Wednesday, July 12, 2006

So What's Wrong With Whining??


[posted by dinah, in response to Peter's Guest post: "A Culture of Whiners?"]

So, I liked the article in Harvard Magazine, and I loved Peter's metaphors comparing taking aspirin for headaches and seeing a doc for a sprained ankle to taking psychotropics for human distress, and I love thinking about this stuff which is why we have this blog.

I think, in my personal, non-affiliated opinion, that we've grown into a society that expects people to fit into a very small box: if you don't think and feel and function in a very limited and circumscribed way, then something is wrong with you. Worse than that, people become very distressed that they aren't living up to their expections of themselves (or other's expectations of them) and become demoralized and consumed by their sense of failure; sometimes it's very hard to get people to look at the idea that maybe they weren't meant to live the life that was prescribed or self-imposed, and the fallout becomes it's own problem.

Having said that, let me limit my discussion to two specific disorders: ADHD and Social Anxiety Disorder, and I may throw in a mention of medicating Grief. Let me also say that I don't know a whole lot about ADHD (I don't treat kids) or even Social Anxiety Disorder, but hey, I've read the DSM, I prescribe the meds, and I even watch the Paxil commercials--I just meant that I haven't read the research in depth and while these problems surface in the course of my routine general adult psychiatry practice, I don't label myself as an "expert" and if my sense on the phone is that someone is calling for nothing more than a prescription for an amphetamine, I send them to someone else.

So part of the box we've created: kids are supposed to sit still and concentrate in school. Let me give you a funny example from my personal life. When my son was 10 and entering middle school, he was accepted into a math/science magnet program in the public school system. The program had an excellent reputation and my son spent a day shadowing another child. The school day went from roughly 8 to 3 with 25 minutes for lunch (it took him that long to get through the line, he ate cookies). No recess, no gym, and the kids were assigned 2 to 3 hours of homework a night. Now whose idea was that to come up with this sort of curriculum for sixth graders? The school he ended up at gives middle schoolers a 20 minute break after 2nd period, a 45 minute lunch, gym 3 days a week, and an extensive after-school sports program. An all boys school we looked at included 2 recesses a day in addition to the other stuff.

So, the ADHD diagnosis is a complicated one, because it entails sometimes unreasonable expectations of children (and some restless adults), it often doesn't take into account that people just don't concentrate well on things they aren't interested in, and with the diagnosis comes the expectation of treatment with an addictive, even dangerous medication that has often unpleasant side effects, so it's not a benign designation. The Last Psychiatrist tells us that little research has been done on the carcinogenic effects of Ritalin, and psychiatrists are uneducated about the few studies that are out there. For the psychiatrist, it's a hassle: all this press about physicians being monitored, prosecuted even for over-prescribing controlled substances (ok, pain meds, but just wait...), and amphetamines in particular can't be phoned in or re-filled in Maryland, so getting the hard copy to the patient is always an issue. And the other consideration is that amphetamines help everyone, even folks without ADHD, perform better, faster... so maybe they belong in the water supply? And I suppose there's this funny little question that no one dares ask adults with ADHD: What if it's not that you're not living up to your potential, what if you're just dumb? (and no, I don't ask my patients that!) When does someone fall far enough off the curve that we question if the problem is disorganization such that it's a Disease, versus a varient of the norm, simply a character trait?

But here's the thing: there are children who just can't function, hyperactive kids who prevent other children from learning, who can't hold still long enough to get educated, and there's no issue here: they need medication and it's preferrable to putting them in special environments (--if you choose to homeschool your ADHD kid rather than give them ritalin, more power to you). And there are people who take stimulants and function much better, hold on to jobs they wouldn't otherwise be able to keep, stop having those funny little episodes of disorganization (hmm, locked the keys in the car while it was running again...) and who feel life is much better on medications.

Social Anxiety Disorder I have less to say about. Mostly, I see this in people who are otherwise anxious, and I don't have a hard time giving someone who is suffering a non-addictive medicine. People have been taking a little inderal (an anti-hypertensive) for stagefright for a long time, and this doesn't seem to bother anyone. If someone is my version of Shy and wants a medication so they can function better in crowds, and I can't convince them that it's okay to be shy or cure them with my great psychotherapy skills, then I'm not adverse to giving someone who is suffering an SSRI, or even a little benzodiazepine for specific events (I write lots of people for a few pills of ativan for flying since 9/11-- I don't think I'm altering the makeup of the world, but maybe I should suggest non-addictive Support Ducks instead?) I tell people the risks of Paxil (since the commercials, that's what they want): I tell people the risks: sexual dysfunction, possible weight gain, a possible discontinuation syndrome upon stopping, and the fact that we don't know the long term side effects, and that it may not work (meds often don't for these milder spectrum problems), I'm willing to prescribe it. Sometimes people I don't think need meds feel much better, their lives improve, and they're very grateful. And if they have side effects or don't work, they can always be stopped.

Grief: just briefly. Most people don't go to a psychiatrist for grief, if they're coming to me they are usually quite symptomatic. Meds don't do much for uncomplicated grief anyway. This view that SSRI's just numbs people isn't usually so--though everyone is different.

The diagnoses themselves, without a demand for medication, can be extremely helpful. It often comes as a tremendous relief to people to have a name for their difficulties, to know someone else somewhere has felt this way before. And there are non-pharmacologic ways of dealing with ADD or social anxiety, or whatever problem you have, things one can do to compensate if one is aware, in which case I don't see a downside to the label. Now if only I could have gotten extra time on those SAT's....

And you can take medicines and get talk therapy, too, I'm all for it, see The Psychiatrist as Therapist post. Of course the insurance companies want whatever is cheapest, and of course they are molding how psychiatry is practiced. It sucks. And do I think psychotropic medications are altering the fabric of society? Yup, but maybe in a good way. Artists don't paint, composers don't compose, and writers don't write if they're dead or so depressed they can't crawl out of bed. A little existential angst does fuel creativity (or worse, the need to have a blog) but I haven't seen anyone rush to the psychiatrist because of their creative juices, they come because they are suffering, and until you've walked in their shoes, try not to judge. Of Course, Tom Cruise knows what's best, but as Brooke Shield put it to him in her New York Times Op Ed reply to his criticism of her taking medications, "I'm going to take a wild guess and say that Mr. Cruise has never suffered from post-partum depression.'

On the issue of illness versus character trait, I think Shiny Happy Person said it best with this thought: "Mental illness robs you of your right to be a weirdo." The designation as such robs you of the right to be many other things as well.

And so the giraffe: He was photogaphed by ClinkShrink's sister and he has a number of issues. For one, he is too small, and growth hormone shots will be starting next week with the hope of giving him a few more inches. He's fond of rainbows, cut out of the pack to shine beneath one, and we're wondering if he's schizoid, avoidant, seclusive, or anxious, or if he doesn't play well with others; perhaps he's just thinking his own, possibly brilliant, thoughts.

11 comments:

NeoNurseChic said...
This comment has been removed by the author.
jw said...

The little box of ADD / ADHD ... that little box contains a goodly many boys who should not be there.

Many kids have ADD/ADHD and need medicine. Ritalin works for those kids. The perverted part of the thing as it now exists is that many boys are put on meds for the sickness of being boys. This is a great wrong and a serious problem. Being male is not a diagnoses of illness, that is a message which must be forcefully driven into the heads a good many people. If need be, as I suspect, we should use the police and jails to drive the message home.

Anonymous said...

I was surprised to see you give "just dumb" as the only alternative to having a "potential" a person is being held back from, because in opening your post you complain how narrow society's expectations are. "Just dumb" sounds like see the expectations as a proper ruler for measuring how smart a person is. Also, unless you disbelieve in nurture or the role of the environment, shouldn't you have included a third alternative "or have I just not found my calling?" It seems to me the most common success story becomes one only after our hero or heroine succeeds. Actually, that's our American dream sort of. Oddly though, celebrity is such that you can write one "important" book and do nothing but drink and beat your wife for the other four decades, and yet you're a success, at least with regard to casual reference. And where were all the brilliant middle-class American women in the '50s? Burning the casserole, a lot of them, presumably. Just dumb? I think by a perspective broader than real contemporary success "dumb" can be apt but for specific capacities more than for whole people. I got myself tested in a zillion ways by an educational psychologist at an age of nearly 40 after scoring Ds and Fs on my first-year law midterm. As I'd suspected all my life, I was very asymmetric in ability--two standard deviations above my age mean on tests of some mental abilities and average or one below in others. I managed a high IQ but the psychologist said (indefensibly, I imagine) that really it should be higher, because of those things that are strangely hard for me. I suspect I owe my brilliances to my stupidities and to society's narrow expectations, which because of my stupidities I've had to invent cognitively costly workarounds. In the way paraplegics develop buff arms. Anyway, though I seriously wonder nowadays if there's any place for my cognitive skill set in the economy, I earned a PhD in the sciences from a super elite school, was highly sought after as a post-doc and have been called brilliant and exceptionally clever by people that society rates as super smart themselves, not only in the sciences but the humanities. C'est la vie. It's some insulation for the esteem, but it doesn't pay the rent. Fortunately, I met my mate when my social stock was high.

Anonymous said...

Forgot to mention--wouldn't you know--that besides the asymmetries also I was diagnosed as very ADD.

Dinah said...

Please forgive me for the "just dumb" comment-- it was meant to be facetious, and here and there I lapse into politically incorrect. Of course there were other reasons, but I spent over an hour typing this post and I couldn't write everything I was thinking or my family would have starved.

There are people out there who believe their child isn't reaching his potential, and their aspirations for that child are just completely out of line with the child's IQ of say 80 (I won't draw a line for my 'dumb' designation, it's a for example).

Here's a better one: I'm a wannabe beautiful music maker. Kicked out of choir in 4th grade, I took 2 years of violin, Voice training briefly, a couple of years of guitar. The reality is that I am completely tone deaf, and once I realized it just wasn't meant to be, I focused my efforts elsewhere (Ah! Blogs! I can do a Blog!!!). There were some who've said that if I'd worked harder, I could have overcome this, but I feel I tried pretty hard and it just wasn't meant to be. If you doubt me, call and I'll sing you a lullaby.

Anonymous said...

If writing "just dumb" was to save the life of innocents, I guess I can just bite the bullet. I think your "Just wasn't meant to be" summation may illustrate social expectations at work. Instead of science and sociology and personality and cost-benefit analysis, it's standard to offer an absolute religious formulation and to assume everybody knows exactly what you mean. We do, but that doesn't mean any of us are really thinking much at all--or anything other than what works to run a society.

Roy said...

Another great post, and series of comments. I know the "just dumb" category was shorthand for "it could be a bunch of other things, not ADD". One of those things is fear of success. This is sometimes the internal conflict that robs one of brain cycles... like a computer worm doing something in the background, the user unaware of its progress-inhibiting nature.

There are many reasons for inattention (that hot fudge sundae calling you, for example, while you try to get the boss' report ready for tomorrow morning).

Wife insists, for example, that I have ADD. I bounce from one task to another, leaving a trail of unfinished home projects and chores behind. I get back to them... or not. Verbal reminders do little to help, while written lists do. The little dopamine rush of filling in the checkbox is often enough reward for fixing the leaky gutter... much more so than the resulting dry spot. It comes back to holding one's interest. And, also, to relative importance (as in "hey, I've got an important blog to write that some 60-80 unique users are dying [dieing?] to read... many fewer will benefit from the occasional need to duck past the drip). [what is it with these damn ducks?!]

Dinah's seen my desk. It wreaks of brilliant disorganization. The big problem is my home office. The 1999 piles belie the problem (though I probably would be able to find that receipt for the CME course I took that year if I needed to). I've got more important things to do than spend several hours properly filing things away or tossing them.

So, while there may be dis-order, does it all truly reflect a "disorder"? I like to think that I'm fairly high-functioning. I've been able to put down my duckie. I even have a good system for keeping all the bills paid on time (thank you, BOA Bill-Pay!). So I probably cannot truly experience the rush of checking the DSM4 checkbox under ADD that says that it interferes with functioning (despite Wife's thoughts otherwise).

As a side note, medication does indeed help me focus. Caffeine helps some, but when I really need to put the hammer down, two of those red Sudafed will do the trick (the poor man's Adderall).

Dinah said...

Dear Roy,

I was your boss once. You don't have ADD and you don't need medications. Your office is a mess because you're a slob.

You have an active, sometimes restless, mind and are very engaged and interested in the world around you; you're extremely intelligent and ambitious, and you take on a lot of projects at once (now can I count how many things you've been president or chair of?) which probably overwhelms your ability to do it all and forces you to prioritize, which you do just fine; if they're not the priorities your wife would set, well that's another issue (and I'm just not going there). In all the time and settings I've known you, I have never heard anyone utter an unkind word about you and I'm not aware that anyone has ever been displeased with your work: your co-workers and patients like and respect you. Even your co-bloggers think very highly of you.

Case in point: why is this family even entertaining the issue of a psychiatric diagnosis of ADD for this successful physician? Why can't he just be a slob?

Lay off the sudafed, Roy.

Roy said...

So Sudafed is the latest off-label drug to be used for that newest of DSM-5 disorders, Slob. I'm sure I have the gene for it (or, more likely, it is polygenic). The criteria are not yet finalized, but those who don't quite fit the criteria will have the more general form, called Messiness, Not Otherwise Specified.

Sarebear said...

Messiness, NOS . . .

Ohmygosh, I SO needed a good laugh! Hee.

Thanks!

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