Attention Deficit Hyperactivity Disorder (ADHD)

Diagnosis

-ADHD is the most common physiocratic disorder in children. 

-Its prevalence is 5-11% in school-aged children 

-It often presents with a classic triad of inattention, hyperactivity, and impulsivity 

– However, it can present as mixed, or primarily inattentive or hyperactive 

-Symptoms must include at least 6 signs of inattention and/or six signs of hyperactivity/impulsivity for 6 months. 

-For patients 17 years and older on 5 symptoms are required 

Symptoms of inattention include

-failure to pay close attention 

-difficulty sustaining attention on tasks or activities 

-failure to listen when spoken to 

-difficulty organizing tasks 

-avoidance of activities that require mental effort 

-losing things necessary for tasks or activities 

-distractibility and forgetfulness in daily activities 

Symptoms of hyperactivity

-fidgeting with hands or feet 

-inability to sit still 

-running around when not appropriate 

-difficulty engaging quietly in activities 

-feeling on the go or driven by a motor 

-talking excessively 

Symptoms of Impulsivity

-answering questions before they are completely asked 

-having trouble waiting ones turn 

-interrupting others 

The pattern of behavior must be more severe and occur more often than in other children of the same age. The symptoms of the disorder must be present before the age of 12 years. The diagnosis can be made after 12 years of age but there must be evidence of symptoms before the age of 12. The last important point is the symptoms must occur in two different settings (e.g., home and school). 

Many patients may be familiar with screening scales like the Vanderbilt or Conners which can be used to help confirm the diagnosis usually one is completed by the parent the other by a teacher. 

Most Commonly Prescribed Psychiatric Medications: Desvenlafaxine/Pristiq

Desvenlafaxine is the active metabolite O-desmethylvenlafaxine (ODV) of venlafaxine and is formed as a result of CYP450 2D6. It shares many of the same properties as venlafaxine. 

  • It’s FDA approved for Major depressive disorder 
  • Mechanism of action: This medication will boost the neurotransmitters serotonin, norepinephrine, and dopamine. It does so by blocking the serotonin reuptake pump, the norepinephrine reuptake pump, and increases dopamine in the frontal cortex because dopamine is largely inactivated by the norepinephrine reuptake pump in the frontal cortex. 
  • The dosing is a little easier than venlafaxine. You can start with 50 mg/day with a maximum dose of 100 mg/day. In some cases, doses of 400 mg/day have been shown to be effective but there is increased risk for side effects at higher doses. 
  • Desvenlafaxine is more potent at the serotonin transporter but has greater norepinephrine transporter inhibition relative to venlafaxine. This is one advantage along with lower does required to achieve that inhibition. 
  • These tablets should not be broken, crushed, or chewed, it will alter the controlled release.
  • It has some of the same issues as venlafaxine when it comes to withdrawal or discontinuation. It can be difficult to taper off and may require starting fluoxetine prior to tapering. 
  • Blood pressure must be monitored regularly during treatment.
  • Most common side effects include: nausea (most common 12%), dizziness (8%), increased sweating (6%), constipation (5%).
  • Other side effects: decreased appetite, decreased libido, erectile dysfunction, abnormal dreams, tinnitus, vertigo 
  • I’ve had many questions about combining this with mirtazapine. It can be combined with mirtazapine. Trazodone and bupropion are other popular medications to combine with desvenlafaxine if monotherapy does not result in remission. 
  • Desvenlafaxine offers some benefits over venlafaxine including more consistent plasma levels due to lack of metabolism by CYP 2D6, it has more potent action at the norepinephrine transporter than venlafaxine. It may be a better option if you are targeting the norepinephrine system. 

Most Commonly Prescribed Psychiatric Medications: Trazodone

  • The only FDA approved use of trazodone is for depression. However, this medication is rarely prescribed for this purpose. The higher dose requirements and lower affinity for the serotonin transporter allows the side effect profile to make the medication intolerable for most patients. 
  • The most common way it’s used is as an adjunctive therapy for sleep disturbances secondary to depression. 
  • The mechanism of action is blockade of serotonin 2A receptors and blockade of the serotonin reuptake pump. 
  • Dosing: To take advantage of the sedating properties you want to use a lower dose. A dose of 25-150 mg/night is appropriate. For depression the dose must be much higher anywhere from 150-600 mg/day 
  • For depression start with 150 mg/day in divided doses (short half-life) and increase every 3-4 days by 50 mg/day as needed to a target dose of 400 mg/day. For insomnia start with 25-50 mg/night and increase as tolerated to a target dose of 50-150 mg/night. That same target range of 50-150 mg/day can be used if trazodone is being added as an adjunct therapy for depression. 
  • It’s very important to start low and go slow when increasing the dose. Patients can have carryover sedation, ataxia, and intoxicated like feeling if titrated too rapidly. 
  • Do not stop the medication prematurely. In difficult to treat patients’ higher doses may be required 150-300 mg or up to 600 mg in some cases. 
  • It’s ideal to try and limit dosing to once nightly at bedtime to avoid daytime sedation 
  • Notable Side effects: Nausea, vomiting, constipation, dry mouth, dizziness, sedation, fatigue, headaches, life threatening side effects include priapism (1 in 8,000 men), seizures, activation of suicidal ideation in patients under 24 years of age.
  • The onset of therapeutic actions for insomnia should be immediate once an adequate dose is reached. There is no evidence of tolerance, abuse potential, or withdrawal
  • Therapeutic action for depression is delayed by 2-4 weeks if it’s not working by 6-8 weeks consider a dosage increase or switch depending on dosage reached 
  • Trazodone offers a nonaddictive option for insomnia treatment and can be used as an adjunct for depression treatment. It’s less likely than other antidepressants to cause sexual dysfunction. It may be less likely to precipitate hypomania or mania and may have some benefit for treating agitation and aggression associated with dementia. 

How to Sleep Better: Prescriptions From Your Psychiatrist

I will talk about sedative and hypnotic medications in future videos, but I want to start a discussion on sleep with sleep hygiene. I recommend all my patients start here and follow this process at least 90% of the time prior to talking about medication. I find most patients are not doing these things and if they are it’s not consistent enough to see a noticeable improvement. 

  1. Stick to a routine by waking up at approximately the same time each day. Do this for seven days, and do not alter the time on weekends. This will help you gradually set your internal clock. You have more control over your wake times than your sleep time as you may not feel tired. Try to avoid taking a nap during the day even on nights where you do not get much sleep.
  2. Avoid all caffeine after 12 PM, the effects of caffeine are long lasting and can interrupt sleep. If you can completely stop caffeine that would be best, but at the very least minimize consumption before 12 PM. 
  3. Try to exercise daily (seven days per week), preferably early in the day and not too close to bedtime. Start with 15 minutes per day and gradually work your way up. A combination of resistance training and cardiovascular training is best.
  4. Stop doing active mental work at least one hour before bed. 
  5. Avoid watching TV, using a phone, laptop, or tablet before bed. The blue light from screens has been shown to worsen sleep. The bed should be used for sleep and sex only. 
  6. Create a bedtime ritual to follow every night before bed, warm bath, mindfulness exercise, gratitude journal, reading, or listening to music. 
  7. Do not use alcohol as a way to promote sleep. Alcohol negatively impacts sleep architecture and the sleep you do get will be unsatisfying. 
  8. The bedroom should be dark, quiet, and the temperature should be cool but not cold around 65 degrees is ideal. Consider blackout curtains, a fan to cool the room, and ear plugs to facilitate these conditions. 
  9. Restrict Food and drink 2-3 hours prior to bedtime. This will reduce the chances of sleep being interrupted to use the bathroom.
  10. If you have any pain, take appropriate pain medications prior to bed. 

Why Psychiatrists Don’t Use Lifestyle Medicine to Treat Psychiatric disorders

My clinical experience indicates that most psychiatric disorders would benefit from the use of lifestyle medicine. As a member of the American College of Lifestyle Medicine, I’ve used lifestyle interventions to treat many of my patients. It’s an underutilized and undervalued part of health care in general and these are my thoughts about why that is the case. 

Immediate Release Vs Extended-Release Formulations in Psychiatry

Highlights From the Video

Immediate release the medication is released immediately and results is quick onset and a peak blood level. This type of formulation is generally less expensive and may be advantageous in some cases. For example, if you are using quetiapine at night in part for its sedating effects, I will use immediate release because I want a rapid effect. The same with methylphenidate or bupropion. 

The problem is this formulation requires twice a day or even three times per day dosing and results in more peaks and troughs. In general, for medications that are being used for maintenance you want consistent blood levels and not peaks and troughs.

With IR formulations, there can be more side effects and addictive potential. We believe it’s the rapid rise in blood levels of the medication that cause side effects and with medications like amphetamines for ADHD it’s the rapid rise in medication levels that can result in euphoria and thus addictive potential.

Extended release does not change the active ingredient in the medication, rather it provides a different delivery mechanism that slows the release of medication over an extended period of time. This has the opposite effect on blood levels when compared to IR. There will be less peaks and troughs and more sustained blood levels of medication. The advantage is once daily dosing and potentially fewer side effects for the pervious mentioned reasons. 

The downside is these medications tend to cost more money and some have argued when initiating these medications, a patient who has an adverse reaction will have symptoms longer with XR. Although clinically I’m not sure this is true and will generally use extended release if possible for maintenance medications.

Introducing Shrinks In Sneakers on YouTube

I’ve done a soft rollout of the Shrinks In Sneakers YouTube channel over the past several months. I think I’m finally comfortable introducing it on the blog. I made the decision to start making videos because I can create content at a more rapid rate, and I can connect with the viewer in a more personal and intimate way. Please subscribe to the channel for updates. If you have specific topics you want covered, or have questions about existing content please comment. I will try to answer all questions and continue creating engaging content based on your interests. 

Cheers,

Dr. G

Link to YouTube Channel

https://www.youtube.com/channel/UCaaywi6nWB4zzpqBCMvxbsA

Record number of guns sold in 2020: Should We Be Concerned?

Amidst the abundance of coverage of the 2020 presidential election mixed with an evolving pandemic, here is a news story you may have missed: it’s 2020 and guns are more popular than ever in the US. According to data from Small Arms Analytics  to date, Americans have purchased nearly 17 million guns in 2020. This is more than any previous year on record. Handgun sales increased by 81% and long-gun sales increased by 51%. We saw a similar trend in 2016 when 16.6 million guns were sold. This was driven by increased rhetoric calling for strict gun control laws in the wake of several mass shootings. 

As psychiatrists and concerned citizens, this data is alarming. We know that the presence of a gun in the home alone increases the risk of suicide. Specifically, owning a handgun is associated with a dramatic increase in suicide risk. Men who owned handguns were eight times more likely to die by self-inflicted gunshot wound. Women who owned handguns were 35 times more likely to kill themselves with a gun. Access to guns in the home is such a concern for depressed patients that it’s a part of every psychiatric evaluation. Suicide is often an impulsive act, and many of those who survive a suicide attempt regret their actions. Guns permit people to be dangerously impulsive. Lethality of means determines whether a person will survive a suicide attempt. In the United States, where more civilians’ own firearms than any other country, our most lethal means are guns. Suicide attempt by firearm will most likely result in death: an irrevocable and permanent result of the combination of an impulsive decision and a gun.

So, what is this about? Is there an increased interest in hunting that some of us missed? The plain answer is no. Most guns purchased in the US are not intended for hunting; instead, people are purchasing guns for “protection.” The increase in gun sales comes at a point in history of great political and social unrest. Maybe it is unsurprising that people feel an urge to protect themselves and their families. Fear is at an all-time high.

You know what else is at an all-time high? Isolation, loneliness, anxiety and depression. The most well-adjusted people are struggling in 2020. Depressed moods can progress to clinical depression which may include suicidal thoughts as part of the diagnostic criteria. Now, we have a country full of depressed people buying guns. In the mental health field, we are scared. You should be too. The financial, political, and public health uncertainties of today’s world form a perfect substrate for depression, fear, and impulsivity. Adding a gun is not the way to fix it.

We know that gun access provides a substantial risk for suicide. It remains important that we educate our patients about the risk of gun ownership. This is especially important for patients who have a history of depression or other psychiatric disorders. All this could be a potentially dangerous combination of psychopathology, and access to lethal means. 

Reducing Anxiety and Altering Patterns of Avoidance

Thinking Style in Anxious Patients 

  • There is a heightened level of attention to potential threats in the environment 
  • Example: A women with fear of airplanes has to fly across the country for work, she believes the plane is likely to crash despite the low risk of this actually occurring.

Predominant thinking patterns in Anxiety 

  1. Fears of harm and danger 
  2. Increased attention towards potential threats 
  3. Overestimation of the risk of situations 
  4. Automatic thoughts associated with danger, risk, uncontrollability, incapacity
  5. Underestimates of ability to cope with fearful situation 
  6. Misinterpretation of bodily stimuli 

Avoidance

  • The emotional and physical response to the feared object or situation is so severe that the person will do anything to avoid it. 
  • Because the avoidance behavior is rewarded with emotional relief, the behavior is more likely to occur when the person is faced with similar circumstances. 
  • Example: A person with anxiety is invited to a party and decides to make up an excuse not to go and the anxiety is relieved. Each time the person is faced with a similar situation they are likely to act the same way. 

CBT Model for Anxiety

  1. Unrealistic fear of objects or situations 
  2. A pattern of avoidance reinforces the belief that I cannot deal with the feared object or situation 
  3. The pattern of avoidance must be broken to overcome the anxiety. 

Behavioral Treatments

  • There are two general methods of behavior treatment for anxiety 
  • Reciprocal inhibition: A process of reducing emotional arousal by helping the person experience a positive or healthy emotion in place of the unhealthy one. (deep breathing, relaxation techniques) 
  • Exposure: expose yourself to the stressful situation, fear will occur but cannot be sustained indefinitely and the person will begin to adapt to the situation. 

Assessment of symptoms, triggers, and coping strategies

  1. What is the event that triggers the anxiety? 
  2. What are the underlying automatic thoughts, cognitive errors, and schema involved in the overreaction to the feared stimulus?
  3. What is the emotional and psychological response? 
  4. Habitual behaviors such as avoidance?

Cognitive Errors

  • Cognitive errors have been found to occur more often in people with depression and anxiety.
  • There are 6 main categories of cognitive errors 
  • Selective abstraction: A conclusion is drawn after looking at only a small amount of information. Other contradictory information is screened out to confirm the persons biased view of the situation.
  • Arbitrary inference: A conclusion is reached in the face of contradictory evidence or lack of evidence
  • Overgeneralization: a conclusion is made about one or more isolated incidents and then extended illogically to cover broad areas of functioning.
  • Magnification or minimization: The significance of an attribute event or sensation is exaggerated or minimized.
  • Personalization: external events are related to oneself when there is little or no evidence for doing so.
  • Absolutistic thinking: judgments about oneself, others or personal experiences are placed into one of two categories: All good or All bad

Techniques:

  1. Relaxation training: reducing muscle tension induces a state of relaxation and often results in reduced anxiety
  • Rate the level of anxiety and muscle tension on a scale of 0 to 100, with 0 being no tension and 100 being max tension 
  • Try making a fist and squeezing to a level of 100, then release it to a level of 0. Try doing so with the other hand. Notice that we have voluntary control over how much tension we feel. 
  • Starting with the legs tense and release each muscle group working your way up to the head. (I prefer to do this laying down) 
  • Try to keep positive mental images in your mind while doing this. Example: picture your tension and worries melting away like ice when left out in the sun. 
  • Try doing this daily for 1 week and record how you feel before and after a session.

2. Thought stopping: Stop negative thoughts and replace them with positive adaptive thoughts. 

  • Recognize: that a dysfunctional thought pattern is active 
  • Give self-instructions to interrupt the thought pattern:  Shift attention away from the anxiety provoking thought. (STOP! Or Don’t go there!) 
  • Consider guided images: try to imagine doing something enjoyable, playing a game, watching a sport, going on vacation. This can be combined with muscle relaxation  

3. Distraction: Develop several positive scenes that you can go to when anxious. Examples include walking in a nice park, going to your favorite restaurant, and spending time with friends/family 

4. Decatastrophizing: examine the evidenceto see that the likelihood of adverse outcomes is much less than we estimate

  • Estimate the likelihood: of the event occurring. Rate it on a scale of 0 to 100% 
  • Evaluate the evidence: for and against the event occurring 
  • Review the evidence list: now re-estimate the risk of the event occurring after going through the evidence 
  • Create an action plan: brainstorm strategies to reduce the likelihood of catastrophic occurring. Write down actions that you could take to prevent the feared outcome. 
  • Develop a plan for coping: if the event should occur. 
  • Reassess: compare the original rating to the new rating 
  • Debrief: What was good about working through a catastrophic event in this manner?

5. Deep Breathing

  • Aim for 30-60 breaths, 1-2 cycles
  • Start in the sitting position, hands on la or knees 
  • Take 10 breathes in through the nose and out through the mouth 
  • Take 10 breaths in through the nose and out through the nose 
  • Take 10 breaths in through the nose and hold for 5-10 seconds, then release out through the mouth 

6. Exposure: systematically or all at once (flooding) exposing yourself to the feared object or situation. This is the most important part of CBT for anxiety. Systematic desensitization: graded exposure, starting with less anxiety provoking situations 

  • Be specific: details matter, “stop being afraid to go to parties” is not specific “go to my neighbor’s house party for 20 minutes and talk to one person” 
  • Rate each step on a scale of 0 to 100 depending on how much anxiety you expect to occur 
  • Develop at least 8-12 scenarios that go from lowest to highest anxiety 
  • Work with the therapist to select to order of steps for graded exposure therapy 
  • Two types: imaginal and real-world exposure, depending on the case both may be used (good for OCD and PTSD)  

Help, I think I’m a Narcissist

Introduction

It seems like everywhere I look there’s a video or article with titles such as “how to tell if you’re a narcissist” or “is your significant other a narcissist.” This got me thinking about narcissistic personality disorder (NPD), and why everyone thinks they or someone they know has this disorder. 

Brief Review of NPD Criteria from DSM-5 (5 out of 9 required) 

-Grandiose sense of self-importance 

-Preoccupied with fantasies of unlimited power, success, beauty etc. 

-Believes they are special and unique 

-Requires excessive admiration 

-Has a sense of entitlement (unreasonable expectations) 

– Interpersonally exploitative 

-Lacks empathy 

-Often envious of others or believes others are envious of them 

-Shows arrogant, haughty behaviors and attitudes 

Distinction Between a Disorder, and being a Jerk 

There is an important distinction between having NPD and having narcissistic traits. In diagnosing NPD there is a long list in DSM-5 of which the person must have 5 out 9 criteria to qualify for the diagnosis. These criteria will be present in all circumstances and relationships. Most importantly it must cause impairment in function and a subjective sense of distress. If the person meets these criteria, and it’s working for them in their life, they would not be diagnosed with NPD. You need to have the functional impairment, that is what makes it a disorder. Although these people may not have a disorder, it still does not make them a pleasure to be around. There can still be relationship difficulties both professionally and on a personal level.

Common Types of Narcissism 

The classic grandiose narcissist, this is the kind of person who cannot stop bragging about what they have, and what they have done. They tend to enjoy showing off symbols of status such as new cars or even attractive partners. They do things based on what will get them the most admiration and recognition from others rather than personal values. These types are encountered on a regular basis, you may know people like this in your personal life. 

There is a classic example of the highly successful professional who will stop at nothing to achieve their goals even if it’s at the expense of others. So naturally one place you may encounter these individuals is in the workplace. These types will exploit other people, cheat, work the system, whatever they can do to get ahead. They are usually successful and superficially charming. This pattern is less commonly encountered in daily life.

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