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Understanding "Adult" Attention-Deficit Disorder (ADD)

Posted Aug 27 2009 11:38pm

Attention-Deficit Disorder (ADD, or ADHD--the H stands for hyperactivity, which may or may not be present) is a fad diagnosis in the U.S. By this I mean that, while ADD/ADHD is certainly a valid condition suffered by some individuals who require treatment for it in order to be able to function to their fullest capacity, there is also what I call an epidemic of public awareness regarding the condition that has led more people than ever before to wonder if they suffer from it, and after a little lay research, into thinking that they do, in fact, "have it."


These individuals then present to mental healthcare professionals reporting symptoms that are certainly consistent with ADD--mainly difficulty concentrating and getting things done--and more often than not, unfortunately, they end up diagnosed by well-meaning clinicians with a condition for which in many cases they do not, in actuality, need treatment. Bipolar disorder is another condition that is exceedingly over-diagnosed these days; the difference is that few individuals seek out a doctor to confirm a diagnosis of bipolar disorder, whereas many more people hear or read about ADD and convince themselves, and ultimately a prescribing practitioner, that they need treatment with stimulant medications.


This article is based on my personal experience evaluating and treating individuals who have presented complaining of inattention, specifically "Adult ADD."


Adult ADD vs. ADHD. One thing worth noting: there is no actual separate condition for adults as opposed to children; the term "Adult ADD" was coined to refer to adults who suffer from ADD because the disorder is one of childhood. That is, it presents very early in life as hyperactivity, inattention and/or impulsivity and tends to improve as a child matures (especially the hyperactive component, if it is present to begin with).


It is so principally a pediatric condition, in fact, that in the past, few individuals with bona fide ADHD who had been diagnosed in grade school or earlier and who had benefitted from treatment remained on medication into adulthood. For one thing, the hyperactive, "bouncing off the walls" component is just not seen in adults, who are better able and more inclined to control their physical behavior; moreover, even inattention often improves enough with age that in the past, most of these individuals were not treated into adulthood, but nowadays--in part because of the trendiness of the diagnosis, in part because problems concentrating do not necessarily improve on their own--more and more adults are being treated for ADD, hence the term "adult ADD."


What is truly disconcerting about this new trend is the number of adults being treated for "ADD" for the first time, as adults, after unremarkable childhood academic and behavioral histories, sometimes because their own children are diagnosed with "ADD." It is my firm impression that the vast majority of these latter-day diagnoses are false and that otherwise normally or even high- functioning adults are being labeled and treated for a condition they do not, in fact, have.


Because of the popularity of the diagnosis and the pitfalls of treatment with a stimulant medication (see below), I always approach every case of suspected "Adult ADD" with a certain amount of skepticism. Not only must other conditions be ruled out, but ADD itself must be ruled in, something I do not see happening much. Because of the highly subjective nature of the symptoms, I personally am very reluctant to assume that a person has ADD in the absence of more compelling evidence to that effect: i.e., objective, practical difficulties at work or school. Interpersonal problems are also common with ADD, but if there are only relationship problems and not also occupational (work and/or school) problems, I look for other, more likely explanations.


Here are some red flags that suggest that an individual who complains of ADD-type symptoms does not, in fact, have ADD:


No history of academic or behavior problems as a child. As stated, ADD/ADHD, with or without the hyperactive component, is a disorder that is present from birth (or at least the potential is there). It may not become evident or clinically relevant until the toddler is old enough to move around and grab things, when hyperactivity becomes a problem, or perhaps later in pre-school/kindergarten or during grade school, when inattention causes problems in the classroom, but whatever else, the disorder does not wait until adulthood to show up for the first time to cause problems. If a person was not singled-out by a parent or a teacher as an unusually impulsive, hyperactive and/or poorly attentive child early on and, moreover, if a person did reasonably well academically, it is extremely unlikely that any ADD traits that may be present were ever significant enough to warrant treatment, then or now.


The retrospective approach. The problem with trying to rule out ADD with a negative prior history is that most people who are presenting for the first time as adults with the complaint of poor concentration and the notion that they are suffering from ADD will in all sincerity adopt a retrospective approach: "Looking back…" they say, "I had problems all along--I just didn't know it!" And while it's certainly one thing to have had problems all along and not to have known what they were caused by, or that anything could have been done about them, it's quite another to have been oblivious to the problem itself, which is usually the case when people look back to try to find justification for a latter-day diagnosis of ADD. In that case, it wasn't a problem at all if no one (parents and teachers especially) was aware of it at the time. That doesn't mean that there isn't a problem now; it only means that the history is not consistent with a diagnosis of ADD. Other things need to be considered and ruled out.


In my practice I've even had adults with advanced degrees--relatively highly functioning Master's and Ph.D.s who were never identified as children and who were never treated throughout their long academic careers--tell me they are more-or-less convinced that they have ADD! When I've pointed out their many accomplishments having required no treatment at all, the standard response is that, yes, that may be true, but "It was really hard for me," and "I had to study extra hard to get by." That may also be true, but if a person is able to buckle down and put forth a little (or a lot) of extra effort and thereby overcome his or her problems with attention and concentration, then obviously s/he is not suffering from an organic brain syndrome that requires treatment with powerful stimulant medications in order to make it by, occupationally and socially. Because that is what ADD is, whether an adult or a child: an organic brain syndrome the symptoms of which require powerful medications in order to be alleviated. Individuals with bona fide untreated ADD suffer the absolute inability, due to a brain problem, to focus on any one thing for more than very brief periods of time, with obvious practical repercussions such as poor grades or loss of employment. They do not excel simply by trying harder.


Other, more common problems have not been ruled out."ADD" may seem common because the diagnosis is so popular, but given the vast number of inaccurate and invalid diagnoses out there, it is not nearly as widespread as it appears to be. Consider the fact that in some countries ADD isn't even recognized as a disorder. While this is an extreme viewpoint with which I disagree, in those countries the official prevalence of ADD is zero: nobody has it! My point is simply that it cannot be a plague in the United States and non-existent elsewhere; somebody is getting the incidence wrong. Either way, mood disorders, for example, are much more common and are more easily, and therefore more reliably, diagnosed. The first thing I do when evaluating the symptom of difficulty concentrating is to rule out depression. Other possible causes of ADD-type cognitive deficits should always be explored and discussed during an evaluation. If you and your doctor never talk about anything else but ADD, the chances that you will discover another reason for your cognitive symptoms are not very high.

One general rule is that, throughout early and middle adulthood at any rate, untreated ADD symptoms will be more-or-less constant throughout, so that if cognitive symptoms are relatively new or tend to come and go, other etiologies are probably to blame.


The idea that one must have ADD because medication used to treat ADD works amazingly well. Another scenario: a person with trouble focusing takes someone else's Adderall and it works like a miracle to improve the "symptom" of inattention. [I place the word "symptom" in quotation marks because a finding is only symptomatic in the strictest sense if it is indicative of a larger problem. You may have legitimate difficulty concentrating after a poor night's sleep, or when you are under a lot of stress, or simply because of a noisy environment. In these instances the problem concentrating is still a problem that may need to be dealt with in the short term, but it's not a "symptom" in the sense that it indicates some underlying pathological process of some sort, of which the inattention itself is merely one manifestation.]


Part of the reason people believe that they had ADD all along and just didn't know it, and so were just working harder at doing well, is that people who have tried ADD medication notice a remarkable improvement in their ability to concentrate, such that with medication they don't have to try at all. This is because ADD medications are performance-enhancing drugs,and so this leads to the mistaken impression that one has ADD simply because one got an impressive response from medication.


The take-home message here is that any level of inattention, including that which is not symptomatic per se, will be rapidly and unequivocally alleviated by prescription medications for ADD. These medicines work to improve concentration, regardless of whether or not you have ADD, just like narcotic pain medications will numb you to physical discomfort, even if you are not experiencing clinically-significant pain, or prescription-strength sleeping pills put you to sleep, even if you are not suffering from insomnia. Stimulants are powerful in the same way: they help you pay attention, whether you need the help or not. And so, just because the medication helps with concentration does not mean you suffer from the disease of inattention.


Does treatment with stimulants make it easier for individuals who nevertheless do not have ADD to focus? Certainly it does; but that is true for everybody. Meanwhile, the potential liability of these medications is serious. They should never be prescribed lightly, and in particular, if a person is no longer in school or is in no danger of being demoted at work or losing clients or customers because of mistakes made due to inattention, treatment with pharmaceutical-grade speed (many ADD medications are actually amphetamines) is simply not warranted.


If you can buck up and plough through, then you should just do that, because 1) there is almost certainly nothing wrong with your brain function and 2) the physical and mental side effects of treatment with stimulant medications are not worth it, even if you are fortunate enough not to be prone to chemical addiction.


The fact that these medications--many of which are chemically related to the "speed" that is purchased on the black market for recreational abuse--also increase energy and motivation and elevate mood, at least initially, make them very popular among those who take these medications, contributing to a widespread tendency to overuse them, even by people who have no intention of doing so.


Like father, like son. "My son has ADD and I think it must run in the family." In today's climate in which children are routinely over-diagnosed with ADD/ADHD even more so than adults, another very common scenario I've run into time and again is when a parent, with an unremarkable history as above, is referred for an evaluation for ADD because his or her child was recently diagnosed, and the parent identifies with the notion of problems concentrating and getting things done.


This is, after all, one of the reasons ADD is such a popular diagnosis, because so many people agree that, at times, they experience significant problems keeping on task. But while most of us experience disorganization and the inability to multi-task from time to time for a variety of reasons (being tired, for example), we are not all suffering from severe organic brain dysfunction, no more than being forgetful and absent-minded means we are all developing Alzheimer's Disease.


It's true we all grow increasingly forgetful as we age, yet thankfully most of us do not go on to develop dementia. Likewise, many of us experience sometimes dramatic mood swings, but we don't immediately think we may have undiagnosed bipolar disorder. Similarly, we all become unfocused and unorganized at times, yet most of us do not suffer from ADD. And yet, debriefing individuals from the notion that they have ADD remains a challenge, because unlike with bipolar disorder and Alzheimer's, people don't seem to mind believing they might have ADD, especially if there is an easy and impressive way to treat it.


When a family member is diagnosed with any unwanted medical condition we don't immediately and excitedly think, "I have it too! Treat me!" But for some reason the core symptom of ADD, inattention, seems universal enough, and the easy, highly effective and well-advertised available treatments for it are very tempting to otherwise healthy individuals.


Finally, when a person is prescribed stimulant medication, it is no surprise that it works remarkably well at improving concentration. But stimulants actually do much more: they temporarily increase energy and motivation, and they elevate mood, so you are not only focused, you are alert and focused, and boredom (which itself can lead to distraction) simply evaporates on these medications, which lends a sense of purpose and accomplishment to even the most mundane of tasks. In fact, one potential side effect of stimulant medications is becoming hyper-focused, where you spend too much time on a task, sometimes embroiled in irrelevant details, and it can actually become counter-productive because your work becomes over-inclusive and inefficient.


Becoming hyper-focused is the least problematic of the common stimulant side effects. Stimulants cause insomnia, anorexia and various physical effects: headaches, dry mouth, queasiness, jaw clenching, intestinal cramps. Psychologically, they are notorious for increasing irritability and often lead to markedly increased argumentativeness and in some cases overt hostility, even violent behavior. In susceptible individuals, stimulants induce manic episodes and psychotic symptoms (paranoia and hallucinations are quite common). And then of course there is the "crash," when the effects of medication wear off and you get the opposite of everything: lethargy, hypersomnolence, rebound distractibility, even clinical depression in some cases.


Another very important thing to keep in mind if you are being treated with a stimulant for ADD: starting and slightly higher doses will always help significantly with inattention (the therapeutic effect), whether you have the disease or not, but you will rapidly develop tolerance to the euphoria that the medications induce. This euphoria (a supratherapeutic effect) comes in the form of increased energy, motivation, and enthusiasm for the task at hand, studying, etc. If the dose is too strong you will actually feel "high" and you may find yourself talking more and sleeping less and having a lot of fun! The higher you go, of course, the worse the crash later.


The thing to avoid is increasing the dose when you begin to develop tolerance to the supratherapeutic, euphoric effect. Many patients make the mistake of thinking that the medication "is no longer working" because it feels different. Suddenly they are no longer as interested in working all night, or they aren't as motivated as they were when they first starting taking the medication. This is normal and does not mean that a dosage increase is indicated. The first time you take a stimulant medication, no matter how modest the dose, you will likely experience some degree of euphoria. But even if you truly have ADD, when this stimulated effect wanes, you will still be able to focus on the task at hand because of the medication. Remember the goal is not to be distractable; it is not to be super-focused and super-motivated. The dose may very well need to be adjusted initially to best suit your needs, but ideally it should be working in the background, helping you without your being aware of it, or "feeling" anything. You are aiming for a reduction in symptoms, not the induction of a stimulated state of awareness (which, again, is more-or-less unavoidable the first time you begin taking these types of medications, so you may very well confuse that stimulated state with the actual intended therapeutic effect). Beware the false notion that the medication has stopped working because you can't feel it anymore and resist the temptation to ask your doctor to keep adjusting (i.e., increasing) the dosage over time as you develop tolerance to the stimulating effect, unless you are truly re-experiencing symptoms.


People do the same with anxiety medication. They may start taking Valium for panic attacks, and the first time they take it they feel a wave of relief in the form of mild sedation and muscle relaxation. Not only are they not panicking, but they are actually "mellow." Over time, with continued dosing, the brain quickly adapts to the sedating effect, and a person will not feel anything after taking a dose. If s/he has confused the initial, supratherapeutic effect with the intended effect, that person might then complain that the medication isn't working anymore: "I don't feel anything," forgetting that the whole point was not to feel anything: not to feel panic! Valium will continue to block panic attacks long after it stops making you feel like you are under the influence. Stimulants work in the same way on the opposite end: they will cease abruptly and noticeably elevating your mood even as they continue to allow you to remain alert and focused on whatever it is you are trying to focus on.


And don't forget the valuable effort you put into everything you do: surely if you are trying to stay focused, you will much better be able to do so with the help of medication, no matter how little you have taken, no matter how long you have been taking it. Most people who choose to be conservative with their regimen do very well, indefinitely, on very modest doses compared to other individuals who, abetted by their doctor, end up on doses that are triple and quadruple what they started out on, and even higher. It is these patients who suffer the worst of the pitfalls of being on these types of medications in the first place.


There is no reason a pill should do everything for you, especially when it comes to your mind. Remember that the more control a pill has over your mind, the less control you have. If instead of helping you stay focused the medicine is forcing you to pay attention, you will become hyper-focused. If the medicine is inducing you to overreact, you will hurt someone you love. And if you are already prone to substance abuse, you may very well lose control and possibly wreck your life.

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