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  #46  
Old 09-26-05, 12:58 PM
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Thought I'd throw my 2 cents in...

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.
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  #47  
Old 09-26-05, 01:25 PM
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Quote:
Originally Posted by scuro
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.

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??
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  #48  
Old 09-26-05, 01:29 PM
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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!
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Old 09-26-05, 02:06 PM
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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,
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  #50  
Old 09-26-05, 02:15 PM
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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."
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  #51  
Old 09-26-05, 09:22 PM
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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.
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  #52  
Old 09-26-05, 09:35 PM
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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.
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  #53  
Old 09-27-05, 02:38 AM
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Quote:
Originally Posted by Jenjor
...
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.
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  #54  
Old 09-27-05, 09:04 AM
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Quote:
Originally Posted by sosninity
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!
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  #55  
Old 09-27-05, 09:18 AM
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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.

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Old 09-27-05, 09:42 AM
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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.
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  #57  
Old 09-27-05, 04:46 PM
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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".

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Old 09-27-05, 05:04 PM
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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.
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Old 09-27-05, 05:15 PM
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Quote:
Originally Posted by mctavish23
...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?
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Old 09-27-05, 05:21 PM
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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!
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