Hi there, I am new here... be gentle with me :p

Was wondering if any have a smilar experience/would like to comment

I was trying to udnerstand my distractability, anxiety, and stumbled on some information which led me to suspect I have ADHD (inattentive). My GP referred me to a specialist after I complained about being unable to focus, doing badly in exams but better in take-home papers.

At the first appointment, the psychatrist looked at the referral, brushed me off and said I do not have ADHD -- all in 5 min. But he insisted I have O/C traits after I answered no to the standard questions (eg going back to check the door, putting away knives, ritualistic behaviour). I was like, what the...

And throughout the rest of the consultation, I felt being pigeon-holed as he took a history to (I feel) justify his diagnosis.

I understand co-morbidity but why won't he consider the ADHD? Or even ask me questions as per the DSM-IV criteria?

cheers

oops... sorry I may posted in the wrong thread. i am 30 y/o

Welcome to the forums! :)

I'd say get a second opinion!

Regardless if you do have ADHD or not you deserve a thorough examination and to be taken seriously!!!

I was diagnosed by a pyschiatrist who specialized in ADD when I was 23. He had me take home all these questionaires and spoke with me 4 times for an hour each over a 2 week period before he diagnosed me with ADD.

Last year, right after I turned 29, I went to a new doctor that told me within 5 minutes that I was misdiagnosed. I told him he was wrong. Because of rules with medicad, I had to see him so I let him to his thing for 3 months and I told him he had 3 months. He wanted to treat the depression and anxiety first.

I told him that my previous Dr. had told me that unless you treat the main problem (ADD) the meds for the symptoms (Depression & Anxiety) will not help much. After 3 months of taking meds and not feeling much better,,, I went in and told him that now he needed to treat me for the ADD.

I told him how my days went everyday and how my depression is because I cannot stand living in my house or being in my own skin most the time because of how unorganized I am and how I get so mad cause I can't think strait and I forget everything. Well he is working with me now and he actually listens to me when I speak.

I'm not sure what the standard of practice is down under or if it's similar to the UK (and the rest of Europe).

Not too long ago I posted on a thread started by someone living in Spain.

I believe she had been diagosed in the U.S.,however, it sounded like her Spanish
psychiatrist was not impressed and was looking more at "personality issues."

I went on to post some history on the split between North America and Europe on how ADHD is viewed.

In essence, European psychiatrist's viewed hyperkinesis as "very rare" and as being caused by brain damage; if I remember correctly.

This is off the top of my head, so I apologize if I'm mistaken. The point is that there were completely different takes on the subject.

About 2 weeks ago, I saw a presentation by a neurodevelopmental pediatrician from Pennsylvania.

She made mention of the differences between NA and Europe. She also said that the UK still uses the now antiquated DSM-II diagnostic criteria from 1968.

Obviously, there have been advances in the research since then.

I don't know if your psychiatrist has that viewpoint or not. However, I do know what needs to be included in an adult ADHD assessment.

The first thing I'd recommend would be for you to print a copy of the journal article:

International Consensus 2002. It's available at www.chadd.org or at Russell Barkley's website.

It contains the best overall operational definition of what constitutes a "disorder" and is signed off on by over 80 of the world's leading scientisits;all supporting the existence of ADHD as a... "medical condition/disorder".

One of the current 15 working defintions of ADHD is that it's a... "normal dimensional disorder of human behavior that all people show some symptoms of to some degree, at some points in their lives."

It's like...."everybody does those things," which is true.

However, everybody doesn't experience problems from them.

That's critical to understanding the difference. The non-ADHD population of our peers don't have problems as a result of those behaviors.

The clinical threshold ( point where it becomes a problem) is : "Impairments in major life activities that cause "harmful dysfunction."

For kids, "major life actitivities are " school and friendships. Later on, you can add driving.

For adults, it's all of the above plus occupational/job related problems.

Adult ADHD's have more job turnover/get fired that non-ADHD's.

The quickest /easiest reference on this is Sandra Rief's 2003 book ..... The ADHD Book of Lists.

Its available at all major book stores. I got mine at Barnes & Noble.

She hasn't written a new book, what she's done is to take the research of the last 10-15 years and put it all in list form, by category and with references.

If I want to look at all 15 current definitions, all I have to do is open the book to page one.

In the States, a proper adult ADHD eval would be to have the person do a checklist, such as the Conners Adult ADHD Rating Scale (CAARS).

Then the spouse ,parents, significant others, etc., who know the person well would do the same.

There's actually research to show that adults under report their symptoms because they've compensated for them so long they seem "normal."

You'd also look at school transcripts, driving records, and occupational history.

The other important info is on prenatal and perinatal care.

Some of the biggest "risk factors" associated with ADHD are nicotine use during pregnancy, premature birth, and birth complications /difficult births.

It goes without saying that alcohol and drug use during pregnancy are huge factors as well.

Since research,mainly on twins, has shown ADHD to be 80% inherited/genetic in origin, a family history of learning problems, school dropouts, etc, is also important.

A really thorough eval would do an intelligence screening and an academic screening ; but not for diagnostic purposes.

IQ tests and neuropsych tests arre "inappropriate" for diagnosing ADHD.

It is ,however, important to get a screening to look for comorbid problems; of which learning disabilities are some of the most frequent.

Computerized test used as the only measure in an eval are also '"inappropriate" as well.

Good luck and I hope this helps you some.

take care

mctavish23 (Robert)

Wow, a five minute evaluation must have felt like quite a blow off -- I don't know how you could know anything about a person in that about of time. I sure how you can see someone else soon!

Draven, just have been frustrating to have had such a through psychiatrist and then end up with such a snap judgment. Sounds like you handled it well -- much better than I could have. Maybe you've educated your need psyc doc a bit and other patients of his will benefit as well!;)

Scattered

I side, as almost always, with the doctor. You don't know what the doctor was looking at, what information he was working with, and what school of psychological thought he was coming from. You said that you listed no to the things about constant checking, and so further, but that doesn't rule out Obsessive/Compulsive traits, especially if he's referring to the Personality Disorder rather than the Anxiety Disorder. He is well within his rights to rule out ADHD.

It also seems, given the fact that you're here, that you are convinced of your own diagnosis. Because of this, you may be missing (unintentionally) points that you don't want to hear. If you believe ADHD is the answer, and it's not, then you are less likely to be receptive to the information that says it's not.

Further, I strongly dispute the idea that the diagnosis took only 5 minutes. He was looking at a referral, and you do not know what was on that referral. And you also mentioned anxiety; that is NOT part of the ADHD diagnosis, or even a common non-diagnostic symptom. While many people with ADHD do develop anxiety disorders, the amount is only slightly greater than the number who would have them without ADHD. Anxiety symptoms DO, however, bring on inattention. That means there is an as good if not a better chance that you have an anxiety problems that are making you demonstrate ADHD characteristics.

It seems to me that you need to talk to your doctor about this. Ask him to explain his rationale, because you are concerned. I am certain his rationale is sound. Not doing well on exams, but doing better on take-home tests, is not indicative (to me) of ADHD. Rather, it's indicative of "Exam Panic," a very common problem on college campuses which is often related to Obsessive Compulsive thoughts of fearing inferiority, fearing you won't function under time limits, or fearing you haven't learned adequately.

This is not the right place to second guess your doctor or even ask if he's on the ball, as most people here, having or thinking they have ADHD, will be far more likely to side with you. As a group, individuals here often attribute many things to ADHD, by the simple availability of knowledge about ADHD. If you only know about ADHD, and not other possible disorders, you're much more likely to assess any problem as ADHD; not because it's the best fit, but because it's the best fit _that you know of_. And, because you have already decided, it seems, that you have ADHD, you are less likely to see the reasoning, however sound, that you have something else with inattention features.

People here saying the doctor may be wrong or the doctor is a bad doctor are jumping on a bandwagon. We don't know your case history and we don't know your situation, so people saying you "probably have ADHD" despite your doctor saying you don't are not working with the necessary information.

Trust your doctor on this one: he has a lot more schooling and training in the matter; and while he might not know you as well as you know you, he might just have a little better insight into what makes you tick. "Educating" your doctor so he changes your diagnosis is not in your best interest: remember, you don't have ADHD just because that's the conclusion _you_ came to. The chances are, if the doctor doesn't think you have ADHD, you probably don't.

I'm sorry I rattled on and likely made some people very upset, I just want to make the point very clear: people on an ADHD board are more likely to assume any symptoms are the result of ADHD, even if they aren't. If you think you have ADHD, you're less likely to understand the reasoning that proves you don't, even if it's very solid.

Most importantly, your psychiatrist has training and experience in making diagnoses. He didn't review that referral in the 5 minutes you were there, he probably had it a few days in advance, and reviewed it in depth. He likely has seen similar cases. He definitely knows more about this than you do. He, and you, are both looking for an explanation of your behaviors using the information you have; and he has much, much more information and experience.

Finally, ruling out ADHD is not difficult; if there are other symptoms, then the ADHD symptoms normally fall under that. DSM-IV has very clear rules: make the diagnosis which best explains ALL symptoms present. If there is another diagnosis, even if it's Anxiety Disorder Not Otherwise Specified, he SHOULD use that instead of ADHD, JUST because the Anxiety is there, and that's not part of ADHD, while the inattention IS part of anxiety. DSM-IV is designed to use the fewest possible diagnoses to explain an individual; your ADHD-like symptoms probably fall under something else - something that he knows, because he has studied it, and you don't, because you haven't studied it. It's fallacious to assume it's ADHD, which you discovered and likely researched and read about because you thought it was correct, and not one of the literally hundreds of other diagnoses that HE knows about, into which your symptoms probably fit much, much better. That's not saying you did a bad job, it's just saying you probably don't know what disorder your symptoms better fit, because you haven't read DSM-IV, and he does, because he has.

In brief: I side with the trained doctor rather than the hopeful patient in diagnosis. It's absolutely wrong in every way for any of us here to think the doctor is incorrect, because we a) don't know the history and symptoms, and b) don't know all the possible diagnoses those symptoms can indicate, and c) have a tendency de facto to assume everything is related to our own disorders, by virtue of the fact that it's all we know about.

Mctavish, not to labor the point, but while all those things need to be included in a proper diagnosis, they are NOT necessary to discount a diagnosis. All that needs to be present to make the diagnosis NOT ADHD but instead something else is a single symptom that makes the symptoms fit that better than ADHD. If, for example, he has a single anxiety symptom, and not all the ADHD symptoms, it's an anxiety disorder, and ADHD is not diagnosed at all...and inattention alone does NOT make ADHD-PI.

Allow me to inject here that I have been a "victim" of a 5-minute diagnosis, not for a mental disorder but for an injury.

If only that diagnosis had been made in the US instead of Japan, I'd be set for life on my nice, fat malpractice settlement.

Doctors can, and sadly often do, make mistakes. Seeking a second opinion is the right, nay the responsibility of the patient.

Conversely, doctors do not have a "right" to make the diagnosis they see fit; they have that prerogative, within certain bounds, but the rights lie on the side of the patient.

I think in this case a 5 minute diagnosis is not having occurred. From what I can make of the case, we're in no position to second-guess the diagnosis. If the patient feels so, a second-opinion is _always_ warranted, but not necessarily good. I'm more warning against the idea of assuming the OP HAS ADHD and was misdiagnosed. There is absolutely 0 evidence that he has ADHD outside of his own opinion. It's fallacious, therefore, to second-guess the doctor saying he doesn't have ADHD. We don't have any reason to doubt the doctor's diagnosis, and based on the OP's own self description of "anxiety" as a major symptom, we have at least one good reason to support the doctor in the Dx being an anxiety disorder, not a childhood-onset behavioral disorder.

We do not know if the psychiatrist was specializing in ADHD.

Anyways, doctors are not perfect and they might make mistakes.

I don't think anyone is saying that dopenuts do in fact have ADHD, just that the diagnosis doesn't seem to be so thorougly done.

He (the psychiatrist) might have taken more than 5 mins to decide, yes. But with what material? We do not know how well dopenuts explained her/his problems to the GP or if the GP got what s/he said right.

At least I think that the psychiatrist should have given the reason why he didn't think dopenuts had ADHD, why he wouldn't even consider doing a proper evaluation. (By this I mean deep interviews, check lists, talking to parents, ruling out physical conditions, etc). He should also have explained why he kept at the OCD-diagnosis. Like "Well, you see OCD is not only about....it can also be...."

Doing a proper evaluation is not the same as saying someone has ADHD.

And by the way; KMiller, how can you be so sure about where the anxiety comes from? Do you know dopenuts? Did you see the material the doctor based his decision on? No, you didn't and neither did I or anyone else here.

What about comorbidity?

Isn't there a number of people who have been diagnosed with depression, etc. earlier in their lives before it was found out that they had ADHD?

Hi dopenuts.


*Silence*

Hmmmm...dopenuts seems to have left the building, at least for now.

I'm wondering if he or she had taken any of the online ADD or ADHD tests.
And "dopenuts"? Just wondering if the screen name implies that he or she (or you, if you're still here or back again) might have been 'under the influence' of some self medication when the doctor did the 5 minute evaluation.

In addition to all the great dialogue above, one other thing to consider is that OCD and ADHD and all the other Disorders are mere labels for collections of symptoms. The fact that there is frequent comorbidity dillutes the value of these labels even further. Perhaps the doctor just wants to focus on the most obvious (to him) symptom first.
Or maybe, because amphetamines are often used in the treatment of ADD and ADHD, he prefers to hold back on them until he's sure the new patient is serious about dealing with ADD or ADHD and not just wanting the controlled substance.

The first Dr. I saw in 1997, said, to me, after he look at what I was in to see him for,
You don't look the type, to have AD/HD, I walked out

It seems some doctors are just hell bent on avoiding it.I dont know why myself.I went through the same experience and then some.I had to practcally fight my way to treatment for it!I couldnt believe how hard it was,but I never gave up because I knew what was wrong and had gained all info I could to arm myself with.

I stayed persistant with friends and family rolling eyes the whole time.In the past I would have never have thought enough of myself or had the energy to do such.After I had my children that changed.I had too and I deserved to get a fair shot at treatment.

My opinion,Go to another doctor and if you have to,another.You know how you feel inside.Also,I battled depression and anxiety attacks almost my whole life.I was a mess.Once I got treated for ADD that all turned around.I believe its all connected.Good luck to you.

The first Dr. I saw in 1997, said, to me, after he look at what I was in to see him for,
You don't look the type, to have AD/HD, I walked outIs it at all possible that he was trying to compliment you, but he had no social skills? Even if so, it would probably not been a very productive relationship.

Dopenuts reported anxiety problems. Having done so, the doctor should have diagnosed without ADHD. Honestly, the question is this: what reason do we have to assume he does have ADHD? Doctors make mistakes, but less frequently than we are led to believe.

I'm not saying dopenuts does _not_ have ADHD. I'm saying we have no evidence to say his doctor is wrong in his diagnosis. Given the history that he gave his doctor, his doctor came to a reasonable conclusion that it is not ADHD.

Let's also remember that a doctor does not need to "specialize" in ADHD in order to make that diagnosis. In fact, it's probably better that they don't, because they may be biased in diagnosing in where it should not be diagnosed.

All I'm saying is that it's irrational and in fact dangerous to assume that his doctor made a mistake because he thinks his doctor made a mistake. After all, his doctor did go to school for no less than 10 years for this; I trust him over the OP.

Also we have seen on this thread that there are extremes!Your opinion is what matters and you should do what you feel is best.Doctors screw up all the time!I know from experience!They are only human and as you can see,we are all diffrent in opinions and stands on issues.
I wish you the best of luck!!!

Hi all, thanks for the concern :) wow, is there always this sort of (constructive) tension?

first off, thought I'd clarify some issues. the sole purpose of my post was to find out if others here had similar experiences. more specifically, I felt brushed off. No, I am not insistent that I have ADHD -- no offence folks, who'd wish it on themselves? And no, I did not join this group because I believe I have ADHD. And no, I have not left the building. And no, I am not on drugs. Doughnuts are my drug, geddit? ;)

to clarify, I thought I had some of the symtoms. I told my GP. My GP wrote the letter. I brought it in to the psychiatrist. It was the first time he had seen the letter. He set me down, chuckled and said, I can tell you right now you dont have ADHD. I asked, "how do you know?" He said," clinical observation. You will see you have compulsive issues. And we'll find it in one of your parents I am sure."

So the issue, is NOT whether the specialist was right/wrong. The issue is, is this the way to diagnose? Is this sort of bed/couch-side manners typical of people's experience here?

So there. I took so long to seek help precisely because I thought it wasn't a problem. And I think it is rather unkind to insinuate that I am fixated on thinking I have ADHD.

that's all folks :)

to clarify, I thought I had some of the symtoms. I told my GP. My GP wrote the letter. I brought it in to the psychiatrist. It was the first time he had seen the letter. He set me down, chuckled and said, I can tell you right now you dont have ADHD. I asked, "how do you know?" He said," clinical observation. You will see you have compulsive issues. And we'll find it in one of your parents I am sure."

So the issue, is NOT whether the specialist was right/wrong. The issue is, is this the way to diagnose? Is this sort of bed/couch-side manners typical of people's experience here?
The guy sounds pretty sure of himself. Can we say god complex?

I think the proper form would be to at least pretend you had an open mind until you finished the examination. :)

I think some important questions for the psych in question would be whether he believed (m)any adults have ADHD; if so, what the prevelance was; and how often he diagnosed it.

One hears a lot of stories about people going in for ADHD-related stuff, having having the psych want to talk about their mother or their repressed shame over that bedwetting incident at their first sleepover.

But if you're ADD, you're screwed up because your brain is screwed up; it's built in, not acquired through trauma.

This is what Russell Barkley said about how to Diagnosis ADHD.

"So notice, the evaluation of an AD/HD child then would include the following five methods because these are the things you have to do to answer those questions. One, a clinical interview with the individual and people who know them well. Two, you must review the DSM criteria for this and other major disorders. Three, you’re going to have to use a rating scale to measure how deviant the symptoms are. Four, you need to screen out low IQ and developmental delay. Five, you need to screen for learning disabilities to see if they’re co-morbid because they will be in 50 percent of all cases. And if you want to add a sixth, it would be get the records from the school and all past evaluations on this individual. And then you can make a diagnosis. No testing. There’s nothing on an intelligence test that will diagnose AD/HD. There is nothing on a computer test. There is nothing in a neuropsych battery that can reliably diagnose this disorder. You’re just wasting time and money".

...and what did this Dr. do?

1) He looked at a letter from the GP which mostly likely simply said that dopenuts has concerns that he may be ADHD.
2) He made his mind up in moments. ("I can tell you right now you dont have ADHD. I asked, "how do you know?" He said," clinical observation. You will see you have compulsive issues. And we'll find it in one of your parents I am sure.")

The Dr. rightly or wrongly jumped to a conclusion. The Dr. calls this clinical observation. A Dr. has that right but it sure sounds irresponsible.

Go get that second opinion, this guy sounds like a smug prick.

He does sound like a smug prick, and he probably has a teaching job (9 out of 10 psychology professors agree: they are God's gift to psychology). However, clinical observation is more than capable of ruling out ADHD. The diagnostic process is not "try and diagnose everything," but rather, try and rule out as many diagnoses as possible, as quickly as possible. ADHD got wiped the minute you had anxiety symptoms on the referral, because it means an anxiety disorder explains those symptoms much better.

Dopenuts, I apologize for insinuating a fixation on your part, like I said, we have/had very little information, and not enough to really go with. I made an assumption based on where you were, and that was perhaps a little reckless. However, I think you can see my point in some of the other folks here who continue to insist you pursue evaluations for ADHD.

As a rule of thumb, if there is no major problem, you shouldn't see a doctor...psychiatric professionals are very unlikely to say "oh you have nothing at all" for a variety of reasons, including insurance payments, time spent and justification, and the fact that, especially on a referal, they are being told "this person has a problem, find it!" You can make any person fit a disorder, it's not that difficult, just find those little quirks and add them up. If you do see a doctor to figure out if there is nothing wrong, make it very clear you're looking for nothing.

..psychiatric professionals are very unlikely to say "oh you have nothing at all"
My daughter had a twenty minute evaluation by a middle-aged psychiatrist who told her that if she had, had ADHD, she would have outgrown it by now. He did not suggest any other "problems".

KMiller, I'm curious (maybe I'm misinterpreting) why you say that if someone goes to doc with attention problems but mentions anxiety than ADHD should be immediately ruled out (and an anxiety disorder diagnosis is likely more appropriate, if warranted).

I have anxiety. (Was dx with PTSD and ADHD). But my anxiety is normally a result of ADHD.

e.g. here is my normal cycle of emotions:

Constantly bored (BORED) >>

Can't figure out what to do with self to solve boredom; can't concentrate on doing anything (RESTLESS)>>

Get frustrated with myself because of boredom (ANXIOUS)>>

Anxiety and frustration makes me feel sad (DEPRESSED)

So I end up feeling bored, restless, frustrated, anxious and depressed. I think that anxiety can exist with ADHD in the way I just mentioned.

Another way I experience anxiety because of ADHD is social. Because I cannot organize my thoughts and I ramble and I say things I don't mean and blurt things out sometimes...I've developed some social anxiety (because I feel I'm going to embarrass myself). It's not in the way of Social Anxiety Disorder. It's also because I'm unable to get through books, newspapers or magazine articles so I'm embarassed socially that I'm not on top of current events in the way I'd like to be or educated about subjects I'm interested in.

My point is not to discuss me (thought it probably seems like it!). :P But I wanted to show examples of how I feel that anxiety does/can exist with ADHD. And I have no idea if dopenuts truly does have an anxiety problem or ADHD or something/nothing at all. I'm not trying to lead this discussion to conclude that.

I do agree with others that doctors do certainly make mistakes. Don't always listen thoroughly. Make quick judgements. Can say silly things about treatments, medication, disorders, etc.

I was told by a doctor that Adderall is a street drug. That Adderall and Ritalin are the same thing. That stimulants work for children but not adults. That adults will become addicts. That the relief I feel from Ritalin is my "high".

I was also told when calling around for a psychiatrist that they won't treat ADHD patients because they won't prescribe stimulants. That they will treat me but won't prescribe stimulants. Etc. So I understand why someone recommended finding an "ADHD specialist". I'm going to pay out of pocket to see a psychiatrist that specializes in ADHD rather than use the choices my insurance company gave me (because after two days of calling around I kept hearing the nonsense above from "regular" psychiatrists).

My insurance company even told me that there's no such thing as a psychiatrist that specializes in ADHD, that they all do (and had no way to search for a psychiatrist by that "specialty"). I want(ed) to scream!

The basic line is,if you (Doughnuts) feel wronged,get a second opinion and don't think you are being a hypocondriac because of it,doesn't matter whether it is ADHD or not,you might get a more indepth view of your problems from another pysch if this guy isn't prepared to spend much time on it.

....However, clinical observation is more than capable of ruling out ADHD. The diagnostic process is not "try and diagnose everything," but rather, try and rule out as many diagnoses as possible, as quickly as possible. ADHD got wiped the minute you had anxiety symptoms on the referral, because it means an anxiety disorder explains those symptoms much better.

......However, I think you can see my point in some of the other folks here who continue to insist you pursue evaluations for ADHD.

As a rule of thumb, if there is no major problem, you shouldn't see a doctor...psychiatric professionals are very unlikely to say "oh you have nothing at all" for a variety of reasons, including insurance payments, time spent and justification, and the fact that, especially on a referal, they are being told "this person has a problem, find it!" You can make any person fit a disorder, it's not that difficult, just find those little quirks and add them up. If you do see a doctor to figure out if there is nothing wrong, make it very clear you're looking for nothing.



I'd have to disagree on several points here.

1)ADHD is almost always not just ADHD. It is ADHD and something else like, anxiety....which is more common for people who have I-ADHD. How far did this Dr. go in considering all the the angles of the symptoms? From the sounds of it, not very far at all. He sounds old...old..school and not at all up to date on current methods of diagnosis for ADHD. I don't think the possibility was even considered and thats why I suggested a second opinion.

2)Doesn't a diagnosis depend on meeting set criteria? Other things shouldn't come into play because Dr.'s are professionals. And...I don't believe for a second that "you can make any person fit a disorder". Unless,... of course, you do the snap 10 second diagnosis based on clinical observation alone. The Dr. would also have to not follow current best practices for the diagnosis of that particular disorder. Current best practices look for confirmation from several sources, including history to make the diagnosis.

Barkley on the comorbidity of ADHD and Anxiety

From San Fran lecture of 2000

AD/HD with Comorbid Disorders

Are there other disorders you will see with AD/HD? You betcha. Three-quarters of AD/HD children have at least one other disorder. They’re no more likely to be psychotic or schizophrenic, but they may well have other disorders. That’s why we put them all together, the disruptive disorders are AD/HD, ODD, and CD. They co-occur very frequently. And by the way, delinquency is just stage three Oppositional Disorder. And Antisocial Personality is just stage four. You go from being Oppositional to Conduct Disorder to delinquent to Antisocial Personality. So that these are not unrelated disorders. They are a developmental pathway, each reflecting a more severe condition, stages in a more severe process. They’re related to each other.


Anxiety disorders.

That’s a very interesting relationship. Twenty-five percent of the kids who come to clinics have an anxiety disorder with AD/HD. We’ve discovered two things about that. First, much of that is a referral bias. Why? Because to get through the managed care gatekeeping you have to have multiple disorders before you get to see a psychiatrist, which means that if you studied populations in psychiatry clinics, they tend to have more disorders than the general population. But that’s an artifact of managed care and gatekeeping. The second thing that we’ve learned about studying AD/HD kids who do have anxiety disorder is that they’re not real anxiety disorders. They’re not fearful, phobic, withdrawn, which is the essence of a real anxiety disorder. Instead, what we find is that parents are over-estimating anxiety because the children are more emotional generally. AD/HD predisposes to greater emotionality, greater affectivity, especially negative affectivity, greater hostility, greater anger, all emotions are shown more by an AD/HD child than by a normal child. And that tends to create a bias in parents’ reports. So that parents tend to endorse these symptoms, but when we bring the kids in and study them, they’re not fear-based, they’re not phobic. They’re driven by just being emotional, negative, immature. So even the kind of anxiety disorder is a bit different here.


and....




"Anxiety and Mood Disorders

The overlap of anxiety disorders with ADHD has been found to be 10% to 40% in clinic-referred children, averaging to about 25% (see Biederman, Newcorn, & Sprich, 1991; Tannock, 2000, for reviews). In longitudinal studies of ADHD children, however, the risk of anxiety disorders is no greater than in control groups at either adolescence or young adulthood (Fischer, Barkley et al., in press; Mannuzza et al., 1993, 1998; Russo & Biedel, 1994; Weiss & Hechtman, in press). The disparity in findings is puzzling. Perhaps some of the overlap of ADHD with anxiety disorders in children is due to referral bias (Biederman, Faraone, & Lapey, 1992; Tannock, 2000). General population studies of children, however, do suggest an elevated odds ratio of having an anxiety disorder in the presence of ADHD of 3.0 (95%CI = 2.1-4.3), with this relationship being significant even after controlling for comorbid ODD/CD (Angold et al., 1999). This implies that the two disorders may have some association apart from referral bias, at least in childhood. The co-occurrence of anxiety disorders with ADHD has been shown to reduce the degree of impulsiveness relative to those ADHD children without anxiety disorders (Pliszka, 1992). Some research suggests that the disorders are transmitted independently in families and so are not linked to each other in any genetic way (Biederman et al., 1991; Last, Hersen, Kazdin, Orvaschel, & Perrin, 1991). This may not be the case for the inattentive type of ADHD, where higher rates of anxiety disorders have been noted in some studies of these children (see Milich et al., 2001 for a review; Russo & Biedel, 1994), though not always (Barkley, DuPaul, & McMurray, 1990), and in their first- and second-degree relatives (Barkley, DuPaul, & McMurray, 1990; Biederman et al., 1992) again though not always (Lahey & Carlson, 1992; Milich et al., 2001). Regrettably, research on the overlap of anxiety disorders with ADHD has generally chosen to collapse across the types of anxiety disorders in evaluating this issue. Greater clarity and clinical utility from these findings might occur if the types of anxiety disorders present were to be examined separately".

http://www.continuingedcourses.net/active/courses/course003.php

There's elements of truth throughout but some things I disagree with.

Clinical observation is basically the only way to "see" hyperactive behavior,however, its not that simlpe.

One of the things that Russ pointed out in the teleconference in March was that there's research to show that ADHD children can sit still and be well behaved in a doctor's office.

I usually "turn the kid loose" to see what happens while Im talking to the parents.

Looking for comorbidity is crucial.

I'm just posting the accepted standard of practice on how to diagnose adult ADHD; per Russ Barkley.

What would you expect to see clinically from someone who could be potentially ADHD subtype innattentive? Are there really any significant behaviours that you could observe in a short period of time that may indicate the possibility of this disorder?

I'm guessing that from straight observation, there is little to nothing that will seperate these people from the general population.

This is what Russell Barkley said about how to Diagnosis ADHD.
"...No testing. ..."Hrmph.

I'd have to disagree on several points here.

1)ADHD is almost always not just ADHD. It is ADHD and something else like, anxiety....which is more common for people who have I-ADHD. How far did this Dr. go in considering all the the angles of the symptoms? From the sounds of it, not very far at all. He sounds old...old..school and not at all up to date on current methods of diagnosis for ADHD. I don't think the possibility was even considered and thats why I suggested a second opinion.

ADHD is almost always not ADHD, this is correct. However, "[ADHD] is not diagnosed if the symptoms are better accounted for by another mental disorder (e.g., Mood Disorder [especially Bipolar Disoder], Anxiety Disorder, Dissociative Disorder, Personality Disorder,...)" - DSM-IV.

Because a) there are anxiety symptoms present and because b) anxiety disorders have in their criteria marked inattention, the combination of anxiety and inattention is better accounted for by an anxiety disorder than ADHD _and_ an anxiety disorder. The purpose of categorical diagnosis is to make the best fit for the symptoms, not to make multiple diagnoses based on each symptom on its own merit.

2)Doesn't a diagnosis depend on meeting set criteria? Other things shouldn't come into play because Dr.'s are professionals.

The diagnosis depends on meeting set criteria based on clinical judgment. I refer you to the DSM-IV again:

USE OF CLINICAL JUDGMENT (pg. xxxii) [READ THIS]

DSM-IV is a classification of mental disorders that was developed for use in clinical, educational, and research settings. The diagnostic categories, criteria, and textual descriptions are meant to be employed by individuals with appropriate clinical training and experience in daignosis. It is important that DSM-IV not be applied mechanically by untrained individuals. The specific diagnostic criteria included in DSM-IV are meant to serve as guidelines to be informed by clinical judgment and are not meant to be used in a cookbook fashion. For example, the use of clinical judgment may justify giving a certain diagnosis to an individual even though the clinical presentation falls just short of meeting the full criteria for the diagnosis as long as the symptoms that are present are persistent and severe. On the other hand, lack of familiarity with DSM-IV or excessively flexible and idiosyncratic application of DSM-IV criteria or conventions substantially reduces its utility as a common languages for communication.

In addition to the need for clinical training and judgment, the method of data collection is also important. The valid application of the diagnostic criteria included in this manual necessitates and evaluation that directly accesses the information contained in the criteria sets (e.g., whether a syndrome has persisted for a minimum period of time). Assessments that rely solely on psychological testing not covering the criteria content( e.g., projective testing) cannot be validly used as the primary source of diagnostic information.

As you can see, use of the DSM-IV criteria alone is not only inappropriate, it's likely patently incorrect.

And...I don't believe for a second that "you can make any person fit a disorder". Unless,... of course, you do the snap 10 second diagnosis based on clinical observation alone. The Dr. would also have to not follow current best practices for the diagnosis of that particular disorder. Current best practices look for confirmation from several sources, including history to make the diagnosis.

You can make a person fit a disorder rather simply if you interpret all behaviors as symptoms rather than behaviors. All you have to do is decide that washing the hands is a compulsion, and brushing the teeth is a sign of fear of contamination, and so further. It can be done.

As far as "current best practices for diagnosing a disorder" there is no such thing. We do not have a special practice for every single disorder's diagnosis. In fact, most clinical diagnoses are made by way of a combination of self-report assessments and clinical interviews. The diagnosis is made by finding the key symptoms (using clinical judgment to determine the importance of them) and then finding which disorder those symptoms most closely match. As the DSM-IV says, you can have a disorder without all the symptoms, and you can not have a disorder with all the symptoms.

Clinical judgment, NOT a set bunch of criteria, is the reason psychologists are paid for what they do. They have years of training (at least 8 in most states and countries) and they apply it in diagnosis.

Hrmph.

Well yeah...because it's a behaviour disorder and how do you measure behaviour? ...through observation.

...and this lead to further thinking about how to diagnosis Inattentive ADHD. It's going to be hard to observe behaviour and rule out anything or come to a diagnosis. Really one of the key tools would be the DSM 4 checklist and you would probably want to see it in at least two environments along with history.

More from Barkley in San Fran 2000: "I said the Inattentive group was a wastebasket. Why did I say that? Inattention is nonspecific. Inattention is unhelpful in defining what disorder you have, because most mental disorders produce inattention. So if somebody walks into your clinic and says, you know, I’m having a lot of trouble concentrating, can’t pay attention, can’t finish work, you have no idea what they have. You don’t automatically say, oh, that’s AD/HD, I’ve heard about that. This could be a psychotic. This person could be a substance abuser. This person could have a generalized anxiety disorder or panic attacks or major depression or bipolar illness. How the hell do you know what they have"?


...and come to think about, how could you conclude that someone has or doesn't have an anxiety disorder by brief observation. I have seen several people in a full blown anxiety attack. That you can observe. BUT..most people with anxiety don't show it most of the time. So what if you go into the Dr.'s office and you're a little anxious because you don't know if you have this abnormal disorder? Perhaps you are sweating, your face is a little flushed, you are flustered. ZING, next thing you know....clinical observation....you have Anxiety disorder. That would be bad practice. Perhaps you are tapping your pencil repeatedly as you wait and worry. What's that, a ritualistic behaviour? ZING....now you have OCD. Again that would be bad practice.

The Dr. wasn't thorough and the odds of false positive or false negative would be high. I call it irresponsible. He should be up to date on current methods of Diagnosis...and that certainly isn't a few moments of clinical observation to label someone with a a diagnosis.

As far as "current best practices for diagnosing a disorder" there is no such thing. We do not have a special practice for every single disorder's diagnosis.

Seems we do for ADHD, because Barkley is instructing Dr.'s at his conferences to consider new information when making a diagnosis. None of this information, by the way is in the DSM4.

"There’s another group, the group that starts out being in the Combined type and by adolescence or adulthood are no longer so hyperactive, but they meet the criteria on the Hyperactive list. Now you would flip them over into the Inattentive type. Don’t do it. You always think of them as Combined type. So, bottom line is this: If any point in your history there was a whiff of problems with inhibition and impulse control, you’re a traditional AD/HD Combined type kid, and it shouldn’t matter what the DSM is telling you about cut-off scores. Clinically that’s how you would approach that child. That’s a Combined type kid. And you reserve this Inattentive group for kids who have never in their lives had trouble with inhibition. Those are the spacey, daydreamy, confused, in a fog, sluggish, hypoactive, slow-moving group. And as long as you conceptualize them that way, you won’t make any clinical mistakes. But if you follow the DSM as it’s written—perhaps you have OCD and you just have to follow all those criteria, just as they’re written—then you’re going to get yourself into some trouble. Because remember, the DSM was not chiseled in stone in Israel. It’s a set of guidelines developed to help make clinical decisions, but it’s to be used with clinical judgment and understanding of the criteria".

Let me clarify that a little.


It's okay to do cognitive screenings with tests like the Kaufman Brief Intelligence Test-2 (KBIT-2),as well as academic screens with tests like the Peabody Individual Achievement Test (PIAT) or the Wide Range Achievement Test-3 (WRAT-3).

The PIAT has been revised but I don't know if it's 2 or 3.

Those wouldn't be used to diagnose the ADHD, but would look for signs of comorbid learning problems.

In terms of diagnosing ADHD, "checklists (still) trump tests."

Using IQ subtest scatter and/or neuropsych tests have NOT been found to have "ecological validity (works in the real world)" for the Executive Functions.

As Ive posted before computerized tests are also "inapproriate" when used all by themselves.

Russ really is the leading and most respected ADHD researcher in the world today.

Perhaps you are tapping your pencil repeatedly as you wait and worry. What's that, a ritualistic behaviour? ZING....now you have OCD. Again that would be bad practice.

Firstly, I have to say I never said it was good practice, I just said that it could be done.

The Dr. wasn't thorough and the odds of false positive or false negative would be high. I call it irresponsible. He should be up to date on current methods of Diagnosis...and that certainly isn't a few moments of clinical observation to label someone with a a diagnosis.

Unfortunately, it's not the best way, but it's the way we have to do things. Managed care makes it so that you have to have a diagnosis for them to pay for it. You have to make a diagnosis within one visit. That means you read a case history, you make an observation, and you work with it. We don't know what diagnosis this guy made. All we know is that he ruled out an ADHD diagnosis: something that is exactly appropriate to make given the existence of other symptoms.

Keep in mind your Barkley quote: inattention is a wastebasket. Also, look at your own numbers...10-40%? That means it's still more likely to be something else, not ADHD and something. 90% likely based on the first figure.

At any rate, in the interest of not drawing this on, I'm proposing we table this; we don't have enough information OR enough training to criticize the doctor or the diagnostic process used. We're not peers to this doctor; he is trained in what he is doing and I have every reason to believe he is doing his job well.

People who know me on this board usually hear me say, "trust your doctor". I support Dr’s because they are the backbone of mental health. I give weight to their authority but that authority comes with a price, and that price is to be knowledgeable and responsible in your field. There is no excuse to do otherwise and if you can’t do it, find another job. I can't express how much mistrust and pain Dr.'s can cause when they misdiagnosis a mental disorder. Try working with a kid who doesn't believe anything you say...or parents for that matter.

I have a Doctor friend and I believe he told me that it is the responsibility of the Doctor to keep current with best practices and know new information in your field. You could write a book on recommended adjustments to the DSM4, the thing is that out of date now. Barkley has 17 paragraphs of recommended revisions on his online course alone. It came out in 1994 and that's a coons age in the field of Psychology. This Dr. has a duty to be current in his practice and grasp of issues.

The one point that you seem to be sticking on, is that once you see anxiety, you can rule out all other possible disorders.

But can you really rule out all else as soon as a patient mentions anxiety? I'd say no. As a Dr. you may be leaning strongly towards this opinion but you should check things out first and this is where the Dr. didn't do his duty. How could he, in 5 minutes?

I'm not saying that he can rule out all other possible disorders. He can't, as anxiety is the feature of many psychological disorders, both in and out of the anxiety spectrum. What it isn't a feature of is ADHD.

I think a point we've both missed here is that the diagnosis itself wasn't made in 5 minutes. It was 5 minutes from the point the guy came into the door till when the doctor simply said it was not ADHD. He didn't say what it was, he said what it wasn't, and that's fine.

DSM-IV is out of date. DSM-IV is a list of diagnoses and criteria, however. Those diagnoses do not change with the research, they only change periodically. This is because those diagnoses are made not only for identification of the patient's likely source of problems, but to allow professionals to communicate and, unfortunately, to allow HMOs and managed care organizations to tell doctors how to do their jobs. For example, an HMO is likely to only pay for 8 sessions of counseling for anxiety disorders. After that, the latest research says it should be cured.

When I took my courses on clinical psychology, they told us something I find very important to remember; they told us that the diagnostic label does not change the symptomology, and that managed care is the worst thing that happened to psychology since phrenology. DSM-IV is used because it's the only categorical list of diagnoses that works with the ICD-9 and which doctors can use for a resource. The criteria for ADHD have not changed just because the research has streamlined diagnostic practices, etc. The criteria are the same, it's the method of collection that changes.

The criteria are likely to change with DSM-V, but that's not for another few years. Until then, we're stuck with DSM-IV and clinical judgment. A blessing, and a curse.

I'm not saying that he can rule out all other possible disorders. He can't, as anxiety is the feature of many psychological disorders, both in and out of the anxiety spectrum. What it isn't a feature of is ADHD.

True, but ADHD and anxiety have a high degree of comorbidity. And as scuro said, it would be nearly impossible to spot an inattentive ADD case based on just a short period of observation. Furthermore, as Mctavish says, checklists trump tests (and by extension -- clinical observation).

No matter how great this doctor is at clinical observation -- he obviously seems pretty confident in his skills -- he is flouting the best practices in diagnosis, namely checklists, verified if possible.

If it really was because he had to come up with some diagnosis in order to get paid, I would have to call that a travesty.

I was taking abnormal psychology at the university while getting my Master's when I was diagnosed with Generalized Anxiety -- I checked it out six ways to Sunday and it definately fit, but it also wasn't the underlying cause. It took another decade to get the ADHD with Anxiety diagnosis. My first Concerta did more for my anxiety than years of counseling had, even though it warns not to take it if you have anxiety. What I keep reading in the literature is that you have to look back to childhood -- which came first? The anxiety or the ADHD? Anxiety doesn't "better account" for ADHD, if the ADHD predates it. Taking the time to get it right is important even in this managed care setting -- while standard anxiety medication taken alone may help, there is also a good chance that they won't help and may actually make the ADHD symptoms worse.

BTW, very interesting discussion, everybody!:cool:

Scattered

I guess I'm pretty fortunate to have a Dr. who's both a Psychologist and Psychiatrist.
More opportunity for observation.
I wonder now if his agreement with my self-diagnosis of ADD (based on online self-tests and anecdotal evidence/memories, as well as my boss' complaints about my personality) was not so much based on the childhood and adult experiences I told (he has narcolepsy and often appears to not be listening) but rather the fashion with which I told the stories -- you know, talking fast, trying to cram all the ideas in before they were gone, interrupting myself repeatedly.
He also is medicating me for anxiety and OCD, which no one else had ever mentioned before either, but the relief from the anxiety is remarkable. Unfortunately, the OCD and ADD aren't doing very well. The depression, which I've always had, is somewhat better.

Okay, it's late (or early?) and long past any ADD meds, and I can't quite remember the point...
but I think I've just demonstrated it.

Oh, wait, yes. On my way to scrolling to the first message, I remembered.

The original question was about if anyone had experienced the 5-minute write-off. I recall walking into a psychiatrist's office about 30 years ago and saying I was depressed. He looked at me after no more than 5 minutes and said that I was not depressed. Then he prescribed the prehistoric version of anti-depressants -- which caused me to attempt suicide and also to not take any meds for 30 years. Between then and now, I have gone to several psychologists, and typically not announced that I was depressed, but they always concluded that I was.

Anyway, it's all just labels. A psychiatrist has to look at symptoms and reactions to meds.

The ADHD is always primary ( unless it's of the "acquired" type).

The most important thing(s) are the "impairments."

This is more "art than science," however,if you really know your science (behind ADHD), it makes it easier.

True, but ADHD and anxiety have a high degree of comorbidity. And as scuro said, it would be nearly impossible to spot an inattentive ADD case based on just a short period of observation. Furthermore, as Mctavish says, checklists trump tests (and by extension -- clinical observation).

No matter how great this doctor is at clinical observation -- he obviously seems pretty confident in his skills -- he is flouting the best practices in diagnosis, namely checklists, verified if possible.

If it really was because he had to come up with some diagnosis in order to get paid, I would have to call that a travesty.

He never flouted the checklist, he compiled the checklist himself using the referal and case history given to him.

It's not so much that he had to come up with a diagnosis to get paid; he had to come up with a diagnosis so the insurance companies paid. Psychiatrists are expensive, and the HMOs won't pay for a visit to confirm you're well. Unless the patient is willing to pay $400 out of pocket, then sometimes it's better. Not the way it should be, no, but it happens.

The entire conversation is becoming increasingly silly as we don't know what the doctor did or didn't do. Chances are with that referal he also looked at a case history as complete as the doctor could gather. The doctor's childhood check-in forms normally have grades and notes like that on them, which establishes an early history (or lack thereof).

I'm sorry, but what I posted earlier as the current (evidenced based) practice for diagnosing adult ADHD is exactly that.

The clinician needs to keep up with what the research supports and then use those techniques or measures,etc., until other changes are substantiated via research.

It's just like when a test instrument is changed or updated, such as the WISC-III becoming the WISC-IV. The clinician is then ethically obligated to learn and then start using the updated test asap.

(The WISC is the Wechsler Intelligence Scale for Children. The WISC is the most widely used IQ test for kids between 6-17 yrs. old).

In the first 2 days at the 2003 Medical College of Wisconsin's 17th Annual Door County Summer Institute with Russ Barkley, he literally "blew away" what most of the psycholgists (including me) in the group were doing in terms of what we thought was the accepted standard for diagnosing ADHD.

He then supported that with the research to back it up. My take was along the lines of..."Okay, show us what does work," and he did.

I no longer use subtest scatter from IQ tests or do individual psychotherapy (regardless of the type ) with hyperactive children.

I now use family therapy to help teach the parents how to set up and maintain a rewards based behavior management home charting program/home token economy .

I recall laughing to myself, because everything comes full circle. Part of my internship at Broughton State Hospital in Morganton,N.C., in 1975, was on the Token Economy Unit. The other time was spent testing on the Neuroscience Unit.

Obviously, a lot has changed since I was first diagnosed with MBD (Minimal Brain Dysfunction/Damage (the latter is what my doc said to me) in 1972.

Today, that translates into ADHD-Combined type for me.

I try and post the most accurate information that I can. I stand by my earlier post.

I've been a practicing psychologist since April / May 1977.

I've been a licensed (clinical /child) psychologist in Minnesota since Feb. 20th 1985.

I am also a board certified Diplomate in Psychotherapy by the National Board of Cognitive -Behavioral Therapists.

Cognitive-Behavioral Therapy is the most widely practiced therapy in the world.

Diplomate status is reserved for the top 10% of therapists practicing CBT in the U.S.

I'm also the only Minnesota psychologist listed in the Who's Who Historical Society's 2001 International Who's Who of Professionals (reserved for the top 1/2 of 1% of professionals from all disciplines in 150 countries).

I'm not trying to brag or be obnoxious here.There are excellent points made throughout these posts.

Because my practice (with kids between 6-19/20 yrs) is 90-95% ADHD based, I honestly try and put forth the most accurate info. possible.

In order to do a better job of that, I've dedicated the last 17 + years making ADHD my primary area of expertise. I certainly do other things, but ADHD is where my practice has gravitated towards;largely by word of mouth.

I respect everyone's opinion in here and the posts are well thought out and articulated.

thanks

mctavish23 (Robert)

McTavish, I'm just curious whether you think I'm questioning your previous post? So far everything you've said has been dead-on accurate and I've learned from it...I hope I haven't come off as trying to argue with research that is critical in the field...

All I've been trying to say is that if he was not making an ADHD assessment but rather a general assessment based on a referal, then it depends on what the referal asks, no? If the referal said "suspect ADHD" and he was able to, based on the history, see ADHD has not been present since 7 years, and other diagnoses better account for it, then I don't see how that's improper?

We don't know the full history, we don't know what methods the doctor was using, all we know is that dopenuts was told he did not have ADHD in a relatively short period of time...and I don't think that that necessarily implies the psychiatrist is out of line.

Keith,

You've always been cool with me. I'm simply trying to be as accurate as possible.

It is harder diagnosing adults than it is kids, because this is a childhood disorder.

With children there's almost always some type of comorbidity.

One of the things I didn't mention was that I like to add different measures for assessing the child's emotional level of function along with the other screenings.

I also encourage parents to get consults from pediatric specialists to deal with the "big picture" if you will.

take care and thanks again

mctavish23 (Robert)

Thought I'd throw my 2 cents in... :D

I was initially diagnosed with GAD and some symptoms of PTSD. Was being treated for over 8 months with therapy and medication, but not improving. Psychologist decided to get a second opinion from a psychiatrist. Went through some tests and the initial review session. Psychiatrist came back with the ADHD / with diagnosis and secondary OCD and GAD. We included Adderall to the treatment and started to see real progress.

The thing is, we looked back at my childhood and this just reinforced the ADHD / with diagnosis. Also, I did not suspect ADHD prior to the diagnosis. So there wasn't anything to sway my doctor's diagnosis.

Get another opinion, but now make sure you answer honestly. You have biases now that you have knowledge on ADHD.

Good luck and let us know what you decide to do.

People who know me on this board usually hear me say, "trust your doctor". I support Dr’s because they are the backbone of mental health. I give weight to their authority but that authority comes with a price, and that price is to be knowledgeable and responsible in your field. There is no excuse to do otherwise and if you can’t do it, find another job. I can't express how much mistrust and pain Dr.'s can cause when they misdiagnosis a mental disorder
I have been a social worker/Counselor for 15 years and with every year I am more and more distrusting of Psychiatrists. Try finding one that hasnt traveled on the Pharmaceutical Industry's dime.
I am certainly NOT saying that all psychiatrists are bad, but all most of them do now is determine meds. If no meds are needed, there's no work for them. I think that most are inclined to think, "Oh, this person is referred to me for medication evaluation, so there must be a need for medication." And rather than start with an open mind and do a thorough diagnosis, they start with reading someone else's thoughts on this person, maybe fill out a check list or two and decide "what" medication rather than "if" medication. Again, not to demonize all psychiatrists, but there are often reasons for them to be particularly loyal to one pharmaceurical company or another. I work with primarily young children and adolescents and I have been absolutely blown away by the "cocktails" I see these children on. Granted, I work with some really damaged kids, but I fear for our future as a culture when these children are some day running the country....


That being said, I chose instead to go to a Clinical Nurse who is able to prescribe meds . I have been seeing a very good psychologist for over a year now. We have been working with a diagnosis of ADD with moderate depression. I have been on Paxil, 40 mg for about a year and a half and concerta, 27mg for about 3 months. As I still have symptoms, and knowing how I feel about Psychiatry, my psychologist referred me to her (C.N) Cant say I am any more impressed. :faint:

After one meeting with her, with no notes from my psychologist, she is leaning toward a diagnosis of BiPolar. Its not that I am not open to this possibility, it just never occured to me. When she asked me how often I "cycled" between my aggitation and not aggitation I told her it was purely situational as I stay aggitated at work and quite calm outside that environment. She informed me that this was still "cycling". She told me that my disorganization, inattentiveness and impulsiveness are indicators of my "cycling" as well.


I have been treated for depresssion a few times in my life, each time after a major relationship break up (or divorce) and have taken myself off the meds as soon as I feel the crisis is adverted. Obviously now I have been depressed again (starting about a year and a half ago) This time I can give all sorts fo situational reasons for it ie, several close friends/relatives dying in a short period of time, feelings of inadequacy as a mother (largely due to my inability to balance a check book or even deal with my financial situation), being in a horrible job that I am incredibly unsuited for (not by choice) as it requires far more organization than I am capable. And just a dire outlook on what my sons future will be like in this country if it gets any more screwed up....:(


I havent spoken to my psychologist about this yet, as this only happened this morning. She has never suggested Bipolar and she is a diagnostic doc as well. I do not have grandiose thinking, ever. It has never occured to me nor has she mentioned that I seem to "cycle" in my mood/affect, except that I am more or less aggitated and more or less depressed, often at the same time. This C.N. says that my anxiety/aggitation are considered mania. Any thoughts? Or is this too little info to go on??:confused:

I forgot to add that this Clinical Nurse totally ignored the ADD as a diagnosis and when I told her I get aggitated sometimes on the Concerta, she smiled and sai "thats because its not working for you" despite the fact that it really seemed to clear my cobwebs for about the first month. Feel free to read my past postings if anyone in interested in responding, they go further in to my ADD symptoms. Id appreciate any input. Thank you!

I appreciate the comments that McTavish23 made about physicians and kickbacks.

My ADD was diagnosed by a psychiatrist who has been treating me for 20+ years. I have also had psychotherapy, but without meds I might still be agoraphobic.

I once had a nonmedical therapist in community mental health read me the riot act because I called him and told him I was agoraphobic and thus could not make my appointment. I realize cmh centers are overworked and pay little, but I don't believe it justifies verbal abuse.

I know there are some quack physicians--including psychiatrists. But I guess I'm just naive enough to believe some physicians care about their patients and ethics--as well as money.

Respectfully,
DBR

There are good and bad practitioners of everything.

One of the things that has helped me the most was the 3 days of aptitude testing I underwent in Chicago, right after my "MBD" dx.

What it said in a nut shell was that I would excell at either becoming a teacher or a clinical psychologist.

I was like...omg.... "What if I was a substitute teacher and had a classroom full of kids like me and my friends?"

It's a noble and indespensible profession, I just don't have the patience.

Since I had just graduated from undergard with absolutely no psych classes, I went to work at a residential treatment center/psychiatric hospital/working ranch for severely disturbed children and adolescents.

I ended up teaching a GED class to some young adult schizophrenics, a few of whom were actually older than me.

I also started graduate classes down there and then transferred to the shcool where I received my M.A. in Clinical Psych.

When we moved to Mn over 20 years ago, it was the last state in the US where you could become a licensed psychogist with an MA.

I guess my point is if you can find your "niche" as a person with ADHD, it helps in making the career more enjoyable.

Where I work we have both psychiatrists and clinical nurse specialists. It really comes down to one of personality for me when I make referrals.

For example, who would be the best choice for seeing this kid and their family. Because I'm right down the hall, it's much easier to communicate the concerns.

It still boils down to more of an "art than a science." It's also true that "good therapist's are born, not educated."

5 minutes.....5...it boggles the mind.

Introduction exchange of pleasantries. - 1 minute

Why are you here/describe your problem - Here it gets interesting. Barkley said that the first thing you should do is a clinical interview, with the individual and people that know them well. Dopenuts went alone. The Doc should be extra cautious here now because we know that ADHD people don't have a good sense of their own problems, especially adults with ADHD. No one can confirm or deny what he states. How much time did he spend here? He should have spent a good deal of time but I'd guess - 2 minutes.

Telling Dopenuts that he didn't have ADHD and all the other mumbo jumbo - 1 minute.

We are now left doing/going over the checklist like the Conners in a mad dash in the final minute...he gets the boot out the door, with the Dr. yelling, "don't call us, we will call you".

I could see this as a spoof on the medical profession, say Saturday night life.


Probably the best criticism of the 5 minute interview/ diagnosis are the personal accounts on this thread. We have people who were aimless for a decade...heck more then a quarter century because it wasn't done right. There is a heavy weight on Dr.’s shoulders.

Final thought here, is that those blasted Antipsych's always use the personal story of their neighbour whose kid went to the Dr.'s and got a diagnosis in 5 minutes...and you know, a lot of people can relate because it happened a lot say 5-10 years ago. Apparently it still happens occasionally. Anyways...as the story always goes, this child was perfectly well adjusted and then his brain turns upside down after he takes medication.

This is why ultimately best practice no longer allows this. There were just too many false negatives and false positives. The field was looking silly....and please don't tell me that we are going to keep things the way they are (circa 1994) until 2015 when the next revision of the DSM4 is due. This is just plain wrong as has been easily refuted on this thread.

Scuro, the only problem I'm seeing in your reasoning, which is correct, is reliance on Barkley's work regarding ADHD. The thing is, he's not doing an ADHD diagnosis. He's doing a general diagnostic interview. He doesn't play by Barkley's rules. Chances are he does do a clinical interview; likely a structured one, if he learned his trade in the last 10 years. We're also fixating on this 5 minutes deal, I guess it is in the title, but...

5 minutes is the time the physician took to rule out ADHD. And it's probably not really exactly 5 minutes. The chance is that the doctor didn't do that in literally 5 minutes. Even if he did, he did it after having reviewed a referal. We don't know what that referal had. It came from a GP, so we know it likely had that GP's observations and the notes from what dopenuts told the GP. So now we have all the symptoms dopenuts reported to his GP, which was likely reviewed for a few minutes before the session even began.

Dopenuts comes in, and the referal says "suspect ADHD" from the GP. That's possible. But this is a psychiatrist. He's probably not up to date on US ADHD research, but that's ok, because he's looking at an adult. All he needs to rule out ADHD is the fact that to date there is no history. Even dopenuts has said that he was looking more to find out what wasn't there.

Without any hyperactivity, impulsivity, or marked impairment from inattention in dopenuts case history, that's all it takes, ADHD is out. It requires a history since before age 7 years. If he made high scores in school, no teachers ever complained, he's never had a problem with it, and if the doctor knows that (and the doctor probably got that information in the first interview, which the pdoc read in the referal papers), then ADHD is out.

I'm not saying that a 5 minute diagnosis is a good thing. It's clinically irresponsible. But if I've been looking at a referal paper that says on it "patient suspects ADHD; reports inattention, anxiety" and then I look at a history of this patient and it doesn't show any impulsivity, and hyperactivity, anything like this, and no complaints in the past, ADHD should be fairly easy to rule out because this looks like something that's developed, not that existed since early childhood.

I've said it a couple times before, might as well say it again: we don't know what the doctor had at his disposal to look at before the meeting; we don't know what the doctor asked during the meeting; we don't know what the referal paper said or if there was a history involved...criticizing this doctor isn't worth the time because we don't have the information to do it. For all we know, he went by the book and ruled out ADHD legitimately...and it's not that hard.

...
I have been treated for depression a few times in my life, each time after a major relationship break up (or divorce) and have taken myself off the meds as soon as I feel the crisis is adverted. Obviously now I have been depressed again (starting about a year and a half ago) This time I can give all sorts fo situational reasons for it ...My parents first took me for tests at age 2 because I cried all the time. By ages 4 - 6 I was consciously rerunning negative experiences over and over again in my mind. At 17 I went for counseling, but stopped after 1 visit. Several times in the next quarter century I sought help because I was depressed, and always I had reasons.
Until last year.
I went to a psychologist and told her that I was depressed, and currently the reason was such-and-such, but explained that the reason was irrelevant, because if it wasn't that, it would be something else about which I was depressed.

Similarly (or conversely), my lack of social skills was going to end up with job termination. Somehow I stumbled upon an online ADHD test, and there I recognized all of the behaviors that had caused me no end of social difficulties since I was 3 and announced to the post office that my father was at home having a bowel movement. The test also outlined the behaviors for which I was about to be fired.
I don't recall the moment of sharing this with my therapist, probably because I had to change health care providers at that time because of a change in my employer's insurance carrier.

But generally speaking, whether it's for a mental illness, or some other organ of the body, it really helps to have done your homework and to be able to bring at least an educated guess about a specific diagnosis to the health care provider. Even if they point out to you the reasons it can't be xyz disease, it can be a good starting place.

But generally speaking, whether it's for a mental illness, or some other organ of the body, it really helps to have done your homework and to be able to bring at least an educated guess about a specific diagnosis to the health care provider. Even if they point out to you the reasons it can't be xyz disease, it can be a good starting place.

I think that's what really bothers me. I have been doing my research for a few years now, and was quite sure of my diagnosis. After fighting it for awhile, I finally conceded to try meds. Now I feel like I was thrown a curve ball. I felt like a square peg being squeezed into a round hole. I just cannot see myself as "cycling" in any way that could be attributed to BiPolar. I am usually pretty aggitated at work, a job I cannot stand and cannot take any pride in and I stop being aggitated outside that environment. And that is what she calls "cycling" Maybe Lithium sales are down.....
Thanks for your input!

Jenjor, I was just reading in Women with Attention Deficit Disorder by Sari Solden that one of the differentiations between bi polar and ADHD is that bi polar has a more internal driven quality to it, while ADHD mood swings are very connected to the situation. ADHD is emotionally reactive right -- I'd definately be questioning her thinking and want another opinion.

Scattered

Bipolar mood swings are episodic. ADHD is 24/7.

One idea worth considering is a medication journal. Tracking how you felt throughout the days & weeks can be a powerful persuader.

When you get right down to it, most docs go by what you tell them regarding the effects of the meds on you.

I was able to show my doc how, out of 39 days in a row, I had 22 bad days and 17 good ones.

I then took 6 random clerical errors I'd made and plugged them into the 39 day total, and all of them fell on bad days.

Ultimately, docs look for how the bipolar meds impact you and your moods.

As both Andi and I've posted before, there is a research derived "one way comorbidity" between bipolar & ADHD.
(Those data are in the bipolar section somewhere).

Good luck.

Keith, I can now pretty well buy what you said in your last post.

Your comment that, "He's probably not up to date on US ADHD research, but that's ok, because he's looking at an adult", caught my eye. That is one issue of Barkley's recommended adjustments for the criteria for the DSM5 and are also ideas this Dr. should have been familiar with. If he were, there may have been a different outcome.


Barkley was on the committee to form the ADHD diagnostic criteria for DSM4. Here he is commenting on recommended adjustments.


"Another critical issue deserving consideration is how well the diagnostic thresholds set for the two symptom lists apply to age groups outside of those used in the field trial (ages 4–16 years, chiefly). This concern arises out of the well-known findings that the behavioral items comprising these lists, particularly those for hyperactivity, decline significantly with age (DuPaul et al., 1998; Hart et al., 1996). Applying the same threshold across such a declining developmental slope could produce a situation where a larger percentage of young preschool aged-children (ages 2–3 years) would be inappropriately diagnosed as ADHD (false positives), whereas a smaller than expected percentage of adults would meet the criteria (false negatives). Support of just such a problem with using these criteria for adults was found in a study (Murphy & Barkley, 1996a) collecting norms for DSM-IV item lists on a large sample of adults, ages 17 to 84 years. The threshold needed to place an individual at the 93rd percentile for that person’s age group declined to four of nine inattention items and five of nine hyperactive–impulsive items for ages 17 to 29 years, then to four of nine on each list for the 30- to 49-year age group, then to three of nine on each list for those 50 years and older. Studies of the utility of the diagnostic thresholds to preschool children younger than 4 years remain to be done. Until then, it seems prudent to utilize the recommended symptom list thresholds only for children ages 4 to 16 years.

The issue of selecting symptom cutoff scores raises a related conceptual problem for ADHD as well. Is ADHD a static psychopathology, the symptoms of which remain essentially the same regardless of age? Or is it a developmental disorder (delay in rate)? In the latter case it must always be determined by comparison to same-age peers. While the DSM criteria imply that ADHD is a developmental disorder (symptoms must be developmentally inappropriate), it also treats the disorder as a relatively static category by using fixed symptom cutoff scores across all age groups. Available research indicates that ADHD is most likely a dimensional disorder (Levy & Hay, 2001), representing the extreme of or delay in a normal trait(s), and so is akin to other developmental disorders, such as mental retardation. If so, then like all developmental disorders, ADHD reflects a delay in the rate at which a normal trait is developing, not an absolute loss of function, failure to develop, or pathological state. It needs to be diagnosed as a developmentally relative deficit, say for instance the 93rd or 98th percentile in severity of symptoms for age (DuPaul et al., 1999).

This notion of changing symptom thresholds with age raises another critical issue for developing diagnostic criteria for ADHD, and this is the appropriateness of the content of the item set for different developmental periods. Inspection of the item lists suggests that the items for inattention may have a wider developmental applicability across school-age ranges of childhood and even into adolescence and young adulthood. Those for hyperactive-impulsive behavior, in contrast, seem much more applicable to young children and less appropriate or not at all to older teens and adults. Recall from above (Hart et al., 1996) that the symptoms of inattention remain stable across middle childhood into early adolescence, whereas those for hyperactive–impulsive behavior decline significantly over this same course. Although this may represent a true developmental decline in the severity of the latter symptoms, and possibly in the severity and prevalence of ADHD itself, it could also represent an illusory developmental trend. That is, it might be an artifact of using more preschool focused items for hyperactivity and more school age focused items for inattention.

An analogy using mental retardation may be instructive. Consider the following items that might be chosen to assess developmental level in preschool-aged children: being toilet-trained, recognizing colors, counting to 10, repeating 5 digits, buttoning snaps on clothing, recognizing simple geometric shapes, and using a vocabulary repertoire of at least 50 words. Evaluating whether or not a child is able to do these things may prove to be very useful in distinguishing mental deficiency in preschoolers. However, if one continued to use this same item set to assess children with mental deficiency as they grew older, one would find a decline in the severity of the retardation in such children as progressively more items were achieved with age. One would also find that the prevalence of retardation would decline markedly with age as many formerly delayed children “outgrew” these problems. But we know this would be illusory because mental retardation represents a developmentally relative deficit in the achievement of mental and adaptive milestones.

Returning to the diagnosis of ADHD, if the same developmentally restricted item sets are applied throughout development with no attempt to adjust either the thresholds or, more importantly, the types of items developmentally appropriate for different periods, we might see the same results as with the analogy to mental retardation shown here. Similar results are found in ADHD (see below) giving one pause before one interpreting the observed decline in symptom severity (and even the observed decline in apparent prevalence!) as being accurate. As it now stands, ADHD is being defined mainly by one of its earliest developmental manifestations (hyperactivity) and one of its later (school-age) yet secondary sequelae (goal-directed persistence) and only minimally by its central features (inhibition and executive functioning).

Also of concern is the absence of any requirement in the DSM for the symptoms to be corroborated by someone that has known the patient well, such as a parent, sibling, long-time friend, or partner. Most likely, this arises from the focus on children throughout much of the history of the ADHD diagnostic category. Children routinely come to professionals with someone who knows them well (parents). But, in the case of adults who are self-referred to professionals, this oversight could prove potentially problematic. For instance, available evidence suggests that ADHD children (Henry, Moffitt, Caspi, Langley, & Silva, 1994) and teens significantly under-report the severity of their symptoms relative to the reports of parents (Edwards, Barkley, Laneri, & Metevia, 2001; Fischer et al., 1993b; Gittelman & Mannuzza, 1986; Romano, Tremblay, Vitaro, Zoccolillo, & Pagani, 2001). If this occurs in adults having ADHD as well, it would mean that self-referred patients might under-estimate the severity of their disorder resulting in a sizable number of false negative decisions being made by clinicians. There is good reason that self-awareness might be limited by this disorder. Neuropsychological research indicates that self-awareness is relatively localized to the prefrontal lobes with disorders affecting this region, such as Alzheimer’s disease, markedly reducing self-awareness (Fuster, 1997; Stuss & Benson, 1986). As evidence reviewed below suggests, under-activity and under-development in these same regions of the brain are likely to be involved in ADHD and so the disorder ought to restrict self-awareness".

http://www.continuingedcourses.net/active/courses/course003.php

"

Scuro, what I meant to imply in that sentence was not that ADHD research doesn't involve adults; it does. But current ADHD research is not adult-centric. It is still considered a disorder of childhood. I suppose I mispoke, I should've said "but it's irrelevant if there is no history, because he's an adult." Being up to date on current research will be very important in the near future, as techniques will be developed to diagnose ADHD in adults.

I'm glad we've finally hit mutual understanding.

...there is a research derived "one way comorbidity" between bipolar & ADHD.

McT, this is an issue which I hope you could shed a little light on. How do you tease out the difference, in say a child with Bipolar and say a child with ADHD+ODD/CD ...or... ADHD+ODD plus child abuse?

Second question is, if a child truly has ADHD, can they ever get BP at a later date? Your post would suggest no. Wouldn't a child with BiP and ADHD combined, display only ADHD symptoms until the BiP was expressed?

Finally, there seems to be a lot more kids getting a BiP diagnosis at a young age. Is this a trend?

Interesting post, Scuro! Especially that part about dropping the sympoms required on both lists to 4 after age 30. That makes sense with other things Barkley has said about ADHD with hyperactivity or combined types always being just that and never morphing into primarily inattentive which he considers may be an entirely different disorder. I was definately confused that as a child I was diagnosed with hyperactivity (back when it was still called that) but was recently diagnosed as primarily inattentive as an adult. Apparently that's not possible (my psychologist eventually did change it to combied type after seeing me for several months). Anyway, another interesting piece to the puzzle -- starting to see an image forming!;)

Thanks for posting this -- very interesting thread and discussion!:)
Scattered

Scattered, I believe most of the struggle, is really figuring out who you truly are....and that goes double if you have a disorder! :)

Scuro, especially if that disorder is ADHD, and as Sari Solden comments, your strengths are totally out of proportion to your weaknesses. It's hard to get a complete view of yourself when you inhabit both ends of the bell curve and hang out very little in the middle! Are you hyperactive or hypoactive; hyperfocused or spacey; responsible or irresponsible; gifted or deficit?:confused: To make matters worse I prefer things to be black or white!:faint:

Scattered

Scuro: Awesome, fascinating stuff.

Scattered: Part of the problem is putting together the pieces of us, because so many of them fall outside what is "normal." But another problem is not having all the pieces. I am convinced about this lack of self awareness thing after comparing notes with my wife.

Scattered, I believe most of the struggle, is really figuring out who you truly are....and that goes double if you have a disorder! :)Wandering back to the original topic -- this is why is seems very important to take more than a 5 minute appraisal of a person -- chances are as Uminchu said that we're already missing pieces of our own puzzle and frequently fall on opposing ends of the spectrum. It seems like real hubris to take one look at a person, sum them up and attach a label complete with treatment plan and prescription. No matter what the disorder is -- any person deserves to have their doctor take more than 5 minutes to get to know and diagnose them! Heck, if it's going to be done that way without any real time for a human connection, we'd be better off having a through evaluation by a computer program! IMHO!:soapbox:

Scattered

Sorry that happened to you.
The double checking that you do to make sure doors are locked , and that you turned off the lights or stove is different from OCD. You spaced out at that moment and need to recheck. I go thru the same thing with my shop. Not constantly but sometimes I truly not remember what I was doing at the moment i was suppose to be locking the door. Almost every time I have locked it...but theres been a few times I havent as well either. So it has been worthwhile to check again.
The doctor should have given you more time than that.....One of more important items is that you have had the same troubles thru your entire life.
As an adult, heres what was done for me.....I did have some records from when I was a kid....so those were looked at. Also spent an hour with a counselor and then refered from there to the psychirist. Within that time other factors discussed. they wanted to make sure these factors not the cause of problems. Drug or alcohol abuse. Depression in and of itself, or similar type things. It would seem to me that an hour would be the very minimum amount of time for a reasonable discussion. Glad you joined the list, and read some of our posts and see if you can relate. Then it might help you to put into words the difficulties that you are having and then go for another appt, preferably with another doctor.