Tuesday, 1 November 2016

Alternative Diagnosis - The Personality Connundrum in Disruptive Behaviour and Impulsive People

ADHD is not a diagnosis of preference in France, where health professionals and parents alike are averse to the neurobiological train of thought which is currently so pervasive in the US and many other western countries.

There are of course various studies and on going research programmes which claim to show that ADHD is related to a disordered or paratypical brain activity, which may be related in turn to a misbalance in dopamine and seratonin acitivity and metabolism. The current umbrella theory is that ADHD is typified by a lack of  neural activity in terms of the cognitive and "central coretex narative"   to which the brain eventually sets off an internal, subconscious alarm and tries then to wake up or you could say, jump start the brain by creating over stimulation of the weaker neural processes. So on the one side we see typical 'glue brain' attention deficy periods, and then rushing of thoughts and disruptive behaviour. This is then bipolar in nature. Hence stimulant therapies such as Methylphenidate, are prescribed because they both match the notion of neuroligical aetilogy and because these drugs do work in a proportion of cases.

However, a disruptive pupil who does not pay attention is then given a social based diagnosis with no actual investigation as to the underlying neuro biological symptoms. The prescription drugs are shown to work in the studies, so why should we seek a more expensive route for differential diagnosis, involving both brain activity and a wider social and personality discussion with the family?  The drugs work of course to the threshold for acceptable efficacy that the FDA and other medical authorities stipulate. However that varies betweeen studies and treatments, as do the criteria for initial diagnosis and inclusion to the clinical trials, which may be far more stringent or preloaded than actual diagnostic practice at the primary health care front line.

In the clinical trials,  there are always two groups though which are then brushed under the carpet when the efficacy is over 40%. The first are non responders, and the second are those who withdraw or are withdrawn due to side effects. Here we touch on the elephant in the living room of chemical medicine: that we often do not fully know the aetiology of a disease at the molecular level, yet we follow a course of drug introduction which are shown to have positive effects on symptoms, bind receptors believed to be involved or are variants of earlier chemicals found to have more specific effect, less side effect, or even as in the famous cases of Viagra and One Alpha, that drugs being experimented upon in one disease area, had powerful indications in another seemingly unrelated one.  We can say with some confidence that up to a third of patients do not respond to  ADHD medicines, depending on the diagnosis and probably the genetics of that population. We can also say that a small proportion will experience side effects, often the 'amphetamine' like experiences of grinding teeth, more micturition and so on.

The 'cures' are to an extent a magic bullet, a key to the lock. But only if you care to see the lock as you have been told to look at it. The trouble is that the pyschological and social therapies or you could say, regimes, which could equally well be employed are more nebulous, outside France that is. They vary and perhaps demand a referal and further diagnosis. Also compliance and attendence may be far lower than for popping a pill before breakfast.

The French take a different stand point, where chemical intervention is the last resort it seems, and is prescribed in less than 0.5% of cases. They consider rather first, the social conditions and context for the child's "misbehaviour" and think more in terms of neuroticism, angst and post traumatic stress for the more severe cases presenting. Milder cases are often considered as just what they present as: misbehaviour - innapropriate talking, impulsiveness and other disruptiveness and a lack of concentration-  in school most often. Alternatively the child may be considered to be just bored, understimulated, with some topics at school.

Here we reach a crux of the cultural differences between several entire systems: medical, pharma business, political and cultural. In countries which show high prescription of ADHD medicine in children, there is most often also a political agenda to make schools less liberal in thinking, and more 'sqaure' in terms of producing better 'hard skills' for the jobs market down the line. The USA, the UK and even Norway under the latest government are all examples of this, where Ritalin (TM) in particular is prescribed first line by many physicians and psychiatrists. Creative subjects and time on them in school have been reduced, and "sqaure" subjects like maths and grammar are even introduced into creative education and physical activities. At the same time many western countries have relaxed direct to consumer market communication, and the borders are fully blurred by the free flow of informatuion on the internet. Physicians have the lock and key now to "arrest" this disruptive behaviour rather than 'wasting time on wooly and lengthy' psychological approaches as was mentioned to the author by a GP.

What alternative diagnoses could or should be aired ? Should we follow more closely the French approach, or would it burden the health care system without the same efficacy as "pill-pushing"?


Our group of adult ADHD sufferers have evolved with most actually now dropping out of the prescription drug programme. Some feel well managed though, especially when using the slow release formulations of the stimulant therapies. Most though either did not tolerate, did not comply enough, or simply did not want to continue on prescribed medicines. Since our group is a little biases and 'self selecting' when it regards further therapy, we cannot say that they are representative what so ever, yet the routes they are exploring in and outside of the health care system are illuminating.

They take us on a laymans journey through their own lives, diagnosis, "first line" treatments they recieved and then why they chose to take the route away from medication, and even to reconsider if their diagnosis was correct in the first place. ( the cases will be expanded , come back to the blog for more later)

CASE A  in their own words

" Getting a diagnosis of ADHD as a man in my forties came as a surprise. In fact with some disbelief. How could I have come this far in life ? University and business school education??  Both the cognitive tests I took and the following discussions with a clinical psychologist and then consultant psychiatrist were almost like getting a diagnosis of cancer. A tumour of the personality. A metastasized, malignant burden on my psyche.

I wasn't by any means devastated, because I knew I was unhinged, which is why I sought help,  and I knew there was now a "cure" with proven clinical effect. Four years on I feel though that I have come full circle to actually reconsider my own diagnosis and the nature of the disease in context of wider personality traits and neuroses.

To kind of contradict this last statement, I actually do believe very firmly that I have neurological ADHD. I have classic symptoms of under stimulation followed by rushing thoughts. I responded well enough to the slow release Ritalin formulation, having had marked amphetamine like side effects and bad stomach from the normal preparation. I had great concentration when dosed up on normal tablets, and more even productivity at work, but found I was grinding my teeth, going to the toilet often, my stomach was getting crampy and I found it hard to sleep at night. I was also experiencing a marked 'down' in the early evening when I would often become drowsy or irritable. The slow release was very much more expensive for me, and came with some bowel disruption. Also I felt that the positive effects were wearing off after three months, while the peeing and the distrubed sleep continued.

During the consultations with first my district psychologist, then the clinical psychologist and then consultant at the hospital I had said over and over again that I thought there was a parallel emotional disturbance that I would like to address, related to some childhood trauma including berievement and some quite serious bullying. That was brushed aside and the route forward was management by Ritalin. After this I had only one short consultation with the consultant, really to see how I was tolerating the normal tablets and if I was benefiting. My plea for more support and investigation of the social and emotional elements I thought were important, were simply brushed aside. I changed the formulation through my GP to the tarmic release and realised that if I wanted some kind of ongoing psychological support, I was going to have to beg for it or come seeking a new diagnosis!

At a couple of points in the consultations I realised it may be going towards these stimulant, neuroactive chemical treatments and asked if there was alternatives. The medical profession went vague on me hear. When I raised the history of valium, that was considered not relevant because these new drugs were shown not to be habit forming. With less than five years of experience and a powerful pharma lobby, it is really too soon to tell IMHO.  No alternatives were suggested. It looked like they were only available via charity and self-help groups.

In the course of this I made some bad career decisions and after a lot of turmoil in the work place, caused largely by circumstances and not myself, I was unemployed two times with only a short period of work in the middle. It felt like a perfect storm for damming me for my own impulsiveness in moving jobs in the first place, and not having a more successful and stable career - this is where and why my ADHD is in the picture as a diagnosis and kind of journey through the whole rigermorole of pharma dominated diagnosis. So I was feeling disillusioned and back to worse than square one.

Luckily I took a nother journey of self discovery and self therapy.  Firstly I accepted an anger management course after the stress of losing my first short lived job having moved from a stable job, buibbled over to family life. This made me think about the impulsiveness of my behaviour in terms of making bad decisions and often becoming angry or withdrawn, or eratic. All features of the 'fight or flight' response.  The self management included firstly seeing your self as others see you when you fly into a rage or become irritable and snappy over a period of time. Also to stop, and back up and assess the situation.

Another fortuity was that my local council have a community psychiatric care centre, which began to offer an open course on Cognitive Based Therapy (CBT) for stress and berievement etc. This built upon my anger management in terms of self awareness and analysing my own feelings and responses before rushing to conclusions and potentially innappropriate and impulsive behaviour.

Not to go into details of a well documented therapy,  I had some real benefits from CBT and could address more of the emotional status issues I experienced. For example, I decided that my stress stomach and panic attacks in the middle of the night were coming from the acid reflux starting my body on the route to negativity, not that I had overly neurotic dreams or semi conscious anxiety. My body and brain wer interpreting my stomach complaint as being a sign of stress, and tyring to offer 'peri conscious' interpretations. As I learned in anger management, these biological routes do not get any better, rather they seem to get more 'hard wired' and become 'second nature'- the normal, the status of choice to act with.

Also I used the alternative resolution techniques to address not only my 4am panic feelings, but also elements of social angst, and how I interpret situations which have gone badly for me. Furthermore I could use the tackling techniques to put my current unemployment as an opportunity to heal and be with the family before the economy picks up and it is easier to get a job.

I haven't stopped there though. I have gone on to look at how my personality may be internally always in conflict. I recently uncovered articles which to some extent challenge the polar personality trait scales- I used to describe myself as an "inner directed extrovert" yet in fact, I am more of an introvert with a compulsion to seek social contact as some way of resolving the inner intimacy-imposed isolation dilema. ( I studied two years of psychology at University while majoring in molecular biology)

It is a big chicken and egg with this and perhaps circular- these personality traits and inner conflict may be in part or whole generated by a neurological condition. However perhaps the condition, being a bit slow in the mornings and having rushing creative thoughts, is the lesser of the evils, and is either masked or exacerbated by my neurosis. I consider that my CBT and Anger Management route has been more fruitful for me by a long margin than the improved concentration and slightly more even temperament on Ritalin.

To myself I am kin dof a puzzle wrapped in inexplicability and clouded by insecutiry and failures which are by in large on the job front, not my fault. As a little boy I was bashful and bumptious and kind of being sociable was something which I tried hard at, yet was completely inept at. I grew a kind of clowning personality, with a very brash side, but made new friends easily all my life.  I fitted well into academia and performed above average and also had a lot more curiosity and imaginative thinking than most peers, whcih got me noticed and ear marked as a future professional scientist. Yet I hated tedious lab work, I just had no patience and I wanted to experience other things in life than being a poor student and post doc through my 20s.

I sought some good degree of excitement in career and hobbies as a kind of way of addressing my inne5r drive to suceeed in something interesting. However I often fel ldown socially, failing to make key relatioinships on a professional level and falling into being the kind og rebel-without-a-cause employee. I struggled to meet 'the right girl' and got involved with some wrong types, wrong time-of-life, wrong situation. My impulsivity drove me to change girls and change jobs like a crazy guy. That was fine as a young bachelor, but evenutally a 'portfolio' career as I was told to use as a euphenism I guess, rubs thin as a middle aged man on the job market.

I do feel that I have made more progress in a year of CBT and reflectiveness, self awareness, self arrest and some meditation to boot, than I did in a year with Ritalin. Also where as for me at least, the drug tickled at the symptoms, the psychological approach takes me into how I tackle much wider aspects of life than just concentration failure. I also think CBT helps me as a parent, a friend to others and that when I do get back into work, it will help my performance and relationships and eventually help me become a better people manager. "