Symptom Sleuth

Meet the 'PARPs' (coming soon)

noreply@blogger.com (The Symptom Sleuth) — Wed, 16 Nov 2011 01:23:00 +0000

Next in line at SymptomSleuth...

Meet the PARPs (paradoxical patients)

The next post in our idea hatchery will be for all you round pegs facing square holes out there.

[image courtesy of Allie Bosch of Hyperbole and a Half.]

Nature and Nurture Trading Spaces

noreply@blogger.com (The Symptom Sleuth) — Sun, 06 Nov 2011 00:47:00 +0000

I ended my last post (about forms of Denial recently seen at our house) with a remark about my own 'rotating frames of reference' on matters of mind.

As a student of psych decades ago at a large university, I was given a wide range of models to learn from, but they were almost all environmentally-driven. Psychiatry and psychology both seemed to think that how you were built was much less important than how you were molded by your environment.

Even then, it seemed to me that we focused on belief and behavior to the exclusion of genes and anatomy, and that those inborn aspects had to matter at least as much. But we just didn't know very much yet about the rest. The biological side of behavior was still a 'black box' to most scientists.

All of this changed in the 1990s, a "Decade of the Brain," with an explosion of clues.

Adding the "Bio" Frame

The '90s were full of headlines about mind-body connections. We were rapidly building new mental maps dotted with scores of physical correlates for symptoms and syndromes that had been long been puzzling.

Many light bulbs were lit by extra funding for research. We acquired new tools, such as high res scans, that depicted a dynamic new cerebral universe of pointers and landmarks. Around the same time, we began to connect the dots in the genome too.

As a result, today we can say with much more specificity that a given behavioral issue may be linked to this synapse, that bodily system, or this and that set of genes.

All of it helped us to see how every thought, every action, and every impediment is mirrored in the physical brain. Taken together, all of it added a biological frame of reference on top of our prior behavioral views.

These new ways of explaining spawned some more forgiving frames too. Bit by bit, we came to grasp that in finding fault with people, we often blamed them for inborn biology that arose from neurons, tissues, genes and biochemistry.

I remember seeing scores upon scores of doctors, shrinks and scientists hopefully claim that all this new science would propel a revolution in mental health. No longer would behavioral problems be seen as "just" the result of poor character, schools, or parenting.

This new, more physical, frame did a great deal to broaden tolerance and increase aid. Today, schools have become much more open to making accommodations for struggling kids, business-folk may be less quick to judge colleagues, and new laws induce insurance companies to give mental health some kind of "parity" with physical issues.

But like any new point of view, adding the biological frame seems to have spawned some unintended consequences too.

A Backlashing Boomerang?

In our excitement over this new way of explaining, it seems to me that we too often behaved as if that one new frame should replace all the insights that came before it.

A the biological frame began to dominate, it tipped the scales between Nature and Nurture so far into the "Nature" zone, it seemed the problems were "hardwired" into the brain in ways that might be even harder to change.

While this was all unfolding, I witnessed many heated discussions of motivation and will, choice and commitment. Clearly such factors count too. But then and now it has seemed to me that few such discussions have been seeking convergence between the biological way of explaining things and the more behavioral views.

As with all the debates one can still see today on the topic of ADHD, the entire conversation has had an Either/Or, All-or-None, Right-or-Wrong, quality. Then and now, people seem to be seeking pigeon holes they can use to narrow their focus, instead of integrating the elements into a wider, more unified view.

All the above and then some

I don't doubt for a minute that a better grasp of brain biology produced broader tolerance or more appropriate help from schools and insurance companies. I lived that whole story while helping my kids at the time. But with hindsight I can also see that for the child or the adult involved, there could also be a paradoxical boomerang.

A brain-based biological frame might feel more demoralizing -- heard less as forgiveness, and more as some kind of life sentence.

The dismissive, denying resistance seen seen among some 20- and 30-somethings seems today seems predictable in retrospect. The first generation to receive labels, prescriptions and concessions en masse might be the first to reject those labels as adults.

So it doesn't surprise me if people gravitate to emotional frames for their own self-portraits today. An emotional obstacle feels more fixable, as the healthy market for self-help books demonstrates. Skillfully used in behavioral therapy, an emotional frame might also help you see the parts of your experience that can, in fact, be changed.

The biological frame that further explains mind and brain may have added a missing link to beliefs that too often tipped towards shame and blame. But now, having made that shift, it also seems we need to broaden our views to include the other views too.

To me, the best frame of reference is the one large enough to include all the above and then some. Our brains are not built by either nature or nurture acting alone, but by both of them shaping each other.

The River in Egypt That Starts With a 'D'

noreply@blogger.com (The Symptom Sleuth) — Sun, 30 Oct 2011 21:39:00 +0000

Denial may be one of the most paradoxical parts of psychology since the very act of rejecting the notion appears to suggest its presence.

Someone says you are "in denial" about Topic X , Y or Z. You see it differently. But before you open your mouth, you know that the very act of objecting makes it seem you are guilty as charged.

It's a classic cant-win-for-losing Catch 22.

My son (I call him "Trey" here) probably feels caught in exactly that kind of double-bind right now. Most of the older heads around him agree about things that we don't believe he sees. But both his pride and his plans make him extra-invested in thinking that the rest of us are wrong.

We think he is ripe for all kinds of denial right now, while in his better moods he thinks he's the only cool head in the room.

The Biggest D on Our Family Tree?
Since last week's post (about ADHD Awareness Week) I have been reminded that one of the D's in "ADD" can sometimes stand for Denial too.
I shared that last post with a few friends from the past. One wrote back and said the biggest ADD challenge in her family today is about now-adult offspring invested in discounting the label entirely.

Despite all the accommodations and meds they may have received as kids, they want to believe it is all ancient history today.

From a distance, it's not tough to see why this might be. Young adults feel an especially strong sense of what they call "personal agency" -- feeling able to make things happen by themselves for themselves.

This kind of autonomy is especially important in the post-college career-launching phase. And that recipe might need doubling for those with prior struggles who now feel they have more to prove to self and others.

A rocky path to a balky launching pad
I've seen many success stories about smooth transitions from college to workplace for former teens with ADHD.The rub is when it is anything but.

These teens turned adults (at least on paper) now hold all the votes and they know it. As 20- and 30-somethings, they may have to stumble far more often than once before they grant that they still need some kind of support. Meanwhile, the parents might not have much choice but to sit on the sidelines watching.

In the moment, it sure looks like what happened with my own offspring

Trey quit his ADD meds senior year in college, and hasn't taken them since. More than one expert might say that what has unfolded since (including his longstanding interest in some things green) is a predictable consequence. But he will hear none of this, even after a series of post-college setbacks.

He grants he blew a number of things after he earned his degree. But he wants to explain every subsequent setback as the product of either his own poor choices or some outside conditions he couldn't change. Then when neither of those theories serves, he wants to point at emotional issues caused by (who else?) his family.

Needless to say, this spawns a recurring Catch-22 for me: What can I say to that last charge that won't sound like denial too?

When Denial and Normality Duel
Whatever the causes, TK wants to think that all of us are making too much of recent events.He thinks he ought to return to life as he knew it at the earliest opportunity. As opposed to the years of feeling stalled and stuck, he now sounds full of renewed commitments to making plans and acting.

At the moment the family is split between hoping he's right to trust in himself, and suspecting he's ducking some uncomfortable truths involving new diagnoses. (They are also doing their best not to fight about this.)

Meanwhile, the pros involved are not much help yet. They are too new to his story and his current picture is still too ambiguous. (Even if I am writing from behind a pen name, I feel obliged not to be too specific while it is still happening.)

One pro ("Dr. Zed") is mostly focused on meds, but he can only help so much while TK refuses to take anything new. Another pro ("Ms. Beta") handles talk therapy which seems to be going quite well, but she also seems torn about what she believes is "really" happening.

All heads assembled have some hypotheses, but few conclusions yet. (My next series on "People of Paradox" will look at some of the reasons for this.)

Still Bobbing in a Sea of Ambiguities
The events that landed Trey back home some months ago seemed potentially dire at the time, but the before and since has not been so far. This makes it tough for the rest of us to find some perspective.

Sure he made a string of loopy decisions the last few years, but show me the 20-something with perfect judgment. But the rest of the story is that he has mostly been so chipper and appropriate, even congenial while non-compliant, that all have had a tough time seeing his road blocks as more than temporary.

One psychotic weekend does not prove much by itself, but it sure suggests a second look at recent history. At this juncture, all hands need to consider that we may have had our own kinds of denial too.

Just as with his diagnosing conundrum, everyone present is hunching about prognoses. Nobody yet has a confident guess.

This would seem to throw the entire puzzle back to "Dr. Mom," the only one present with a detailed picture in mind, from birth to current day. Explaining that picture to self and others has led to repeating shifts in my own rotating frames of reference over the years.

More about this in my next post.

ADHD: The "A" in Our Alphabet Soup

noreply@blogger.com (The Symptom Sleuth) — Wed, 19 Oct 2011 06:30:00 +0000

It is some kind of karmic irony that I picked this particular week to launch a blog meant to help with a mental health puzzle that is up close and personal.

This also happens to be "Awareness Week" for ADHD, which I first found out on Twitter. (If you are new to the topic, there is an informative site at adhdawarenessweek.org involving the partners shown in the graphic below.)

We are not new to this topic at our house. Quite the opposite. Until recent events (see first post on this blog) ADD appeared as the largest ingredient in the mental health brew spawned by our gene pool.

The coincidence makes me feel as if it was not a coincidence. Perhaps I needed a vivid reminder of what could still be our most relevant theme.

My husband and I have almost 20 years of experience with ADHD. Our family contains a boatload of relevant genes, three impacted offspring and two affected mates. To say that I have more than a few opinions would be to put it mildly.

However to say much about my own story would build a bigger trail of bread crumbs than our current need for privacy permits. Since our situation is still unfolding, I can't write frankly without a cloak for my now-adult offspring.

So for now, I will simply weave my current impressions about ADD into the larger story I was already planning to share.

A Launch Pad Lacking Ignition

Like many a parent before me, I wanted to think our own needs for added awareness of ADD were largely behind us once the youngest finished college.

That physics degree of his seemed like some kind of finish line to us, his own 'Mission Accomplished' banner. That banner said he had made it over the hurdles and through the gates that met his needs for self-pacing high-level engagement from elementary through college. For that we credited many things, including good advisors, good meds, and flexible educators.

At that point, we all hoped that his launching pad was complete. None of us really looked at the question of fueling the engine. He was living with friends two hours away, happily attached to a very nice girlfriend and full of "gotta do it myself" energy. It was the peak of his 20-something pride and all of the adults in his orbit, including me, were happy to second the motion that he was now well-equipped to execute.

Today, I am left to wonder how many ways there are to spell 'wishful thinking.'

But I would digress to serve up the rest of that story yet. Let me confine my first ADHD posting here to my first take on Then & Now.

(continued past the jump below)

The More Things Change, The More They Dont
I am no longer on top of what's new or 'hot' in discussions about ADD, but just clicking around this week I was struck by how little some perceptions have changed since my own kids were young, bright and struggling in school.

Below the top three persisting myths about ADHD that quickly struck me:

Too Much/Too Little Labeling
We are still torn between perceptions that we either diagnose ADHD too much or too little. I agree with the experts who say that both things are true, then wonder about the ever-shorter attention span of some doctors. The need for speed still fuels a rush to judgment. That problem may have worsened today.

The 'Yuppie Flu' Hangover
The skeptics who were calling ADHD the "Yuppie Flu" a decade ago certainly left their mark. It saddens me how often I meet intelligent people who still minimize the condition. I have often wondered if it hits too close to home. Or perhaps short attention spans seem so common now, it feels self-indulgent to call it a 'condition' in an otherwise functional adult. This issue appears to intensify the closer you come to what some now call the "creative" stripe of ADD. In coming posts, I will get into how I see this dividing line myself. For now, I simply note that our default position on this topic often still sounds dismissive.

Narrow Pigeon Holes
Another persisting perception is that a person with ADHD will be ditzy, defiant, or both.The dreamy space cadet who can't connect two dots and hold the link in mind is one recurring portrait. So is its opposite, the defiant young rebel who is constantly flirting with trouble, if not already knee-deep into it. Common wisdom still seems to say that if you do not fit into either one of those slots, you must not 'have' the condition at all. This aspect was underlined for me when I took the brief screening survey at the awareness site above. After I reported a fairly low-drama life, the survey stopped midstream and presented a screen that literally said "tell us again, are you sure you have ADHD?" Thus it appears the first cut analysis has still not progressed very much.

All the above makes it doubly difficult for the paradoxical patient, such as my son, to get good help in his current crisis. He rarely fits the classic picture of any single condition. This paradox and what it says to me about how we lump and split our perspectives will also be an ongoing theme in this space.

Please subscribe to this blog and follow the twitter feed at right if you'd like to see future updates.

Postscript: You may also enjoy Dr. Donna Krutka and her own take on the "Top 5 Myths" of ADHD. There seems to be a good deal of overlap between her take and mine.

Treading Water in Limbo

noreply@blogger.com (The Symptom Sleuth) — Mon, 17 Oct 2011 17:55:00 +0000

There are few things in life more unsettling than watching one of your kids lose most of his marbles.

At times like that it doesn't matter what you already know about mental health, neuroscience or genes, or even how many personal histories you've seen. For now you are just a parent quivering, as any parent would, groping for answers, grasping at straws, trying to prepare for the worst while deeply hoping it isn't as bad as it seems.

A few weeks later and all of that feels like a dream, outwardly everything seems so normal once more.

What was that train wreck and how likely is it to happen again? Nobody yet has a guess.

On the surface, what we are seeing does not compute. An extra-bright, yet extra-relaxed, late twenty-something whose only known prior is the non-hyper form of ADHD, went around the bend for a few weeks, then returned to almost-normal (emphasis 'almost') amazingly fast.

Meanwhile everyone else is wondering if another shoe will be dropping soon, uncertain which events are more and less significant.

Watchful Waiting
For the time being, family, friends and the pros (MS, MD, and a PhD) watchfully wait to see, while he insists that he now feels fine and thus needs no meds. This may or may not be a pivotal issue. For now, things seems so normal again that we want to believe that Trey is right not to fret, especially given some recent headlines about neuroleptic meds. (This sets off his mother into a flurry of web surfing and fast-forwarding updates, consulting sources from NAMI to patient groups while reading memoirs, studies and journals.)

Could it really be "only" a very odd burp in an ADD brain? Or might it be some chronic disorder kindling despite his "what me worry?" temperament that rarely tips to extremes? Was there more of a substance history than he admits or anyone knew? Or did he minimize a scary encounter that happened aways from home, and might it have been a PTSD-ish event that shut him down for awhile? And how would these pieces fit with a brain that may also contain at least a few flecks of ASD?

None of the standard labels really fit the visible history and no one yet has more than a half-guessing theory.

This leaves us to mix and match from a long list of hints until a pattern becomes compelling.

First-time psychosis is like that. It could be a one time event, akin to what they used to call a 'nervous breakdown'. Or it could be quite the opposite, something chronic just now coalescing into some form of repeating distress. So here is the mom unit sleuthing the heck out of it, applying a sieve to the alphabet soup of diagnosing codes, seeking patterns that make more sense.

Meanwhile, we get to keep treading water in limbo, not knowing how to orient.

Sit tight and stay tuned while we try to help ourselves. Perhaps some of you who are reading this will be helped or help us along the way too.