially in college. And the reason for that is not because of a problem of attention. And if you have OCD and it's getting away from your schoolwork, it can happen...
To seem like hyper focusing but I see this a lot people are actually engaging in mental or School work based obsessions and compulsions reading and rereading note-taking editing essays Just in the process of doing homework many different manifestations of obsessions and compulsions can come through and it can be honestly the first time it's been really clinically significant for a lot of people and early on in college.
So don't forget to check or consider for OCD as the clinician. And I think the most efficient way to do that is to have them do a Y box, Yale Brown obsessive compulsive scale, but then review diagnostically in a narrative fashion, the Y box at a later visit.
Do you mean the scale itself or the screener questions?
The screener questions, and you don't have to do the screener questions every time. You just do the screener questions once, and then, again, you can have a totally positive Yale Brown, and it's not OCD, and you can have a one or two positive Yale Brown, and it is OCD. But by doing the screener, it at least gives you an anchor to start inquiring in a narrative fashion about how those kinds of preoccupations, obsessions, or compulsions come through for somebody, and then if you are adequately trained and experienced, you'll be able to tell whether that is or is not an OCD problem.
So just to give a practical point, if you Google like, because whenever I'm doing these things, I Google like Ybox PDF and click the first thing that comes up. What you're saying is we're not asking the questions of like the, because the scale itself is just your, essentially your obsessive thoughts and your compulsions and quantifying them. If you click on the first thing, you scroll to the bottom.
And then the bottom is the symptoms checklist. And that walks through 100 different things of aggressive obsessions, different types of compulsions. So you walk through that part where you're kind of just doing a screener.
Actually, whether it's at the front or the back depends on the PDF. And then the different PDFs describe them in different levels of detail. So if you're a clinician, please review the PDF and find the various ones and see which one you think is most suitable for your patient population.
great when i google the first one that pops up it's usually at the end but it's very possible it's at the it's at the beginning oh no i use a specific one i won't
name the website because you know i have no affiliation with them i don't know if they want to be named and they uh you know who knows that they're going to take it down someday but there's one that really describes the different obsessions and compulsions a little better than the other ones and so i like to use that and so just just take a look the pdfs are online and see what you like
So, yeah, to go back what you're saying about OCD, I think you're capturing a lot of these patients in that they come, they present in college and it's not just OCD. That college age, you know, like the 18 to 25 range is when a lot of the more serious mental illnesses start to develop. And there often is a prodromal phase where the core symptoms that they experience might be inattention.
So screening for things like OCD, bipolar, schizophrenia, making sure you have the full understanding. We talked about our intake thing. We're getting a life history and an understanding of the patient. If you do just an ADHD screen and just ask the Diva questions, you won't develop a great differential. It might say in the Diva, like, screen out for these things. But if you do it very quickly with just one question and not understanding the patient, you're going to miss these major things.
Yeah. I treat a lot of transitional age youth, so I get a lot of people who have been in pediatric psychiatry treatment, and then they kind of, quote, graduate out, and they're now going to see me as their first adult psychiatrist. And I have access to their records, and if I don't, I ask them. And maybe about once a year, I have a patient who genuinely had ADHD as a child, and then once they're starting to turn 18 or in their 20s, they start developing stimulant-induced psychosis.
Okay. And how do I know it's that? Because I pull them off the stimulants and the psychotic symptoms stop. Of course, I will say it can be very subtle. I've only caught these stimulant-induced psychotic disorder late onset cases because I am so experienced in trying to suss out psychotic symptoms from people who are actively trying to hide it from me. But I have seen this about once a year, and that's not including all the plain old stimulant-induced psychotic disorders, primary psychotic disorders.
I'm talking about specifically people who were just going along their merry way with stable treatment of ADHD and then start getting the adverse effect in their 20s.
So give us the pearls. You mentioned you have a lot of experience in this, given your background. What are the pearls of those subtle things?
I think that's going to be an entirely different episode. We can't get into it today, but look at the intake episode. It really is about fundamentally getting narrative, trying to get narrative instead of using structured questions. Should we talk about the sleep and physiological causes? Sorry, you said what? Sleep and physiological causes.
Oh, you know what?
I forgot to just say bipolar disorders. I kind of grouped that into mood disorders and depression. But it should be noted that bipolar disorders, of course, have depressive episodes. 95% do. And... We already talked about how that impairs concentration and attention task switching. But of course, mania and hippomania causes significant distractibility. Again, crowds the brain full of thoughts, makes the thoughts race, disrupts sleep, which itself impairs concentration.
And it also should be noted that unfortunately, in true bipolar disorders, the research shows and clinical experience shows that even when mood stable, somebody with a bipolar disorder is going to have more executive functioning, attentional, neurocognitive impairments compared to people without bipolar disorders. and in my experience this is also compared to them prior to the onset of the bipolar disorder it's upsetting but i want people who have developed a true bipolar disorder to be a bit kind to themselves it's a medical condition we're all going to get older and suffer certain symptoms and impairments based on just how our body and mind progresses over time this can be unfortunately early but it is not insurmountable Please seek mood stabilization primarily, even if you don't have clear mood symptoms remaining.
If you have any problems with the sleep, you might benefit broadly from more mood stabilization or lifestyle changes and different skills. That will really help you get as close as possible back to where you were before the onset of the bipolar disorder.
Yeah, and going back to the bipolar ADHD link, it hurts my heart when I see it's not uncommon for people with bipolar who haven't fully accepted their diagnosis to, after a long period of time, find a psychiatrist and think that they were misdiagnosed. And say, I see Kanye West did it. I don't know if anyone follows Passion Pit. It's like, oh, it turns out my diagnosis was wrong and I had ADHD this whole time.
And what you're really seeing are symptoms of hypomania or mania in a person who hasn't come to terms with their disorder.
Yeah, if you shop around with enough psychiatrists, you will eventually find someone who is not a very good diagnostician and who will diagnose you for whatever you prefer to report. Okay, that is going to happen eventually if you... good enough people. It's just like taking a lab test too many times. A lab test has a certain number of false positives and negatives. If you repeat it too many times, at some point, even if you have diabetes, it will show that you don't have diabetes.
And if you just hold on to that one test result and say, this means I don't have diabetes, I don't need to change how I eat. I don't need to change whether or not I take insulin or other diabetes treatments. Then you're going to be in for a very bad time in the body long term. And that's the warning and wish I have for people who have true bipolar disorders.
It's a medical condition. It is treatable and it will worsen without treatment. So please, it's emotionally difficult, but I see it too much that there's some people who go a good way with it. And then there's people who essentially let the disease ravage their brain and body functioning.
Yeah. And I've had patients, I feel like the thing I say is, listen, I hear that you're struggling. I hear that you're having a tough time concentrating. And I know that you can go to another provider and get this diagnosis and get put on Adderall if you wanted to, but I'm worried about you. And I'm worried that, yes, maybe the Adderall will help you today and tomorrow, but these things have consequences.
And by not treating... a bigger thing. I'm worried about your, your long-term future. I'm worried about how you're going to be in six months. I'm worried how you're going to be in a year. Really trying to connect with the patient that like, I hear your concerns and I care about you. And because of that, I'm not giving you, I'm not going to just hand over these medications that feel like a quick fix and feel like they'll fix things today.
I say, I don't want to prescribe anything that's going to harm me. I'm only going to try to give you things that are going to help you in the long run. Of course, that's received differently by different people. But anyway, looking at the time, I think we should rush through the final three major categories. Okay. Medical physiological substance conditions. Mismatches in social environment and personality. But what were you gonna say?
Sleep is through.
Oh, yeah. Sleep. Yeah. Sleep is a big one. There can be a lot of different sleep disorders. Right. Sleep is fundamental to your ability to function during the daytime. Sorry to say. Right. It's a basic thing of how the brain works, how the brain clears out. uh metabolites that are not good for its functioning you all know how it feels to be sleep deprived and for people who are so chronically sleep deprived that they don't even notice it it's just normal for them you'd still have certain impairments right you've heard about driving when sleep deprived being similarly to driving drunk while working and trying to concentrate sleep deprived is going to do a similar thing so don't neglect the sleep disorder set analyze and Check the history of the sleep and the sleep functioning and consider a referral for a sleep specialist if you have appropriate suspicion for a sleep disorder.
Big time. And listen to the patient. You'll hear all the time like, oh, no, my sleep's good. I sleep five hours a night. Trust your heart. Yes, there are some people who can sleep five hours and function great. Those are rare, rare, rare, rare exceptions. Yeah, pretty unlikely. Yeah. So so, you know, listen to the patient describe their problems. And it's to me, a stable sleep schedule should be a part of absolutely every single treatment.
I feel like a huge one of the major things I do with nearly every patient is make sure as best as they can that they're they understand how to have a good sleep hygiene schedule structure. The importance of trying to go to bed at the same time, waking up at the same time, protecting your bed in regards to not using your phone. I've mentioned, I say this all the time to patients.
I have cured so many conditions by having people take their iPhone cord and their iPhone charger and moving it to the kitchen. That one single thing so that they're not going to sleep with their phone and waking up with their phone can do drastic improvements in so many areas of their life.
Yeah. And in a similar way, please consider what kind of substances, herbs, supplements, natural remedies, energy drinks, caffeine, medical conditions, other psychiatric conditions. Like I mentioned, the eating disorders, if you're not eating correctly, you're not going to be able to function correctly. Other causes of basically a physiological process that is going to mess up the attention. cannot neglect those, right? Withdrawal from medications, impaired sleep, for example, from alcohol, just because you seem like you're sleeping doesn't mean it's quality and restful sleep.
Please consider and assess for all those things in every patient.
Yes. And you mentioned alcohol. I'm one of those people, I think it's lucky that I'm hypersensitive. If I drink one beer, I'm like incapacitated the next day. People don't believe me if they have an aura ring or a sleep tracker. If you have one drink in a night, it significantly impacts your sleep score. You don't need to be drinking six or seven drinks and really feel the hangover.
Even just one drink has a significant impact on sleep architecture. And if you don't believe me, look at your aura ring. Some people are different. Some people can... drink a lot more or tolerate certain substances, can smoke weed before they go to sleep and not have it impact their sleep structure. If you have that Oura Ring or Apple Watch or whatever, you'll see it in the data.
Absolutely.
Yeah. And, you know, that kind of goes back to the sleep hygiene, sleep schedule thing. I really think that if you don't have any clinical problems in your life, feel free to live as wacky as you want in terms of your substances and your sleep schedule and your day to day schedule. But if you have enough of a clinical problem that you feel like you need professional help or other people feel like you have professional help.
That's the time to start living a more stable, you know, scheduled and health oriented lifestyle. You don't need anything else complicating things. You want to live a good life. You got to make some positive changes. And, you know, speaking of life changes, then that gets us to the topic of mismatch of social or work or school environment
to the individual. I do want to mention the substances. And I have said this before. Like, I don't want to be a person who wags their finger and says, like, you know, you need to cut that. It's really all the alcohol or all the partying. But as you say... We all know people who can go and have a bunch of drinks and function and crush it at work.
But you're in my office and you're saying you have problems. You know, letting people understand. Because what a lot of people do is they look and they go like, yeah, but my friend is doing this six nights a week. I'm doing it two nights a week. What do you mean that this is not the problem? You know, so I try to take a non... authoritative stance and that like, I'm not wagging my finger and saying this is, I don't have a moral problem with you going and doing these things.
But you're saying you have a problem and I can see the problem.
Yeah, you got to consider your individual situation. And, you know, on that topic today, more than ever, it is extremely simple to and convenient to medicalize a social problem. OK, sometimes you are in a situation that is just not good for you. And sometimes there really isn't a choice, but often more often than not, there is a choice to change something. It could be a situation. over demand from a bad boss.
It could be a stressful work environment. It could be traumatic events in your work environment for certain types of professions like nursing, medical care, police officers, to only name a few. Or it can be you're trying to study or do something in your life that really doesn't suit you as a person, but you have certain values that make you think I have to be, let's say, a computer scientist.
There can be all kinds of ordinary mismatches and stressors in the life that aren't medical problems. But if we hide that behind a diagnosis, a medical diagnosis, and we have you push through it at the cost of your physical and mental health by putting you on essentially amphetamine speed, that's a detriment to your overall life, right? Think of all the opportunities or changes that you could have had in your life if you had reflected upon this as more than just a medical condition this is a pretty common one i think in the higher ses set in the relatively more well-off population
Yeah, and the thing I think I want to tell practitioners is trust your gut and not what the patient is telling you in regards to how these things impact the patient. And I'm not saying don't listen to the patient. I think it's important to collaborate with the patient. But what I'm saying is don't let a patient justify something and have it end there. Keep the conversation open.
I'm going to make up a scenario of a case that I supervised, change a bunch of the details. There was a patient who was 50 years old and was kind of getting bored in his marriage. So he asked his wife for an open marriage. And then the wife was going out and dating and sleeping with all these people. And he, despite being the one who wanted to do that thing, wasn't able to go on any dates at all.
And now he's presenting for ADHD and difficulty concentrating at the age of 50. So should it stimulant or should it be a non-stimulant treatment? Or should it be a viagra treatment? Sorry. Take a second. Sometimes because the mental health community is so open and it's like I do – We do need to be accepting of differences and accepting of poly relationships. But there's also things in the story that, like, there's also not everyone is made for those things.
There are people who can have multiple partners, who can date... outside of the normative culture expectations. But there are a lot of people who can't, and it's not something to be ashamed of. So sometimes our hyper-acceptance of differences can make it so that we're missing things that it's like, hey, it's okay to feel bad about this. It's a pretty normal human emotion to experience jealousy, to experience regret.
This isn't like something that you need to... I don't know. It's not like you're... yeah you don't need to transcend these human normal human emotions yeah maybe the situation you put in yeah
Yeah. You know, in the psychotherapy world, I refer to this principle as don't take yes for an answer. Don't take yes for an answer. You got to go beyond the conclusion or affirmation from the patient. In your example, you might say, and you're sure that you're emotionally OK with this, that you're handling this. This is what you want after all. And maybe a patient might say, yes, of course.
Don't take yes for an answer. Dig deeper. Get more details. uh this is at the root of therapeutic neutrality that we don't neglect any particular part of the patient that may be there right and if you take yes for an answer you're going to miss parts of the story so uh this is a particularly complicated uh explanation for presenting inattention you know mismatch of social environment acute changes stressors etc you really have to get story and values for this one it becomes more psychotherapeutic and of course that brings us to our final one that I think we'll cover today, probably the most controversial personality.
Oh, boy. Yeah.
How do you see this as an explainer for apparent ADHD?
You know, it's tough because I was watching a video that was explaining what ADHD was, and it's like emotional dysregulation, difficulty in social situations, difficulty understanding others, negative self-concept as a result of all the shame from ADHD. And it's like, oh, God, that's... just a different descriptor of a personality disorder yeah i am not kidding most or
many at least uh social media conceptualizations of adhd are describing a personality disorder as class you're gonna you are and just calling it adhd
This podcast is going to get me reports to my license.
Hey, this is this is at the 50 minute mark. They're probably not listening at this point. Then again, they didn't listen last time. And they said that we said ADHD.
I wish I had assumed him. I'm going to get reports.
ADHD is real. OK,
let me explain in two months when I don't have my job because my license has been stripped because 30 different complaints came in. I'm going to be called paternalistic. I'm screwed. Don't worry.
I do medical board reviews. They're not going to they're not going to uphold those kinds of things. Okay, so how can a personality condition cause what seems like ADHD? Keep in mind that in older editions of the DSM, it was explicitly mentioned as one of the possible explainers that isn't ADHD for the presentation. And keep in mind that it's still discussed under the DSM-5TR under the differential diagnosis area.
It's a complex issue. And why is that? If you have a severe enough neurodevelopmental disorder that will also cause impairments or struggles in your developmental progress. Right. That will lead you to have a personality disorder as well. OK. Also, if you have enough. adverse parenting experiences let's call it if your parents or caretakers were not very good to you or if you had enough traumas uh your fundamental neurodevelopmental problems that you can call adhd will be way worse than if you were raised in a different family where there was love trust care and adequate parenting right so these things really knit together but fundamentally when we look at the adult that has personality problems What are our personality problems?
It's not the traits. It's about personality functioning. And we're talking about self-direction. We're talking about self-regulation. And those aspects are really going to be fundamental in your ability to persist in tasks. Organize your tasks and apply yourself to tasks long term. On top of that, your relational problems, if you frequently run into stress and anxiety in your relationships, those are going to really throw you off and prevent your ability to kind of stay on task because you have to spend so much energy and time dealing with the fallout or consequences or complications of those chaotic relationships.
So personality in a lot of different ways can definitely contribute to apparent ADHD symptoms, even if it's just a matter of sort of the added stress from that mental condition.
We could do a whole podcast on the nuance here. But another point is that we also have to remember that these things, you can have both. And I think a big lesson here is that ADHD isn't this thing that explains all aspects of an individual. You can't say this person's ADHD, so that's how I explain this characteristic, this characteristic, this characteristic, this characteristic.
Even though there's that commenter on whether he's going to say that, I guarantee it.
So it's important to understand that you don't just stop it. Like ADHD can explain all these different things. People are complex. And one label that is capturing a large percentage of the population isn't going to account for every single individual difference. That doesn't make any sense. Now, I do want to talk... I know we have a little bit of time. I do want to talk about, very quickly, the line...
Because you mentioned, we talked about this, there are patients that they're right in the middle. They have problems, they have a little bit of anxiety, they have a little bit of depression, they have some neurodevelopmental issues. How do you make the call for those patients that are on the edge? Or it's not like this clear history. When you look at the symptoms, so you're looking for six of the nine.
I'm going to do inattentive because that's the one that's very common. Six of the nine symptoms for six months in two different settings. But the thing is, those symptoms are pretty vague. And nearly anyone, if desired, could find evidence of those things. So I'm curious how to go about for those patients that it's not a blaring thing and it's mild, but it's also there.
Yeah. You know, I think we should get into diagnosis and the entity itself of ADHD, maybe in a part two episode. If people can comment, if they do want to hear about that, that's an easy part two episode for us at some point. But in short, you have correctly identified that the diagnostic criteria for ADHD have become almost useless because if someone is motivated enough for any reason, unconsciously or inadvertently or just based on their understanding of what is or is not ADHD.
If someone is motivated to answer an affirmative to structured interview questions, those structured interview questions become worthless to determine whether or not a diagnosis is there. So fundamentally, I would say don't get into structured interviewing until you really have a good understanding of every part of the patient's functioning and mental life. I don't mean a complete idea, but a good idea of their functioning and mental life.
So you must know their early life course in school functioning. You must know their adult life course, school and relationship functioning. And you have to know about the onset of illness, right? with a course of illness and why not? Why are they presenting that? Those are the things that will help you more globally determine which mental disorder or set of disorders does this patient correspond to most in their illness course and overall life functioning.
Only then can you use the ADHD diagnostic criteria because we do not have biomarkers. We do not have a diagnostic test. We do not have any psychological test that actually is diagnostic of ADHD. It's simply a clinical syndrome that has been described and recognized. That's all it is. Right. And so we can't use the DSM criteria without knowledge of the greater practice of psychiatry and medicine. You know, when they're using that criteria for a research study, they have diagnoses of exclusion.
Right. If they find that you have any other condition, they're not going to include you in that study. And in the same way, if you find something on hierarchy, you see evidence for it, and you see a treatment process for it that is higher on that hierarchy than ADHD, you must advise the patient and you must work together to treat it.
Okay, so let's say, let me give you an example and tell me how you can help think through it. You have a patient who's had mild anxiety, mild to moderate emotional dysregulation their whole life, but not perfectly fitting into any sort of specific personality disorder. Now presenting mild inattentive symptoms and maybe some disruption in school and that they were getting in trouble a little bit, didn't perform maybe as well as they could, but still did pretty well.
Now presenting in grad school with an increased work demand for wondering if they have adhd that's the kind of picture i'm in different words like with small things change that i do see a lot and that there's it's not one of these like clear cut but but and they do have something going on that has increased their work demand um how do you parse it out there
Again, it's so individualized and it's so specific that I can't give you a straight answer right now. In the end, I need to really deeply explore why now, what's been going on, how long has it been going on, and what else is going on. That's basically it. You know, it might be interesting if you can prepare a disguised, almost real case that we can really play out or inquire about in the case conference fashion.
I think that might be most useful, but there's no pat answer for this. It's just way too complicated because at this point, ADHD has become a general marker for psychosocial distress of some kind. Right. And so it's almost meaningless in terms of a chief complaint. All it tells us is that this person is not functioning to the degree that they want to be in their work or school.
That's pretty much it. If I see physiological physical complaints. mental status exam signs within the interview that weighs me in one direction if something in their longitudinal function history shows me something that weighs me in one direction it's just far too complicated i think we should save that for another episode
No, I think that answer by itself is helpful and that it is it is complicated. There's no, you know, one quick question to help solve all your problems or one little trick. It's a complicated issue.
So I think that where neuropsych testing is useful is to detect any other learning disorders and to really get a sense of intellectual functioning. I think that's where we can hang our hat on things. You can easily confirm those, whereas you really can't confirm ADHD using a psychological test, contrary to what many people think.
I think people throw that out. It often has a punishment to the patient. I don't feel like making the call. I just want to acknowledge that neuropsych testing isn't this definitive thing that it gives you the answer. For most patients, if you're unsure and they get neuropsych testing, it'll say rule out ADHD, clinically correlate. I used to think before residency that neuropsych testing was giving me the answer.
It was telling me what was going on. It's just as... there's a reason that that that clinical it's a clinical diagnosis yeah not even
for cognitive testing where it's like arguably the most objective thing that we have can you absolutely rely on the test results you the test results always need to be correlated to the overall clinical picture and presentation all right i think we're definitely at a longer time than usual so we should probably wrap up any final thoughts
No final thoughts.
No final thoughts.
This will be the last time I'll be a licensed doctor. It was nice. It was nice.
All right. Well, maybe I'll be a little bit more attention than usual. We'll see. All right. Until next time.
Later.