Saturday, June 25, 2011

Mind-Body Connections: Evaluating the Whole Picture

I usually ask patients--particularly when they complain of depression and anxiety--if they have had a recent physical exam. I always ask new patients if they are taking any medications, and I've been pondering the possibility of asking patients to bring in a copy of their most recent physical exam results.

Many medical conditions and medications can cause psychiatric symptoms. Such medical conditions include stomach cancer, diabetes, and certain heart defects, among other conditions. Less serious but more common problems such as anemia and hypothyroidism cause sluggishness that mimics depression.

Hormone drugs such as birth control pills and hormone replacement therapy medications can cause depression. Several of my female patients have told me their depression decreased markedly when they stopped taking birth control pills.

Sleep medications and short-acting anti-anxiety medications can cause rebound anxiety. And let's not forget that caffeine is a drug--although it's "over the counter" at Starbucks--and it can cause anxiety and insomnia.

Most persons who go to a doctor complaining of depression, anxiety or insomnia will be prescribed a pill. Sadly, not all doctors evaluate the possible underlying causes of these symptoms--which sometimes can be a pill the same doctor previously prescribed.

Before you start taking pills for anxiety, insomnia or depression, it's important to evaluate any possible role of a current drug or a medical condition.

Saturday, June 4, 2011

The ADHD Conundrum

Different factions have claimed ADHD is underdiagnosed, overdiagnosed, or misdiagnosed. They are all correct.

ADHD (Attention Deficit Hyperactivity Disorder)is a neurological dysfunction, although for some reason it is classified as a psychiatric disorder. Because it is classified as a psychiatric disorder, it is commonly treated by psychiatrists and psychotherapists. In reality, because ADHD is a disorder of brain functioning (probably in the frontal lobes that control impulses and attention) it does not respond much to psychotherapy. The only purpose of psychotherapy for people with ADHD is to help them understand the illness and cope with the stress it creates.

Medication also doesn't cure ADHD, but it may be the only treatment that controls the symptoms. ADHD medications are usually stimulants that work to pep up the part of the brain that is malfunctioning. By supporting the part of the brain that controls impulses and increases attention and focus, the stimulant medications--seemingly paradoxically--make people calmer because they are less distracted.

It's my observation that many adults who've had chronic problems with disorganization and underachievement have ADHD that has never been diagnosed or treated. Meanwhile, many children who are diagnosed with ADHD are actually having a reaction to a negative environment, manifested in their behavior because it is primarily through behavior that children communicate (see my last post). In some cases, agitated behavior with no apparent environmental cause is diagnosed as ADHD but is really the onset of Bipolar Disorder. In these cases, the administration of stimulant medications designed to treat ADHD can make the patient worse.

An evaluation for an adult or a child with ADHD symptoms must include a comprehensive assessment of their environment and social, educational and/or vocational functioning. Psychological testing that includes an IQ test may be helpful, because a low IQ can also cause problems with functioning (unfortunately, there is no treatment that can make people smarter, so the best intervention for someone with a low IQ is vocational counseling to help them find something they can do in life).

I believe there are many, many persons with undiagnosed ADHD. At the same time, I believe there are many children who are diagnosed with ADHD who are really victims of parental neglect or abuse. Sadly, many clinicians do not take the time to do complete evaluations.

Thursday, June 2, 2011

Why I No Longer Work With Children

I used to work with children in mental health clinics in Brooklyn and the Bronx, from 1997 to 2003. I also worked with children as 50 percent of my private practice from 2001 to 2005. I no longer work with children, however. I decided that since most of the problems I was seeing in the children were caused or exacerbated by their parents, it didn't make sense to treat the children. Psychotherapy was not what they needed.

Of course, some children do have real disorders, but those disorders, such as Attention Deficit Hyperactivity Disorder, Childhood Onset Bipolar Disorder and Childhood Onset Schizophrenia, are neurologically based illnesses that often require medication and frequently don't respond to psychotherapy. Children do develop anxiety and depression, but in most cases, anxiety and depression in children is just a response to a negative environment. Some of the most commonly diagnosed childhood "disorders" such as "Oppositional Defiant Disorder" are just terms used to describe what children do when they are angry about they way adults around them are behaving.

Here's a case that illustrates the pitfalls of diagnosing and treating children: In 2002, when I was working at clinic in the Bronx, I was assigned to work with a 12-year-old boy, whom I'll call as "Jose." He presented with many symptoms of depression and ADHD, including anger, agitation, restlessness and verbalized unhappiness. He was unable to sit still and seemed distracted. He had a history of being abused by his mother, and had been removed from her care and placed with another relative. We agreed I would see him weekly and also that he would be further evaluated by the clinic psychiatrist.

Jose's relative didn't bring him regularly for his scheduled sessions, and after he didn't attend his appointment with the psychiatrist, I called in a report to ACS (the Administration for Children's Services, New York City's child welfare agency). The ACS worker arrived at Jose's home to discover that he wasn't there and his caretaker had no idea where he was. After Jose was found, he was placed with a different relative.

The following week Jose was brought to his therapy appointment by his new guardian. All of his symptoms had miraculously disappeared. He was no longer restless, distracted, or agitated, nor did he appear to be sad. The clinic's receptionist asked me "is Jose taking some new medication?" All of Jose's symptoms had been a reaction to his environment. Because his new caretaker was empathic and genuinely interested in him and his welfare, he adapted to this new environment by acting like the normal boy that he was. I continued to work with him, because of his history of abuse, and he seemed well on his way to a complete recovery when unbelievably, his former caretaker went to court to try to regain custody of him. She'd felt insulted that someone had decided she was not a fit parent. Jose was dragged into a legal situation that re-traumatized him. The situation was eventually resolved, but only after Jose was subjected to further damage.

One could argue that if it hadn't been for my intervention, Jose would have continued to have been neglected and his mental health would have been in serious jeopardy. I would agree, but it doesn't change the fact that most of what I did for him was work that I wasn't paid to do. I worked as a "fee-for-service" therapist at the clinic and was paid only for therapy sessions. This model is extremely common in New York. All the work I did advocating for Jose--calling ACS, attending his court case and making follow-up phone calls--was unpaid.

Our mental health system simply isn't designed for children. In later posts, I'll describe more pitfalls of the system. For my personal well-being, I had to remove myself from working with children. Most children's problems need to be addressed by professional child welfare workers and advocates, not by psychotherapists. But because the system continues to describe children's natural reactions to negative environments as disorders, therapists and other mental health workers are often the persons who end up advocating for children's basic needs.