Why I Love ADHD

Disclaimer time: this site should not be used to diagnose or treat readers. Although I am a psychiatrist, if you have any concerns you should go see your doctor to talk about any symptoms you're struggling with That being said: let's talk about good old Attention Deficit Hyperactivity Disorder. This was previously classified as two disorders, Attention Deficit Disorder, and it's "hyperactive cousin" Attention Deficit Hyperactivity Disorder. Now, it's one disorder with three classifications: predominantly inattentive type, predominantly hyperactive or impulsive type, and combined type. This is a disorder of the frontal lobe of the brain. The frontal lobe is the part of your brain responsible for things like focusing, paying attention, and stopping to think before acting. It's also responsible for what we call "executive functioning" which is what helps you get things done. It teaches you how to make decisions, see the "big picture," and work through a problem. It helps you plan, remember details, and multitask. Dysfunction in this region leads to the problems you see in people diagnosed with this disorder. Not only is it hard to sit still or focus on a problem, it's difficult to start a task and see it through to completion. People with ADHD have difficulty getting started on things, especially if the task has too many "part." They don't know how to organize or prioritize. They also have trouble regulating their emotions. In kids, this can sometimes be seen as an explosive temper. All of a sudden your tiny friend is enraged, having a tantrum, but quickly defuses and often acts as if nothing happened. They can have trouble in social situations. Things like getting to close to others, talking over other people, or being impulsive and impatient can make it hard to make friends. ADHD, like all psychiatric disorders, is based on a set of criteria found in the Diagnostic and Statistical Manual, or the DSM. We are on version 5 now. Within the DSM we have our list of symptoms. Things like, inability to focus, pay attention, losing things easily, not completing work (or rushing through tasks), not turning things in, being disorganized, etc. Other symptoms could include not being able to sit still, fidgeting, feeling like an internal motor is running inside you, speaking without thinking, being impulsive/risky, not waiting your turn, etc. They must struggle in multiple settings (like home or school, or home and work). Symptoms have to be present by age 12, but some people don't get diagnosed until much later in life. It isn't considered a "benign" problem. People who suffer from symptoms of ADHD have difficulties with social situations. They often say things they regret (lacking a filter), are intrusive, can be "too much" to deal with, and are seen as unreliable. It's difficult to succeed at school or at work. They also can struggle quite a bit with emotional regulation. They have fits of anger or passion that can be easily triggered, often easily defused (though not always), and quickly forgotten. Although often seen as only a problem "getting ahead in school," people with ADHD can have lifelong dysfunction in a variety of settings. Not being able to pay attention can cause motor vehicle accidents. Impulsive behaviors increases your risk of drug use. Other disorders can go hand in hand with ADHD. Many are diagnosed with conduct or behavioral disorders. Some have anxiety disorders, or depressive disorders. There's a connection between ADHD and Autism Spectrum Disorder. It's also highly genetic. Parents who struggled with ADHD have a higher chance of having a child with ADHD. It's no longer considered a problem only of childhood. There's a general thought that about 50% of kids grow out of ADHD. Why? Currently ADHD is conceptualized as a dysfunction of frontal lobe development, but some of these kids eventually catch up. We also think that treatment with a stimulant may hurry along the development, allowing the brain to catch up. Of those that don't "grow out of" ADHD (ie, they have difficulties extending into adulthood), half generally can do well without medications. Either through learning coping skills (like taking notes, getting an organizer, etc), or by finding a lifestyle that fits them better than sitting in a classroom or office all day. But that still leaves 50% of the ADHD population that has symptoms into adulthood, and 50% of THAT population still needs medication. But since so many health care professionals think of it as a childhood disorder, they feel hesitant to provide medications. And the medications that work best are addicting, controlled substances they don't want to prescribe. So why do I love ADHD? Because it's such a highly treatable disorder! In psychiatry, we really don't have "miracle medications." Our success rates with medication are not as high as we'd love to see. But with ADHD, 70%+ of people respond to treatment. SEVENTY PERCENT Y'all! Those numbers might not seem impressive, but they ARE. And treatment can be (not for everyone, but for the majority) really easy. Our treatment of choice is stimulants. These are medications like methylphenidate and amphetamines. Stimulants get a bad rap, but I think they're awesome. Stimulants directly and indirectly release dopamine, which helps focus, attention, motivation, impulsive behaviors, and executive functioning. They generally work fast (usually within days people notice a benefit) and can be easily increased or decreased. They're relatively well tolerated. They can be addicting when misused, but in controlled prescribing we believe we can actually decrease the risk of substance use in ADHD patients (a huge co-morbidity) because we're helping people make better decisions, not be as impulsive, and giving the brain what it needs. Most common side effects are usually headaches, decreased appetite, and decreased sleep. Really worrisome side effects include aggression and risk of psychosis. The aggression can be a big problem, but often when aggression is a symptom of poor impulse control and mood regulation, a stimulant can be helpful. The risk of psychosis is real, but small. In high doses stimulants can cause psychosis, but not usually in the doses used to treat ADHD. This means, when I meet a kid with ADHD, I've got a 70% chance that by the next visit they're going to be doing great. And they usually maintain a level of stability going forward. Sure, we have to make dose adjustments, and sometimes have to change around meds a bit, but for the most part we do great. In a job with disorders that can be very difficult to treat, it can be so refreshing. When I was in training, I felt very differently. It was so easy to treat, there was barely a challenge in it. I felt like I was wasting my precious clinic time with these kids who do great, and I could be seeing more challenging patients needing more TLC. But after a few years of seeing very challenging kids struggling to get better, I now LOVE having a bit of ADHD sprinkled into my day. I'm generally surprised by how much stigma there still is around ADHD. Parents come in so defeated by their hyperactive, trouble making kids who are doing terribly in school. Homework is a constant fight. They're being called at work daily because of their children's behavior. They are at their wits end. But when I tell them it's ADHD, and we can easily treat it, they struggle with the decision. It seems so easy to me. Take this magic medicine and your kid will be "like new!" But the stigma around ADHD being some "behavioral problem" and treatment being "medicating your kid because you don't want to deal with them" is so prevalent in our society. Why do we treat people this way? We wouldn't shame a parent for treating their child's diabetes! ADHD can really mess up a person's life, so why not give people this potentially life changing disorder? But the stigma is real. And it lives within all of us. I know there will be some part of me that will feel like a "bad mom" if my daughter ever needs treatment. And I'm a professional! I'm sure I'll get all sorts of grief over it too, if she needs medicines. Why are we so desperate to power through this instead of giving ourselves the kindness of treatment? Heck, I'm starting to believe that I probably should have listened to the psychiatrist who years ago told me he thinks I might have ADHD and if I wanted a stimulant we could talk about it. But even for myself I was like "how dare you sir?! I can make it on my own." I think my high levels of anxiety are more the culprit of why I struggle to focus and do things (I generally get so overwhelmed by tasks I can't figure out where to start or how to finish a job). I've always adapted and done very well, but maybe things didn't need to be this hard. Medical school was definitely an eye opener, and maybe I wouldn't have struggled quite so much if I'd done something to address my inattention. Looking back, the combination of being so overwhelmed and fighting so hard to keep my focus on anything could have been ADHD. I like to tell my husband that I got by (obviously, I made it), but I probably could have taken over the world on a stimulant. Even now, getting things done is very difficult for me (this blog has taken me over a week of starting and stopping). I should probably go see someone about this instead of diagnosing myself... For more details on my dramatic journey through medical school, feel free to check out my other blog (I hate medical school). Last thoughts: ADHD is a highly prevalent disorder in the US. Why is that? When I was in residency we were talking about culturally bound syndromes. This is a "disorder" that shows itself only in a certain culture. For instance, anxiety disorders in Hispanic cultures often show up as "ataque de nervios" and is characterized by high emotional distress within a short period. You'll see things like crying, shouting, uncontrollable displays of emotions, headaches, seizure like/fainting episodes, and a sense of being out of control. It's seen mostly in people of Latino descent and is understood within a cultural framework. I won't get into it too much here, because that's not what we're talking about. But we were presented with the question: "Is ADHD a culturally bound syndrome of the west?" I was of the minority of people who thought that yes, maybe it is. Maybe there's a part of ADHD being so prevalent in the US that means our society is set up for it. Does our school system increase the incidence or prevalence of ADHD in our society? Or are we just better at understanding, recognizing, diagnosing, and allowing for treatment? I don't have the answers. I do believe that ADHD is a real disorder that can probably be found across the world, but does our culture have something to do with our high levels of it? Feel free to comment below.

Words have meaning. Meaningless misuse of words increases stigma

When I was younger I remember having a vague understanding of why we couldn't use words like "retard" in daily life to describe things that we didn't like, but it was always more of a "I can't do this" than a "I shouldn't do this because" kind of thing. It didn't really fully make sense until I was older. And even when I was teaching high schoolers (which I did for a year after college), I had difficulty explaining to them why they shouldn't call things "gay." The easily spouted wisdom of "how would you like it if your name was used to describe things other people considered uncool or dumb?"I would say. To which they'd always reply "I probably wouldn't care." Of course, they would care, but it actually isn't a great example. Because really, that's not the real problem. It's taken me years to realize it's a matter of stigma. In my daily work as a psychiatrist, I listen to people's stories and symptoms and I help formulate a diagnosis and treatment plan for them. It's been a pet peeve of mine for years now when people tell me about how they're "manic" or "bipolar" with no understanding of the words or what they mean. "Well Dr, I have these mood swings you see. One second I'm fine, and the next I'm mad, and a second later I'm angry, and then I'm fine again." Or they use it to mean that they sometimes get very angry for no reason. But they casually throw out the word "bipolar" as if any unwanted display of emotions meets the criteria. I then painstakingly go through the diagnostic criteria, and more times than not, the patient realizes they in fact are not bipolar. Why does this bother me? First, bipolar disorder has been portrayed as this whimsical, unwanted disorder of too many emotions. It's nothing to be bipolar, other than to have some mood swings, in this day and age. Everyone is "bipolar" at some point, according to this rule. The truth is, bipolar disorder is a very difficult disorder to diagnose and treat. And it can have devastating effects on people's lives. Being manic isn't this state of mind to aspire to. It's not just a high level of energy and changes in mood that everyone experiences. A true manic episode includes days without sleep, high energy, increased risky behaviors, and poor judgement. I'll likely end up writing an entire blog about bipolar disorder, so I'll only touch on it here. People in a manic episode sometimes quit their jobs, spend all their savings on trinkets, sell their homes, uproot their lives, only to "wake up" or crash out of it later, and find themselves unable to repair the consequences. This isn't something to aspire to. Sure, some artists do their best work when manic. And I'll also likely one day get to a blog on the possible Darwinian advantages to mental illnesses. Many people go undiagnosed for years because the mania feels "good" and they don't recognize it for what it truly is. But it's not something enjoyable. Treatment for bipolar disorder is also not pleasant. Mood stabilizers and antipsychotics have many side effects, and shouldn't be taken lightly or unnecessarily. The same can be said for OCD. Everyone comes in with "my OCD is acting up. I like things organized a certain way and I'm always cleaning things." Again, OCD is a life altering disorder that is very difficult to live with and treat. People with OCD spend their day fighting off obsessions and intrusive thoughts. Not only about germs and contamination. Some people have intrusive thoughts or obsessions that they may have killed someone, or hurt someone. And the only way to protect themselves and others are from the compulsions. Not just washing their hands a lot. But "if I don't wash my hands seven times, I'll die." or "I have to lock the door five times, otherwise someone will break in and murder my family." They may know it's not true, but they can't fight off the thoughts, and they can't stop themselves from the compulsions. You diminish the distress someone else is experiencing by misusing the diagnosis. It's very important to understand that. I wouldn't say "ugh I was so asthmatic today" if I had some trouble breathing during a workout that was beyond my skill. To say that would be to assume that asthma is somewhat controllable (ie, if I worked out more I wouldn't have gotten winded) and that it is transitory. It would diminish what asthmatics go through on a daily basis if their asthma is poorly controlled. Second, causal misuse of words increases stigma in mental illness the same way calling something "gay" does. Here's how. If I call something I don't like "gay" I'm not only using it to describe something that is bad, but I'm inherently calling being gay bad, right? So if I call my friend "bipolar" when they're acting in a way that I don't approve of, I'm inherently calling being bipolar a bad thing. If my friend who truly is bipolar hears me say this over and over again, they feel like there is something else wrong with them. Not only their illness, but that people don't accept it. They will hide their symptoms and not seek help. Calling someone "schizo" when they're acting differently than the norm makes people think schizophrenia is something funny, and demeans people who actually suffer from this illness. So let's all take some time to be more conscientious about the words we are using, and the way we describe things.

The Who, The What, and The Why

Hi All Welcome to my new blog. This blog will be dedicated to my personal journey through life, medicine, and motherhood. I hope to use this not only as an outlet, but as an educational experience for the reader. I'll talk about issues in medicine, psychiatry, motherhood, and whatever else comes to mind. I will not be diagnosing or treating people through this site. A little about me. Professionally: I'm a psychiatrist who specializes in children and adolescents. I went to medical school and hold a doctorate in medicine (I am an MD). I graduated in 2012, went through a general psychiatry residency (3 years) and then transitioned into child and adolescent psychiatry fellowship (two years). I now practice at a children's hospital, doing predominantly outpatient work. This means I see children and teenagers in my office. Sometimes I work on the inpatient unit, with those hospitalized for their illness. While in training I had the opportunity to work at a stand alone psychiatric hospital in an smaller city, as well as working at a psychiatric jail. More personally: I'm an Arab American (second generation) Muslim who grew up in Colorado. My parents divorced when I was young and I didn't have contact with my dad for the majority of my life. I (almost) always knew I was going to be a doctor, and come from a family of medical professionals. I went to college in a tiny town in Nebraska. I spent a year in the Middle East after college, then another year teaching at an alternative school before finally getting into medical school. For my journey through medical school (which was it's own, special form of disaster) you can check out my other blog: I Hate Medical School. I am married to a non-medical professional, non Arab, wonderful man who had a much different childhood than I did. It helps add a lot of perspective. We recently had a beautiful baby girl. New motherhood is wonderful and terrifying and could be it's own blog. As someone who has gone through her own bouts of anxiety and depression, I think it's very important to stop the stigma of mental health and illness. I hope to help do that through this blog. At times personal and professional, I hope to always be entertaining. So sit back and enjoy the posts.