May 20, 2010

Goal: Remember So As To Do

The last couple of weeks have been tough, but easier than the hundreds of weeks that went before in my life. I am amazed at how I am becoming aware of how impaired my working memory is. I forget shit all the time. I don't just forget stuff, but I forget shit.

All. The. Time.

Everyone gets distracted. Everyone's attention is diverted by compelling stimuli. If we weren't distracted, we would risk being hit by a car, or be seen as socially inept when someone tried to get our attention, etc.. etc...

And it is our working memory, the theoretical construct within cognitive psychology that refers to the structures and processes used for temporarily storing and manipulating information that allows us to recall that which we were initially doing, and return to it. What differentiates ADHDers and non-ADHDers is the poor quality or deficit of working memory. After a distraction has redirected their attention, ADHDers do NOT return to task, whereas non-ADHDers do return to task - e.g. the document they were writing, or the clothes they were folding, or the food they were cooking.

For example, I go downstairs with the express intent to get a pair of pliers from the tool chest. I notice some batteries on my desk. I remember that my Motorola camping walkie-talkies need new batteries. I insert them and feel good. Then I see a book on camping near where I had stored the walkie-talkies and pick it up, because I intend to read it later on. I come upstairs again with the book, excited at the thought of sitting down later outside in the sunshine and reading through it. But then I recognize a lingering suspicion within me that I've forgotten something. It takes me a minute or so to mentally retrace my steps, and actually talk to myself quietly to figure out what I'm missing: the pliers.

My wife asked me the other day to pop downstairs to grab a print-out from the printer we've networked across the house. She prints a document upstairs and the print-out appears downstairs. I went downstairs. On my way to the printer, I changed my socks quickly, as I had a hole in one of them. I then noticed my garbage can needed emptying so I quickly emptied it into a garbage bag. Then I went to the washroom. Then I thought it would be a good time to trim my goatee with my new fancy trimmer. Then I saw a T-shirt that I wanted to wear. So I returned upstairs with my nice T-shirt, feeling good, and got back to making the tea I'd started on when she'd initially asked me for the print-out.

Now that she is realizing (I believe) that my ADHD plays havoc with my working memory, she sort of smiled, and asked me gently where the print-out was. I told her (thinking quickly on my feet) that I needed my special T-shirt first so that I could go get the print-out. I'm clever that way. I skulked back downstairs and fetched the print-out.
"[...]most patients with ADHD continue to struggle with a substantial number of symptoms and a high level of impairment.

For example, adults with ADHD are thought to have deficits of working memory as exemplified by less ability to attend to, encode, and manipulate information. Such deficits in working memory may decrease the ability to filter out distractions, which contribute to further symptoms of inattention in adults with ADHD. Although less defined within ADHD, organizational difficulties and procrastination also appear common.*"
My new motto and new mantra is something that Dr. Russell Barkley said in a presentation - that a very important goal for ADHDers is to "remember so as to do".

So now when I forget to grab that print-out or grab my T-shirt, or close the garage door, or forget to close the kitchen cupboard, or forget my security pass for work, I am kinder to myself than I've ever been. Normally I have chastised myself and told myself that I'm 'such an idiot', and when appropriate apologize and apologize to whomever is blaming me for leaving something undone.

I now remind myself that I am working hard at developing new habits and coping skills, and learning more and more of the ADHD limitations that I can work to overcome - including with the help of medication. And I remind myself that my new goal is to more effectively "remember so as to do".

Cheers,

Mungo

*Seidman LJ, Biederman J, Faraone SV, Weber W, Ouellette C. Toward defining a neuropsychology of attention deficit-hyperactivity disorder: performance of children and adolescents from a large clinically referred sample. J Consult Clin Psychol. 1997;65(1):150-160.


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May 14, 2010

Video: Dr. Russell A. Barkley - Management of ADHD

Dr. Russell Barkley is a great educator and researcher. If you have an hour and 20 minutes, watch this. Or just watch it in chunks. But watch at least the first 10 minutes... You will learn a lot about ADHD.
"Russell Barkley, Ph.D., discusses the recent advancements in understanding the nature and subtyping of ADHD as well as recent discoveries in what might cause the disorder and medications that might help treat ADHD. Series: M.I.N.D. Institute Lecture Series on Neurodevelopmental Disorders"

Cheers,

Mungo

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Managing My Physical & Mental Health

If I am to find a way to manage my mental health - i.e. find a way to cope with and treat ADHD, I think it is important to have a positive attitude. Having a positive attitude comes with good self-esteem. Years of failures and struggles and frustration in part due to ADHD will lead to low self-esteem.

For many years now - probably since I ditched my bicycle and learned to drive a 4-cylinder internal combustion engine powered automobile (A.K.A. a car), my weight has slowly crept up. I used to be a skinny kid. Then in high school I was a wiry kid. And in the first couple of years of university I was a slightly muscled, thin guy. Then I worked as a butcher for a couple of years in summers and in the year I was put on probation and told to take a year off university. I worked out at a gym and ate meat each day. I remember getting to 200 pounds and was happy - bulk and great strength was required when hoisting sides of beef about a very slippery floor in the shop.

Then that weight became more tipped to the side of fat, as opposed to Herculean man-strength and Sean Conneryesque Mr. Universe tone (the fun thing about a blog is that you don't have to have it peer reviewed or authenticated by any authority).

In 2003, when I was married, I weighed about 220 lbs. My suit was ill-fitting, or at least I was ill-fitted to my suit. I had more chins than an Argentinian, United Kingdom, French, French Canadian or Portuguese toast (Chin Chin).

My Body Mass Index calculation suggested that I would no longer be overweight once I reduced my weight to 184 lbs. Yeah right. That seemed a little outlandish. In November I decided to stop drinking for good. Not that I was reeling drunk all the time, but I was certainly having a few too many drinks on the weekends, and this helped me forget (a) what had happened previously and (b) what was to happen to me - and thus was a nice temporary relief. So I stopped. No twitching, or spasms or shrieks of agony. Just stopped. And I think for all the lack of those calories I began to shrink.

Around the same time I decided to stop drinking the 6 to 10 cans of full calorie Coke that I was drinking to (in retrospect) self-medicate my ADHD and help me focus. I switched to Diet Pepsi. Diet Coke tastes like barely-fizzy diluted cat piss. Diet Pepsi is nicer. And so I shrank more. Then I decided to replace each breakfast with 2% milk with Slim-Fast powder mix - which is really just milk powder, sugar and some Aspartame - and vitamins. Then I stopped snacking during the day.

The longer I've been on this calorie-reduced diet, the less I get urges to binge on food.

So here is my progress since then (graph below) - I want to go down to 180 lbs and stop there. I think I would like my upper range to be 185 lbs.



My point of this rambling post? Well, I feel proud of having done this. I'm not doing this for beauty reasons (despite my Sean Conneryesque appearance), but because I'm nearly 40 and I don't want to be putting extra weight on my heart and joints. I want to be a positive example to my little boy. And I want to be around for a long time.

And doing something I take pride in, makes me feel proud. And feeling proud increases my self-esteem.

Cheers,

Mungo

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Another Step: Blood & Cardiac Function Testing Needed Prior to Medication

I'm writing this and other recent posts in order to give you a sense of what is involved in getting a diagnosis of ADHD, and what is involved in getting treatment, and the steps in between. That is, what has and will be involved for me. Not everyone has to go through so much, and some may have a more tedious and lengthy experience. And of course, I am not just talking about pharmaceutical treatments, but changes involving and that result from the very fact of receiving a diagnosis, and everything that follows from that (including medication, but also self-help, counseling, lifestyle changes, implemented tips and techniques etc...).

So this morning I left early so that I could make it to a local hospital where a clinic is located so I could get blood-work and an ECG (electrocardiogram). These were needed prior to being put on Strattera. The results will be shipped to my family physician, and I have an appointment booked with him in a couple of weeks to followup. Hopefully (and I expect) everything will turn out well - that my blood will be found to be the purest and most balanced in every respect that the clinic has ever seen and that it will be written about in medical journals and texts for decades hence, and they will need to ask for a release form (with mentions of plush royalties payable to this author) to feature my ECG printout in a world standard cardiac textbook on what a 'perfect' ECG should resemble.

These tests are necessary because Strattera should be prescribed 'with caution' to people with a preexisting condition of tachycardia, and to people with preexisting impaired hepatic function. Since stopping any alcohol intake since November of last year (seemed a wise thing to do, given that it probably didn't help me focus all that well), and since I don't smoke (never have) or inhale solvents from a plastic bag (honestly, never have) in the alley behind my house, I'm assuming I have a lovely, ripe, healthy, delicious and chortling liver. I believe that my heart beats with the regularity and the robustness of a fine - and extremely expensive - Swiss Chronograph.

Since I could go to any clinic to get this testing done, I did a quick web search yesterday, and called a clinic that appeared (on Google Maps) to be along my route to work. They answered, and said that no appointment was necessary - just to come in with my Provincial Health Card (I live in Ontario, Canada) and with the requisition form that my doctor gave to me.

I arrived at the hospital 10 minutes before the clinic opened. I was the first in line, and the policy there was first in, first out. 15 minutes after entering the clinic, I was pressing the elevator button to return to the parking lot. I made it to work a half hour early, missing only a few milliliters of the red stuff, sporting a cute band-aid on my left arm, and with a hearty (no pun intended) kick in my step.

Feelin' good.

Cheers,

Mungo

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May 13, 2010

Another Step: Appointment with Family Physician, then Blood Tests, etc...

Well I went to my doctor's office this morning and it turns out that prior to getting the Strattera prescription, I must have a battery of blood tests, and an ECG or cardiac test. Apparently normal routine stuff. He took my blood pressure and said that it was 120 over 80. Which is good.


My weight is down 25 pounds or thereabouts since November because I deliberately decided to lose my beer gut etc... by stopping drinking beer, and sugared (actually high-fructose corn syrup sweetened) cans of Coke. He was pleased with that too.


Anyway, to expedite this whole matter, I've made an appointment tomorrow morning at 8:00 to go to a clinic on the way to my work to quickly get my tests done.


The sooner the better, because then the sooner I can get on the medication and hopefully regain some focus. I have another appointment with my family physician in 3 weeks, and the ECG tests etc... take about 2 weeks to come back, so I'm working within a time line here. If I were rich, I'd have a personal physician named Horace and he'd get this done faster.


Hope everyone is having a fine evening!

Cheers,

Mungo

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May 12, 2010

About Atomoxetine - ATX Strattera®

The Canadian ADHD Resource Alliance has a huge amount of resources on their website. I highly recommend you browse on by...

Here is a section in their Medications for ADHD about Strattera, the medication I will be put on this week (hopefully).

I have read about all sorts of less-than-positive experiences on Strattera, and had some very helpful e-mails and comments to urge me to research it. I'm going to see how it goes - but will definitely be my own advocate in the event that I am badly affected by side effects, or if it simply doesn't do anything for me. Thank you everyone for your interest and input - I really appreciate it!
"Atomoxetine - ATX
Strattera®

Atomoxetine is a specific noradrenaline (a.k.a. norepinephrine) reuptake inhibitor and comes in seven doses (10, 18, 25, 40, 60, 80 and 100 mg). ATX is not classified amongst the psychostimulants and it is not a controlled substance.

The major strengths of ATX are that: a) it provides continuous coverage including the late evening and early morning periods; b) it is indicated by Health Canada in all ADHD patients across the lifespan; c) it may be particularly useful for ADHD patients who have tic spectrum disorders or comorbid anxiety, resistance and/or side effects to stimulant medications, and there is little problems with worsening of sleep; d) at this time, there appears to be no substance abuse or diversion potential; e) samples may be available to establish efficacy before a commitment is made though it is covered by the majority of private insurance carriers; f) it may be covered by some provincial special access programs, and g) a new indication may be emerging for its use in enuresis.

The onset of action is slower than stimulants as they act on different neurotransmitters and the maximum treatment effect may not be reached for two months. The clinical changes are gradual. It would not be suitable in cases where there is an urgency to obtain a rapid onset of action. The dose is calibrated to the weight of the patient (see relevant tables for initiation, titration and maximum doses). There appears to be no increased benefit past 1.4 mg/kg/day though there may be some improvement of ODD after 1.8 mg/kg/day.

The American Academy of Child and Adolescent Psychiatry has stated that the doses could go as high as 2.2 mg/kg/day but this is much higher than the Canadian standard. If higher doses are contemplated, a referral to an ADHD specialist should be made. If the doses should exceed one pill a day, the cost of the medication is doubled. The capsules should never be opened as it may cause irritation of the gastric lining. The medication's safety profile has been established including the same risk factors related to cardiovascular conduction irregularity similar to those of stimulant drugs. Two cases of reversible alteration in hepatic enzyme are noted. No special monitoring protocol is required (i.e., blood tests) but patients should be advised of the clinical symptoms of hepatic dysfunction. Poor metabolizers (i.e., 7% Caucasians and 2% African-Americans) are unlikely to have toxic effects given the slow titration schedule.

Measurements of blood levels are not required. There have been rare reports of increase in suicidal ideation; one suicide attempt (overdose) was identified; no completed suicides occurred. Clinicians need to carefully monitor suicidal ideation, especially in the early phases of treatment not unlike many antidepressant medications. The clinical efficacy was the same as stimulants in patients who were treatment naive. ATX can be combined with stimulants to augment the effect in the case that the clinician feels the patient has not achieved an adequate response, but in these circumstances, a referral to an ADHD specialist maybe indicated."

Cheers,

Mungo

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May 11, 2010

Thank You All for Visiting my ADHD Blog!

Since I started this blog less than a month and a half ago 2,620 readers have dropped by to read what I've written about my Adult ADHD assessment, diagnosis and treatment experiences. 485 of you have returned to read my entries week after week. Amazing.

I've had visitors from the following countries (in descending order of visits):
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Because of the number of international visitors, I've decided to include a translation tool - have a look on the right side of this blog. Now you can translate this blog into most major world languages.

Welcome everybody, hope you are learning as much as I have been learning, and are enjoying my posts about Adult Attention Deficit Hyperactivity Disorder.

Cheers,

Mungo

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Adult ADHD Books & Making a Medical Appointment

I have been reading several books over the last week to learn more about ADHD. One suggestion that the psychiatrist made was for me to learn about mindfulness. Though I'm not suffering from depression, the principles in "The Mindful Way through Depression" can easily relate to anxiety disorders and specifically to Attention Deficit Hyperactivity Disorder. I am finding it to be a very interesting and intelligent read. I highly recommend it.

Being as I am tending towards distraction, I am also jumping back and forth between that book, and "Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood Through Adulthood", "Driven from Distraction: Getting the Most out of Life with Attention Deficit Disorder", and "The Disorganized Mind: Coaching Your ADHD Brain to Take Control of Your Time, Tasks, and Talents" - all of which I highly recommend.

Yesterday afternoon I did a bit of juggling.

The ADHD clinic was to have transcribed my treatment plan and faxed it through to my family physician. I found out on the weekend from a family member that my family physician was soon to embark on a vacation... so I wanted to get the prescription for Strattera before he flew off.

But when I called his office, they said they had not yet received anything from the clinic. So I made an appointment for later this week in the morning, and then phoned the clinic back, explained my predicament. They said they'd get it all faxed through by the time of my appointment. I will follow up later this afternoon to be sure.

I felt good after doing that. I felt like I was taking control of my treatment plan. Doesn't sound like the biggest deal on earth what I did, but when juggling a busy day at work - along with the rest of life - sometimes mundane administrative tasks like this can seem almost unachievable, especially before even embarking on it. Ah, ADHD.

On another bright note, I am finding that chunking my daily schedule out into discrete patterns of time for more mundane items like - take shower - leave for work - create resourcing document - prepare for management meeting - review daily task list - evaluate daily task list before leaving work - leave work - take baby bottle from fridge to warm up etc... has been very useful to me. It is helping me work on developing a time sense. This is a topic I will be covering shortly - something ADHDers with their poor working memory have to work on.

Cheers,

Mungo

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May 5, 2010

It's Official: Adult ADHD Combined Subtype

Yesterday I had the final session of my Adult ADHD assessment at a specialized ADHD clinic. I met with a new psychiatrist and the psychometrist who had administered and analyzed a series of psychometric measures, and who had interviewed me in the first session.

We all sat down, and they said they had reviewed the notes from the original doctor, the psychometric results and the historical and interview information. I was watching carefully, waiting to hear the 'verdict', almost afraid to hear that they didn't think I had ADHD, but in fact was simply a nervous hypochondriac (!). But the psychiatrist nodded affirmatively as he finished his statement, and then leaned his notes towards me where it was written "ADHD-C". He said that the diagnosis was ADHD, and that the subtype was the combined type. He said the subtype was more of interest for the diagnostic process and less important to me, but suffice it to say, I have ADHD. The psychometrist commended me on the volume of historical records I had brought to bear, and then said that all the test results indicated that I had 'all the hallmarks' of the diagnosis.

So I asked a few questions about the diagnosis. They asked me if I was intending to pursue counseling beyond their office, and I said yes. They asked me if I had self-harm or suicidal thoughts. I said no (I guess they need to ask that as it relates to medication). Then the psychiatrist presented his conclusion that medication would be appropriate. He said given my age, my history, and my comorbidity of anxiety, the best course of medication would not be one of the stimulants (Concerta, Ritalin XR, etc...) but rather a norepinephrine reuptake inhibitor (NRI) called Strattera. I didn't know much about NRIs so I asked a lot of questions. I think he was getting a little irritated with me at one point for trying to understand the benefits of NRIs over stimulants, but I steeled myself thinking that I was owed at least a good explanation (noting of course my tendency to perseverate!). In the end I was convinced it was a better choice.

Adults are better candidates for NRIs because while the results may take up to 3 or 4 weeks to kick in, they have better self-control and don't need an immediate fix - they've developed sophisticated coping mechanisms for the disruptive and painful symptoms of ADHD. Instead of two or more doses a day of stimulants - which may end up causing insomnia, NRIs build up and provide 24 hr relief that does not affect sleep. Children on the other hand often need to demonstrate a quick response to medication because they have a lot less self-control over their symptoms, for all of the obvious reasons, and so stimulants are a better candidate for them. Also, because of my anxiety (which stimulants can increase), NRIs (which do not increase anxiety) are a better choice.

A quick note about anxiety etc... You should imagine a Venn diagram with circles for anxiety, depression and ADHD symptoms. Adults generally (something like >85% of adults) suffer from comorbidities that have arisen due to or in concert with ADHD symptoms. Being able to tease out which is which can be important in some cases, but in my case, it is enough to help me be more functional, and less affected by ADHD and anxiety symptoms at the same time - which NRIs can address. I was told that it would be a good idea to lay off the 6 or more caffeinated drinks I have daily, as that would increase my anxiety. I figured that it would help focus me, but I have decided only decaffeinated cola for me now, and I will try to limit my caffeine intake to maybe a single cup of tea or coffee in the morning. I am to take the NRI in the morning along with my SSRI antidepressant (Celexa). It may be that in short order I will be able to come off the SSRI, as I am not exhibiting signs of depression currently - both shown by their examination, but also by my self-report.

They are going to pass the consultation notes on to my family physician who will then prescribe me the Strattera. This could take up to 2 weeks.

I am relieved. I was thinking that there was my life before yesterday and then there is my life from today onwards - ADHD never goes away. One cannot be cured of ADHD. But many report incredible changes to their lives post diagnosis and upon the start of a medication regime - and this gives me a great deal of hope. I am weary, and I am tired, but I know that I have headed down the right path. I wish I had known about this years, or even decades ago, but so it goes. I'm here today, and have only the future to fulfill. I am doing this for me. I am doing this for my wife. I am doing this for my lovely 16 month old baby boy. I am doing this for the person I was, who I am in a way reaching back into time and taking care of.

Onwards and upwards,

Mungo

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May 4, 2010

One... Two... Three! (of a Series of Sessions of my Adult ADHD Assessment)

Today I have an appointment at the ADHD clinic - my third session of my Adult ADHD assessment. It will be a meeting with a psychiatrist and I believe with a psychometrist. I don't have details of the agenda, but I expect they will be drilling down a bit more on a possible diagnosis (to sort out comorbidities, and to clarify diagnostic subtypes), all towards a goal of presenting a treatment plan.

Or they may simply pronounce me irretrievably mad, and suggest I be locked away in a nice room with soft walls. Irretrievably mad - although not an official DSM-IV diagnosis - is sometimes an appropriate label for how I think of myself, at least in darker times.

But I am certain they will be kinder with me than I have been with me. They have all been nice up until now, anyhow.

I figure if the treatment plan includes medication, there will need to be a few meetings to follow to review the dosage, type and regime.

Hope everyone is having a fine day. I'm guessing I will be worn out by the end of the day, so will follow up shortly with details.

Cheers,

Mungo

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May 2, 2010

My Recent Visit to the Clinical Psychologist - 45 Minutes of Hmm...

Last Wednesday afternoon, I met with the clinical psychologist who is part of the team of specialists tasked to conducting my Adult ADHD assessment.



I immediately liked him, he seemed very experienced and very curious about me. He stated that he had not yet reviewed my file. Bruno Bettelheim said that is was always best for a clinician to go into a first meeting without ever having read the case notes of someone else prior to a first meeting, in order to avoid unconscious expressed opinions (found even in the most fact-driven notes). Perhaps that's the reason he didn't read mine.



We spoke as though we had met at a friend's house during a party. He asked a lot of questions, and I felt more and more comfortable with each question. He focused on my current life, on the last year or two, and asked about my symptoms. He asked a lot about the significant people in my life - my immediate family, but focused more on my family in which I grew up.

He said that it sounds like after all of my reading, I had diagnosed myself. I hesitated, because I didn't know how to answer that. I squirmed a bit. After all, a lay person can't diagnose themselves or anyone for that matter, in the same way that they can't conduct an official arrest or absolve someone of their sins, or certify a bridge is sound and can take road traffic. They don't have the role authority, nor have they got the relevant experience. I cannot therefore utter the performative phrase "You are diagnosed with this psychiatric condition".



I replied that having read book X, Y, and Z, after a previous therapist with experience in ADHD had suggested I pursue an assessment and after having thought about many of my behaviours (I gave many that were criteria-based to the DSM-IV diagnosis), that pursuing a diagnosis through the clinic seemed the best thing to do.

He was explicitly complimentary, and that made me feel really good. He said I was obviously very psychologically minded and very sophisticated in my thought processes. It was nice to hear what sounded like an authentic compliment of certain qualities I believe I hold. In fact by the end of the 45 minute long meeting, in which I think I spoke about 80% of the time, I was feeling really good. And calm. And sane. And confident. And OK. Which ironically made me wonder if the doctor was really getting the guy who worries so much, who forgets so much, who can't perform like he thinks he should, who is clueless and desperate for some answers. The guy who procrastinates and can't focus in meetings with more than one other person, who hops about thought processes like a lumberjack hops about on rotating logs in the strong currents of the Athabasca river.



He asked what I would like to get out of this process. I answered that I wanted to develop strong, consistent and controllable qualities of focus, follow-through, insight of chronology, and would like to overcome the behaviours and indeed self-opinions that hamper me at my work and those that hamper me in my personal life. Didn't know what else to say. "A cure" would have been disingenuous, but in the same way we all want to win the lottery and never have to worry again, I was tempted to answer "I want this crap to be cured". And I suspect he would have understood.

I was a little uncertain, as though I wasn't sure if a person with whom I had shared such secrets, would be interested in ever learning more about me. I asked him if he had any sort of feedback or a sense of me as it related to a possible diagnosis. He hedged and said that he would be speaking with the psychiatrist (who I would be meeting with next week) and reviewing my file with him and with the psychometrist I had previously engaged with.



That seemed reasonable, I thought. He gave me his business card, and told me to call him at any time if I had any questions prior to my next meeting. That was a nice expression of trust and caring, and I put the business card in my pocket.

I will be attending my next session this Tuesday, with a psychiatrist, and possibly with the psychometrist, to answer the same sort of questions I'd been posed in my first interview, but this time with the benefit of the first psychiatrist's notes on meeting with me.



Like most things that hold great interest for me, I am utterly fascinated with this process. I want it to be done already though so I can move on to the next steps. But I guess if patience is what the universe is suggesting for me, who am I to argue with the universe? After all, the universe made spitting cobras, and black holes, and arguing with the universe would seem hazardous. You never know what the universe will throw at you, you know.

Hope everyone is having a nice Sunday night, and for those ADHDers out there, I hope your journeys are progressing strongly.



Cheers,

Mungo

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April 28, 2010

Coming Soon: 2nd Session in my Adult ADHD Assessment - Clinical Psychologist

This afternoon I'm off for my second meeting at the ADHD clinic for my Adult ADHD assessment. I will be meeting with a clinical psychologist.



I am nervous, excited, distracted. Good luck with me getting the high priority work task that just landed on my desk done for tomorrow... But I have chunked it out into little pieces, so I should be good. Oiks.



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Cheers,

Mungo

April 27, 2010

New Feature: AdultADHDBooks.com

One of the essential elements in a diagnosis and subsequent treatment (and coping) plan for Adult ADHD is education. To assist with achieving this goal, I have opened an online bookstore at AdultADHDBooks.com which is now available via the navigation bar on the right side of this blog.

I have partnered with Amazon.com to offer books related to Adult Attention Deficit Hyperactivity Disorder at competitive prices. All transactions are secure and take place through Amazon.com's site.

Please browse and consider buying books at AdultADHDBooks.com.

Sincerely,

Mungo

April 26, 2010

Journal Article: Diagnostic Approaches to Adult Attention-Deficit/Hyperactivity Discord

I was reading some articles on Adult ADHD, and came across the online resource called "Primary Psychiatry". A search on Adult ADHD on this site led me to a number of very interesting articles - and I have pasted one below. This is all about the diagnostic approaches to Adult ADHD. Obviously this interests me because of my Adult ADHD assessment - and it goes into some detail about the tests and symptomatology of the disorder. It gets into some detail that some readers may not be interested in, but presents a fairly authoritative description of how they go about diagnosing Adult ADHD.

My next appointment in a couple of days - a couple of sleeps - will be with a clinical psychologist. I'm curious how this meeting will go. Is 'eagerly curious' a phrase?

They say ADHD adults are prone to thinking "That's great, but what's next?"... even when something wonderful has just occurred (like a gift or a significant conversation). BUT damn it I wish it would hurry up already.
If I may go off on a tangent for a minute: I have read that a symptom of ADHD is a certain difficulty with extracting the signal from the noise - noticing what is singularly important. The other side of that coin is the ability to pick up on a larger number of signals from the environment than other folks. ADHDers as adults sometimes learn to cope with this by becoming good at picking up many signals and using it to their advantage. ADHDers are often 'good' at finishing other peoples' sentences ('good' as in effective, but 'good' can be annoying) probably because they are perceptive enough (when interested) in reading all the subtle cues of communication to effectively tune in very clearly on a person's message.

This may be why (if you know me) I'm often finishing your sentences for you, or even cutting you off - to get to the next part. It is as though I am impatient, and thinking 'yes, yes, yes, I know what you're saying... get on with it, I want to know the next part'. Which is ironic, in that I'm often verbosely prattling on while telling a story, or drilling down into the minutia of a description - likely leading non-ADHDers to think 'yes, yes, yes, I know what you're saying... get on with it, I want to get to the next part'.
That's great. Now cut to the chase:

Diagnostic Approaches to Adult Attention-Deficit/Hyperactivity Discord

Abstract

Attention-deficit/hyperactivity disorder (ADHD) remains under-diagnosed in adults. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, ADHD symptom criteria anchor the diagnosis but require interpretation that is sensitive to symptom expression in adults. For example, hyperactive symptoms may become more subjective and hidden in adults. Inattentive symptoms may involve so-called executive functions, such as planning, multitasking, and time management. While collateral reports from significant others are helpful, often the afflicted adults can report meaningfully about their lifelong condition. In addition to symptoms of ADHD, other diagnostic indicators include specific educational, occupational, and psychosocial difficulties. A number of rating scales and diagnostic interviews are available to assist in the diagnostic process.

Introduction

While childhood attention-deficit/hyperactivity disorder (ADHD) was first recognized in the early 1900s, recognition of the disorder’s persistence into adulthood did not occur until the 1970s. Nevertheless, much is known about the persistence of the disorder into adulthood, the common presenting problems of adults with ADHD, and the manifestations of the disorder that are unique to adults. This article seeks to highlight these presenting symptoms of ADHD in order to aid clinicians in making a diagnosis of ADHD and then goes on to examine diagnostic measurements and interviews that can be used to make a diagnosis of adult ADHD.

Presenting Problems

Adults with ADHD usually describe symptoms of poor attention, lack of concentration, easy distractibility, shifting activities, day-dreaming, and forgetfulness.1 They often begin one task and then find themselves in the middle of several projects. These patients appear to have a poorly developed sense of time and are often harried and late. They lose and misplace important personal items, such as keys, as well as items from work and family projects. They usually avoid tasks that require high levels of concentration and patience, such as balancing their checkbook, filing tax returns, and helping children with homework. Projects are often put off until the last minute, at which time they may become highly motivated and able to focus. Often these patients are drawn to novel stimuli, usually at the expense of the designed object of their attention. Their boredom or intrusiveness often compromises conversations with coworkers, spouses, and children. Others may view adults with ADHD as either flighty or self-centered. Adults with ADHD usually have difficulty regulating their attention, which can lead to repeated problems as they attempt to manage affairs at work, home, and with friends.

Additionally, these patients report symptoms of impulsivity, impatience, boredom, fidgetiness, and intrusiveness.1 These symptoms are often evident in the context of social situations. Frequently, adults with ADHD have long histories of social impairment, and are often perceived as aloof or self-centered, as they easily become bored or may interrupt or make socially inappropriate comments. Others are quite gregarious and talkative, “the life of the party”—almost an adult equivalent of the “class clown.” Adults with ADHD have a sense of urgency and immediacy to their lives and have little tolerance for frustration, delay, or planning. They are easily irritated waiting in lines and often make decisions without proper consideration of alternatives. Collaboration with others may be a mutually frustrating experience. Also, adults with ADHD experience increased rates of traffic accidents, traffic violations, and license suspensions.2,3

Symptoms of overt hyperactivity may be diminished in patients who have developed compensatory strategies. Recent data support the clinical observation that symptoms of hyperactivity-impulsivity decline over time while symptoms of inattention persist in ADHD patients.4 However, these investigators note that most patients with ADHD continue to struggle with a substantial number of symptoms and a high level of impairment.

For example, adults with ADHD are thought to have deficits of working memory as exemplified by less ability to attend to, encode, and manipulate information.5 Such deficits in working memory may decrease the ability to filter out distractions, which contribute to further symptoms of inattention in adults with ADHD. Although less defined within ADHD, organizational difficulties and procrastination also appear common.

Like children with ADHD, adults with the disorder may be stubborn, demoralized, and develop low self-esteem.6,7 Relationships with family, friends, and employers are often conflictual, which may contribute to high rates of separation and divorce, as well as to the academic and occupational underachievement characteristic of these adults.8,9

Relationships and Family Life

The constant activity of an adult with ADHD can lead to family tension. Problems include difficulties with organization, setting and keeping routines, day-to-day supervision, stress tolerance, mood stability, and compliance with ADHD treatment plans. Parents come home to children who need time and attention, dinner, and help with homework, which adds to the tension. Difficulties juggling family, work, and other responsibilities highlight executive functioning deficits.

Relationships for ADHD patients can be unstable, so reports of counseling or relational difficulties can indicate an ADHD diagnosis if the underlying problems are due to one partner’s symptoms of inattention or hyperactivity. Common issues include not listening, interrupting when the spouse is speaking, or a disorganized or inattentive approach to household responsibilities. The diagnosis of ADHD alone can help considerably, enabling the couple to understand that ADHD is a condition that interferes with planning and sharing tasks. Effective treatment for one partner’s ADHD can possibly lessen or eliminate problems that a couple is experiencing.

Education

Educational or vocational performance below that which is expected (based on a patient’s intelligence and education) may provide an indication of the diagnosis of ADHD. According to evidence gleaned from self-reports and high-school transcripts in the Milwaukee Young Adult Study,10 young adults with ADHD experience significantly more grade retention, suspensions, and/or expulsions than their non-ADHD peers. The dropout rate is also higher and, on average, students with ADHD may have lower class rankings and lower grade point averages. In addition, fewer enter college. For the students with ADHD that do go to college, the graduation rate is much lower than those without ADHD.10

Occupation

Patients frequently present with occupational problems, such as difficulty finding and keeping a job and job performance below the level of competence. Questions to ask a patient about his or her history of vocational difficulties include: How often have you changed jobs? What was the reason for the job change? and has it been hard to get along with bosses?11 Adults with ADHD often have a low frustration tolerance, which can lead to issues such as high job and relationship turnover and explosive or irritable episodes.

A sense of internal restlessness in adults with ADHD can lead to a compulsive tendency to overwork or choose occupations where frequent movement is an essential component of the job, such as sales and marketing. Childhood hyperactive symptoms, such as difficulty remaining seated, running and climbing excessively, squirming and fidgeting, difficulty playing quietly, and talking excessively, are commonly manifested in adults who work two jobs, work long hours, or choose very active jobs.

Many adults with ADHD do not regulate themselves well and do not self-correct when problems arise, in part due to poor self-monitoring.12 Poor time management and difficulty completing and changing tasks are common manifestations of inattention. If possible, adults often attempt to compensate for limited organizational skills by enlisting the assistance of support staff.12

Diagnosis

ADHD can be diagnosed in adults by carefully querying for developmentally appropriate criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV),13 and attending to childhood onset of symptoms, persistence through adolescence, current presence of symptoms, and impairment. A variety of issues arise in the assessment and diagnosis of ADHD in adults. The appropriate diagnosis of ADHD in adults initially relies on accurate recall of childhood symptoms and a reliable account of current symptoms and their impact. Some clinicians have questioned the reliability of adults with ADHD to accurately report this information,14 though recently, Murphy and Schachar15 evaluated correlation symptoms between adults with ADHD and other informants and found that ADHD adults can give a true account of their symptoms.

Thus, diagnostic information is obtained from the patient and, whenever possible, from significant others, such as partners, parents, siblings, and close friends. If ancillary data are not available, information from the patient is acceptable for diagnostic and treatment purposes since, as Murphy and Schachar showed,15 adults with ADHD, like adults with other disorders, are appropriate reporters of their own condition. Careful attention should be paid to the childhood onset of symptoms, longitudinal history of the disorder, and differential diagnoses including medical, neurological, and psychosocial factors contributing to the clinical presentation. Neuropsychological testing should be used in cases in which learning disabilities are suspected, or cases in which learning problems have persisted in treated ADHD adults.16-18

A clinical interview with the patient remains the basis of the adult ADHD diagnosis. Rating scales and neuropsychological testing may help to gauge ADHD symptoms, but a structured or semistructured clinical interview enables practitioners to accurately assess all three core features of the disorder in adults: symptoms dating back to early childhood, significant impairment in at least two settings, and moderate severity ratings for at least six of nine symptoms of inattention and/or hyperactivity.19

Symptoms of inattention in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR),19 include failing to give close attention to details or making careless mistakes in schoolwork, work, or other activities; having difficulty sustaining attention in tasks or play activities; not listening when spoken to directly; not following through on instructions; and failing to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions). Other inattentive symptoms include frequently having difficulty organizing tasks and activities; avoiding, disliking, or being reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework); frequently losing things necessary for tasks or activities; being easily distracted by extraneous stimuli; and being forgetful in daily activities.19

Symptoms of hyperactivity listed in the DSM-IV-TR19 include fidgeting with hands or feet or squirming in one’s seat; leaving one’s seat in the classroom or in other situations in which remaining seated is expected; and frequently running about or climbing excessively in situations in which it is inappropriate (in adolescents or adults, this last symptom may be limited to subjective feelings of restlessness). Other hyperactive symptoms include having difficulty playing or engaging in leisure activities quietly; being “on the go” or acting as if “driven by a motor”; and frequently talking excessively. Impulsive symptoms include blurting out answers before questions have been completed, having difficulty awaiting one’s turn, and frequently interrupting or intruding on others (eg, butting into conversations or games).19

In the current DSM-IV13 nosology, at least six of nine symptoms of inattention must be present for the inattentive subtype diagnosis, at least six of nine hyperactive-impulsive symptoms must be present for the hyperactive-impulsive subtype diagnosis, and at least six of nine symptoms for both subtypes must be present for a combined subtype diagnosis.13

A range of ratings scales, forms, and structured interviews have been developed to assist with the diagnosis of ADHD in adults. Rating scales, such as the ADHD Rating Scale (ADHD-RS)20 or the Conners’ Adult Attention-Deficit Rating Scale (CAARS),21 can be used to assess current symptoms, while semistructured interviews, such as the diagnostic portion of the Conners’ Adult ADHD Diagnostic Interview for the DSM-IV (CAADID)22 and the Mini-International Neuropsychiatric Interview,23 can be used to assist with diagnosis. In addition, forms such as the CAADID are designed to assist in obtaining the history of symptoms from the patient. Current symptom scales, as well as diagnostic questionnaires, are available in self-report, observer-rated, and clinician-administered forms. For childhood history, collateral information obtained from a parent or older sibling, if possible, is extremely helpful. Formal records, such as report cards and conduct reports, are also illuminating. To assess comorbidity, one can either conduct a semi-structured interview or use an assessment tool, such as the Structured Clinical Interview for DSM-IV Axis I Disorders.24 These scales are discussed in greater detail below.

Rating Scales

Rating scales are a useful tool for assessing whether a patient meets the DSM-IV13 diagnostic criteria necessary for an adult ADHD diagnosis. Because they provide structure and, in some cases, extensive prompts that can be used to probe patients further, they are especially helpful for clinicians with less adult ADHD experience. Rating scales can also be useful in assessing current symptoms. In terms of diagnosis and severity, the use of the 18 core DSM-IV13 symptoms has been well established as valid and reliable. There are a number of diagnostic systems and rating scales that assess domains outside of the traditional DSM-IV13 core symptoms. While they may provide useful clinical information, the relationship of these additional domains to ADHD itself remains unclear. For instance, while functional impairments, such as social and occupational deficits, are important features of ADHD, they are not specific and are frequently present in individuals without ADHD who have other disorders.

Diagnostic Scales

The CAADID is a clinician-administered interview that assesses the presence of the 18 DSM-IV13 symptoms for childhood and adulthood.22 Specific prompts and examples of symptoms are provided for each query, and impairment in school or work, home, and social settings is assessed for childhood and adulthood. A diagnosis of ADHD, including subtype, can then be established. The interview queries patients about childhood history, including gestational, delivery, temperament, developmental, environmental, and medical history risk factors. Childhood academic history and adult educational, occupational, and social/interpersonal histories are also queried, as are health history and psychiatric history.

Barkley’s Current Symptoms Scale–Self-Report Form25 is a self-report scale of 18 symptom items that correspond to those listed in the DSM-IV13 diagnostic criteria. Odd-numbered items assess frequency of inattentive symptoms and even-numbered items assess hyperactive-impulsive symptoms on a 0–3 Likert-type frequency scale (0=never or rarely, 1=sometimes, 2=often, 3=very often). The scale also asks patients to note how often their symptoms interfere with school, relationships, work, and home life, and to report the age of onset for their symptoms. Finally, it addresses oppositional defiant disorder (ODD) comorbidity with eight questions about symptoms of ODD. Barkley also has a Childhood Symptoms Scale–Self-Report Form, a Developmental Employment, Health, and Social History Form, and Work Performance Rating Scale–Self-Report Forms, all of which can be sent to the patient to complete before their first clinic visit. In addition, the Current Symptoms Scale–Other Report Form provides observer ratings. Together, these scales form a picture of the patient’s past and present symptoms and functioning.25

The Brown Attention-Deficit Disorder (ADD) Scales Diagnostic Form26 is clinician-administered and begins with queries about clinical history, including impact of symptoms on work, school, leisure, peer interactions, and self-image. Patients are also asked whether early schooling was impacted by their symptoms. The clinician asks the patient about the clinical history of his or her family and about the patient’s physical health, substance use, and sleep habits. The clinician also obtains collateral data from an observer or significant other and screens for the full array of comorbid disorders.26

Current Symptom Surveys

Current symptom surveys can be divided into clinician-administered and self-report forms. Some scales are normed and can provide population comparisons. Because some symptoms, such as internalized restlessness, feeling disorganized, and being easily distracted, are not always apparent to observers, self-report scales are an effective way to capture the symptoms of adults with the disorder. However, for new patients who are less self-aware of their symptoms, it is very helpful for the clinician to be able to ask about symptoms in a semi-structured format that allows them to utilize an extensive list of examples given as prompts.

The ADHD-RS20 is an 18-item rating scale that rates symptoms using a 4-point Likert-type severity scale (0=none, 1=mild, 2=moderate, and 3=severe). It is based on the DSM-IV criteria for ADHD, with nine items assessing inattentive symptoms and nine items assessing hyperactive and impulsive symptoms. The ADHD-RS has been developed and standardized as a clinician-administered rating scale for children but can be used as an adult scale after the clinician has been trained to do so.

The Brown ADD Scale26 is a frequency scale with 40 items. In response to descriptions such as “misunderstand directions for assignments, completion of forms, etc.” and “starts tasks (eg, paperwork, chores) but does not complete them” patients give a rating from 1–3 of how often the symptom occurs (0=never, 1=once a week or less, 2=twice a week, and 3=almost daily). This assessment has normed, standardized, validated clinician-rated and self-report forms.

The Wender-Reimherr Adult ADD Scale (WRAADS) is intended to measure the severity of the target symptoms of adults with ADHD using criteria from the Wender Utah Rating Scale.27,28 It measures symptoms in seven categories: attention difficulties, hyperactivity/restlessness, temper, affective lability, emotional over-reactivity, disorganization, and impulsivity. The scale rates individual items from 0–2 (0=not present, 1=mild, 2=clearly present) and summarizes each of the seven categories on a 0–4 scale (0=none, 1= mild, 2=moderate, 3=quite a bit, 4=very much). The WRAADS may be particularly useful if the clinician wishes to assess possible mood lability symptoms of ADHD.

The screening version of the CAARS21 is a 30-item frequency scale with items such as “has difficulty organizing tasks and activities” and “is on the go or acts as if driven by a motor.” Symptoms are assessed with a combination of frequency and severity. Patients respond on a 4-point Likert-type scale (0=not at all or never, 1=just a little, once in a while, 2=pretty much/often, and 3=very much/very frequently). All 18 items from the DSM-IV13 can be extrapolated from the CAARS. There are also observer and self-report versions of the CAARS. Both the clinician-administered and self-rated versions of this scale have been validated and normed.

The full Adult Self-Report Scale (ASRS) Symptom Checklist (version 1.1) is an 18-item scale that can be used as an initial symptom assessment to identify adults who might have ADHD.29 The scale queries patients about the 18 symptom domains identified by the DSM-IV, with modifications to assess the adult presentation of ADHD symptoms. Furthermore, a context basis of symptoms is provided. The scale is intended to be used in patients at risk for having ADHD, whether secondary to presenting symptoms, family history, or comorbidity. A six-item screening version (extracted from the full 18-item symptom assessment scale) is available for assessing patients in the community, regardless of whether they are at increased risk for ADHD. Neither the six-item screening version nor the full 18-item symptom assessment version is meant to be a stand-alone diagnostic tool. The diagnosis of ADHD is still predicated upon assessment of current symptoms, impairment, and childhood onset of symptoms. The ASRS and other symptom assessment tools are designed to be diagnostic aids in fulfilling the first criteria. As this section reviews symptom assessment tools, the discussion will focus on the 18-item ASRS Symptom Checklist.

The ASRS was developed by Adler, Kessler, and Spencer, and a steering committee of experts on adult ADHD. The ASRS Symptom Checklist is now available through the World Health Organization (WHO) and on the New York University Web site.29

In the ASRS, symptoms are rated on a frequency basis: 0=never, 1=rarely, 2=sometimes, 3=often, and 4=very often. Nine items assess inattention and nine assess hyperactivity-impulsivity. Once the patient has completed the scale, it can be readily scored and used as a starting point to talk more in depth about a patient’s clinical history. There are scoring guidelines based upon the total score in either the inattentive and hyperactive/impulsive subsets (using the higher of the two) that yield a diagnostic likelihood of the patient having ADHD. The scale has been validated using the National Comorbidity Survey cohort and in well-characterized adult ADHD populations.

Differential Diagnosis

As always, it is important to remember that when diagnosing for ADHD, a variety of medical and psychiatric conditions should be considered as part of the evaluation of ADHD in adults. Such conditions include sleep disorders, headaches, visual and auditory disorders, seizure disorders, endocrine disorders, hepatic function, use of illicit substances and herbal remedies, and impact of concurrent medications on cognition (eg, anticholinergic or antihypertensive medications). Laboratory tests, such as thyroid studies, electroencephalograms, baseline electrocardiograms, or baseline hepatic function tests are generally not necessary unless indicated by the patient’s symptoms or family history. Additionally, clinicians should obtain a history of anxiety disorders (including trauma), mood disturbances (including bipolar disorder), current and past substance use, aggression and impulse control problems, legal involvement, and psychosis. Furthermore, current stresses, as well as issues involving the patient’s adherence, are important to the overall treatment plan.

Conclusion

DSM-IV13 criteria provide the standard for diagnosis through all age ranges. The cardinal criteria for diagnosing ADHD are the presence of sufficient current symptoms and impairment in two realms (realms include home, school or work, and social interactions). A clinical interview, aided by the use of rating scales and (when appropriate) collateral information about childhood from parents or siblings, provides data for a comprehensive assessment. The poor psychosocial outcomes of patients with ADHD, often a consequence of unrecognized, untreated symptoms, can also serve as diagnostic indicators. Diagnostic and symptom assessment scales can be helpful in diagnosing and establishing the symptoms of ADHD in adults. PP

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29. New York University School of Medicine Web site. Department of Psychiatry home page.

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Mungo

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