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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 10 of 10. This is the beginning of the thread.
Posted by trialerror on August 31, 2002, at 3:36:53
Hi Folks!
I'm new here but have been reading through the archives quite a bit - and also trying to find a Pdoc who can help me out.
One thing (among many) that I've noticed in reading the archives is the "rite of passage" that so many go through to become a certified, DIAGNOSED ADHDer, and thereby more readily eligible for Schedule II medication.
My problem (among many) is that in NO way did I suffer ADH-Disorder as a kid - although I've had debilitating "look alike" symptoms of ADD (inattentive & higly distractable) since late adolescence. So under a "strict" diagnosis of ADHD, I don't seem to meet the "guidelines" - i.e., onset (even if undiagnosed at the time) during childhood by no later than age 7 or 8.
I'm aware there are physicians out there who may have a less strict definition of the ADHD disorder.
But I think it's probably fair to say that my ADD symptoms may actually, instead, be related to depression, anxiety and social phobia I've also suffered from since late adolescence.
Here's the ISSUE:
I recently discovered the almost miraculous (for me, anyways) anxiety reducing powers of fluoxetin (40 mg/day), which my GP has prescribed for me. At the same time, this has done virtually nothing for my ADD "look alike" distractability symptoms. AND I can't seem to find any Pdoc who is even willing to discuss "augmenting" my medications to include a stimulant (dopamine enhancer) that might help in this regard.
What's particularly troubling is that as soon as the words Ritalin or Dexedrine pass through my lips, I see a tremor of fear, discomfort or "professional distancing" briefly flicker in the face of the Pdoc I'm talking with. (Believe me, I would really rather play coy and not have to utter those taboo words, but at some point if the Pdoc doesn't bring it up, I must.)
In the article "Making the Three Tenors Sing," Dr. Alan Salerian makes a pretty good case for augmenting SSRI's with P-stims in cases of anxiety and depression where ADHD is not diagnosed.
See:
http://www.washingtonpost.com/ac2/wp-dyn?pagename=article&node=&contentId=A25065-2000Jun20¬Found=true
Quite a few contributors to this forum have also attested to their personal experiences confirming the benefits of a combined serotonin, dopamine and norepinephrine enhancing "cocktail."
BOTTOM LINE -- I really really wish I could get a "silver star" from a Pdoc, a certified diagnosis of DSM-IV ADH Disorder. At the same time, it really goes against the grain and my (albeit limited) self-respect and sense of integrity to have to force fit the "facts" of my life into a dubious case that meets the ill-defined specs of this DSM-IV disorder, so as to make the PDoc him/herself feel relaxed and at ease in presribing "dangerous" Schedule II medication.
Does this make sense?
Can anyone relate?
It can't be true, can it, that one must go & somehow pass the test for DSM-IV designation, and then have the ADHD dx badge proudly affixed to one's lapel in order to get medication for attention deficit "symptoms" that may be little or no different from "inattention" symptoms experienced by certified sufferers of this "disorder"?
In other words, how on earth do I go about finding a PDoc, like Alan Salerian, who is not utterly paranoid about prescribing Schedule II p-stims for "mere" anxiety/depression accompanied by high-level, long term distractability?
Maybe I should give Dr. Salerian a call for a reference in SoCal?
Or maybe I should be mentally preparing myself for a monthly dash down to a pharmacy in TJ?
Any insights, comments, criticisms &/or perspectives would be HIGHLY appreciated.
Thanks!
-trial&error
Posted by trialerror on August 31, 2002, at 20:03:59
In reply to How 2 find good Pdoc 4 non-ADHDer w/ ADD symptoms, posted by trialerror on August 31, 2002, at 3:36:53
On Mar 19, 2002, Fachad wrote:
>>> The only current approved uses are treatment of ADHD and narcolepsy, but many pdocs are finding them useful for augmenting SSRIs and other ADs. <<<
(See - http://www.dr-bob.org/babble/20020318/msgs/98949.html )
This leaves those of us with attention deficit SYMPTOMS, but who are NOT blessed with a "certifiable," etiologically correct, DSM-IV sanctioned ADH "DISORDER," in quite a bind, as regards obtaining psychostimulant medication.
Now if I could find a doctor who medicates according to actual current symptoms rather than what my mental health was 40 years ago, I might not be in such a pickle.
As it is, a monthly trip to Tijuana is looking more and more likely.
I can't be the only one who's been faced with this dilemma, can I?
-trial&error
Posted by sudhira on September 1, 2002, at 17:39:19
In reply to And to follow up on something Fachad wrote . . . ., posted by trialerror on August 31, 2002, at 20:03:59
Levels of stimulant paranoia vary from one doctor to the next. In WA I had a doctor who let me try ritalin as an AD augment after one session of discussing my symptoms. He supposed I may have inattentive ADD--but I was not evaluated by a specialist. Like you I have many but not all the symptoms that would indicate ADD--
I moved to OR and my new doc was very anti-stimulant; suspicious of my diagnosis because it was not "official". Before she would consider a prescription for a stimulant she first wanted to see if other less risky medications would address my symptoms of SSRI induced apathy and lethargy. Medications that "act" like stimulants. I tried Provigil, no luck. Used Wellbutrin for 2 months, same story. It became obvious that since the supposedly activating meds did nothing for me that adding a stimulant ought to be the next step. Have you tried any of the activating meds that "act" like stimulants? Docs are much more willing to prescribe these and sometimes they prove so helpful that real stimulants aren't needed.
So finally I was prescribed ritalin again. I don't know whether or not I have ADD. I do know that adding a stimulant has benefited me signifigantly. There are studies and posts that indicate that stimulants can further potentiate the positive effects of ad's. Doctors also use them in cases of refractory depression. I have noticed some mood improvement and better ability to organize my thoughts and be productive.
I read in a post that someone wrote a letter to a doctor before she met with him. She described her situation and detailed why she felt a trial of a stimulant might be helpful. She wanted to find out if he was open minded enough to have this discussion or not.
Basically in some cases the use of a stimulant is justified even if a person has not been diagnosed with ADD. I brought research to show my doctor. It might be helpful for you to share the article you provided in your first post with your doctor. If you have no history of drug abuse and have used prescription medications responsibly there's no reason why a closely monitered trial of a stimulant should not be considered. Especially if you feel that your ad does not address all of your symptoms.
Am I making any sense? I wish I wrote as clearly and effectively as you. I related to your situation. Docs can make you feel so defensive about wanting to improve the quality of your life. I recall thinking: Aargh! I'm not trying to get high, I just want to function better!
Posted by fachad on September 2, 2002, at 5:44:38
In reply to And to follow up on something Fachad wrote . . . ., posted by trialerror on August 31, 2002, at 20:03:59
Well, those creteria are pretty arbitrary, IMHO. The checklists for the disorders are a lot like horoscopes - you can say, umm, YES, that is true for me!
And it really is true for you, in a sense. Don't forget that the primary purpose of DSM is to try to make psychiatry seem like "regular" medicine, and more importantly, to give insurance companies something concrete to reimburse for. Don't take a DSM diagnosis - or the lack of one - too seriously.
Besides, the only ADD creteria that could be called into doubt is the prior diagnosis, and that would be hard to prove either way - it could have been undiagnosed, your parents might not have believed in it so they refused to let you be diagnosed, you could have moved and lost records, etc.
> On Mar 19, 2002, Fachad wrote:
>
> >>> The only current approved uses are treatment of ADHD and narcolepsy, but many pdocs are finding them useful for augmenting SSRIs and other ADs. <<<
>
> (See - http://www.dr-bob.org/babble/20020318/msgs/98949.html )
>
> This leaves those of us with attention deficit SYMPTOMS, but who are NOT blessed with a "certifiable," etiologically correct, DSM-IV sanctioned ADH "DISORDER," in quite a bind, as regards obtaining psychostimulant medication.
>
> Now if I could find a doctor who medicates according to actual current symptoms rather than what my mental health was 40 years ago, I might not be in such a pickle.
>
> As it is, a monthly trip to Tijuana is looking more and more likely.
>
> I can't be the only one who's been faced with this dilemma, can I?
>
> -trial&error
Posted by trialerror on September 2, 2002, at 6:24:50
In reply to Re: And to follow up on something Fachad wrote . . . . » trialerror, posted by sudhira on September 1, 2002, at 17:39:19
Sudhira wrote:
>>> Levels of stimulant paranoia vary from one doctor to the next. In WA I had a doctor who let me try ritalin as an AD augment after one session of discussing my symptoms. He supposed I may have inattentive ADD--but I was not evaluated by a specialist. Like you I have many but not all the symptoms that would indicate ADD--
>>> I moved to OR and my new doc was very anti-stimulant; suspicious of my diagnosis because it was not "official". Before she would consider a prescription for a stimulant she first wanted to see if other less risky medications would address my symptoms of SSRI induced apathy and lethargy. Medications that "act" like stimulants. I tried Provigil, no luck. Used Wellbutrin for 2 months, same story. It became obvious that since the supposedly activating meds did nothing for me that adding a stimulant ought to be the next step.
[snip]
>>> So finally I was prescribed ritalin again. I don't know whether or not I have ADD. I do know that adding a stimulant has benefited me signifigantly. There are studies and posts that indicate that stimulants can further potentiate the positive effects of ad's. Doctors also use them in cases of refractory depression. I have noticed some mood improvement and better ability to organize my thoughts and be productive. <<<
DSM-IV seems to contain large regions of "terra incognito" inhabited by the likes of you & me (and likely many, if not most, "certified" ADHD adults) who may not satisfy the strict "B" prong diagnostic requirement of symptoms by age 7.
And yet we may well benefit from CNS stimulant meds as the FIRST line of treatment.
I've finished up my internet research for the time being. It looks like prescribing Schedule II p-stims to kids is pretty much a no-brainer. But writing p-stim prescriptions for adults requires a much more conscientious and dedicated physcian, one who is prepared to use his or her own best professional judgment and not follow robotically the most simple minded interpretation of the DSM and Merck guidelines.
It seems that under DSM, Merck, and the "literature", p-stims are permitted as a FIRST line medication ONLY in cases of:
1. certifiably dx'ed ADHD;
2. narcolepsy;
3. depression in the terminally ill.P-stims are permitted as a THIRD or FOURTH line medication to "augment" or use as an "adjunct" in cases of "TRD" - treatment resistant (or "refractory") depression. So in other words, the paranoid physician will put you through months of trials on Schedule IV SSRI's and other meds before daring to stick his or her neck out and prescribing one of those fiendishly addicting Schedule II drugs.
I've also done a little research to try & find out exactly what this physician p-stim paranoia is all about.
Virtually no doctors, it appears, are being officially reprimanded or have their medical licenses and/or DEA controlled substance privileges suspended or revoked simply on account of over-prescribing p-stims.
Some MD's are disciplined on account of their own substance abuse.
The real fear, however, seems to be of malpractice suits and/or criminal negligence in case something goes deeply awry, such as a serious drug reaction or OD (if the patient is also getting supplied from other sources), or the patient just decides to sue for the heck of it, as many do. The doctor's records would then be subpoenaed & audited; the physician's notes would be examined to determine how complete the diagnosis was and how closely "established" (i.e. robotic) guidelines were followed; and his or judgment in prescribing the drug would of course be questioned & second guessed & harped upon before a judge & jury -- if it ever got that far, because the insurance carrier would probably pay out a costly settlement in aniticipation of a runaway jury verdict.
That's the only explanation I can come up with for this hyper-CYA, patient-welfare-be-damned paranoia. In the case of Ritalin and Dexedrine, however, if prescribed in low, controlled dosages, I don't see how such paranoia is at all justified. But then no one calls me "Doctor" either.
>>> Have you tried any of the activating meds that "act" like stimulants? Docs are much more willing to prescribe these and sometimes they prove so helpful that real stimulants aren't needed. <<<
Not yet.
I'd really rather not have to go through a long trial period wishing & hoping but not actually knowing whether we'll eventually get down to business with something that has a higher likelihood of working. (If it ends up that I have to do my own unsupervised "trials", I'll order Provigil by mail; supposedly it's OTC in UK & France.)
>>> I read in a post that someone wrote a letter to a doctor before she met with him. She described her situation and detailed why she felt a trial of a stimulant might be helpful. She wanted to find out if he was open minded enough to have this discussion or not. <<<
Thank you for pointing that out. I found a couple of threads describing "mass mailings" to pdocs to find one with an open mind and whose committment to healing outweighs his or her acute risk-averseness.
>>> Basically in some cases the use of a stimulant is justified even if a person has not been diagnosed with ADD. I brought research to show my doctor. It might be helpful for you to share the article you provided in your first post with your doctor. If you have no history of drug abuse and have used prescription medications responsibly there's no reason why a closely monitered trial of a stimulant should not be considered. Especially if you feel that your ad does not address all of your symptoms. <<<
I'll give it a try.
>>> Am I making any sense? <<<
Splendid sense!
>>> I wish I wrote as clearly and effectively as you. <<<
Coming from one whose writing flows so well and whose points are expressed so lucidly, I take that as high praise. But were it only so. ;)
>>> I related to your situation. Docs can make you feel so defensive about wanting to improve the quality of your life. I recall thinking: Aargh! I'm not trying to get high, I just want to function better! <<<
I'll second that emoticon. :)
-trial&error
p.s. -- To anyone who's read this far - my knowledge of this subject is obviously very recent, no doubt superficial, and certainly full of e's & o's (errors & omissions) if not outright bs. Corrections, comments, criticism, etc., is much appreciated.
Posted by trialerror on September 2, 2002, at 6:41:48
In reply to Meeting DSM Diagnostic Criteria » trialerror, posted by fachad on September 2, 2002, at 5:44:38
Fachad wrote,
>>> . . . the only ADD creteria that could be called into doubt is the prior diagnosis, and that would be hard to prove either way - it could have been undiagnosed, your parents might not have believed in it so they refused to let you be diagnosed, you could have moved and lost records, etc. <<<
Sort of a wink-wink approach?
Maybe that IS the best way.
Tho' it does stick in my craw a bit.
And even if didn't, without wasting even more time & treasure, how am I too find a p-doc willing to read my ADHD horoscope as I need it to be read?
In any case, very nice to hear from you, Fachad. I've greatly appreciated your wise "babblings" on this forum!
-trial&error
Posted by fachad on September 2, 2002, at 12:19:13
In reply to Re: Meeting DSM Diagnostic Criteria, posted by trialerror on September 2, 2002, at 6:41:48
> Sort of a wink-wink approach?
>
> Maybe that IS the best way.
>
> Tho' it does stick in my craw a bit.Not really a "wink-wink", just a realization of the limitations of the DSM system. It's modeled to look like the pathogen / disease / therapeutic agent medical model - think about the classic example of strep throat.
Everyone with strep throat will test positive on a strep culture. And that strep bug is the REAL CAUSE of the disease. And because it is a known bug, a known class of antibiotics will kill that bug, eliminate the cause of the disease, and cure the patient.
The situation is NOWHERE near that with DSM diagnosis. The diagnostic criteria are not based on the etiology (true cause) of the disorder; they are based on external symptoms. And the grouping of symptoms is arbitrary.
Imagine if an MD gave the diagnosis of "Fever Disorder" to patients with strep, malaria, food poisoning, and hyperthyroidism! They all meet the "criteria" of a body temperature above such and such, for at least 36 hrs, and they all have chills, and cold sweat...
So much for the validity of "symptom group" based diagnosis. Now the other thing with the regular medical model, in our example strep, is that the diagnosis is tied to the specific cure. Strep is CAUSED by a strep bug, and will always be CURED by a strep killing antibiotic. The treatment is specific, because the diagnosis is made based on a known cause.
But with DSM diagnosis, you get people who are diagnosed with depression responding to ADs, APs, BZDs, mood stabilizers, and even stimulants! If I respond to a mood stabilizers, does that mean I "was really bipolar" all the time? No. If my depression responds to a stimulant, does it mean I must have at least a touch of ADD? No.
That turned into quite a little rant.
Posted by trialerror on September 3, 2002, at 1:41:18
In reply to More on Meeting DSM Diagnostic Criteria » trialerror, posted by fachad on September 2, 2002, at 12:19:13
Need to mentally digest all this before considering my next move.
Best regards,
-trial&error
Posted by fachad on September 3, 2002, at 11:25:57
In reply to Food for thought - thank you, Fachad, posted by trialerror on September 3, 2002, at 1:41:18
Just to let you know, I was not prescribed stimulants from the start. I tried a lot of different ADs and my pdoc and I got to know each other pretty well in the process.
When the time came that I asked for a stimulant trial, I was not just "some guy" asking for speed. The fact that we had worked together for some time helpled him feel comfortable with the trial.
I don't know if there is any quick way around that; in defense of pdocs, they really do have to be careful or they may have professional difficulties.
Here are a few links of prior posts on stimulants for depression:
Stimulant Monotherapy for Depression
http://www.dr-bob.org/babble/20020215/msgs/94717.html
Re: Dexedrine Tolerance? A Theory
http://www.dr-bob.org/babble/20020215/msgs/94906.html
Ritalin for SSRI Induced Apathy Anergia
http://www.dr-bob.org/babble/20020307/msgs/97130.html
Ritalin is not marketed as AD
http://www.dr-bob.org/babble/20020307/msgs/97442.html
Marketing Hype and Specificity of Drug Treatments
http://www.dr-bob.org/babble/20020408/msgs/103154.html
> Need to mentally digest all this before considering my next move.
>
> Best regards,
>
> -trial&error
Posted by trialerror on September 4, 2002, at 4:05:13
In reply to Getting that RX and More Food for Thought » trialerror, posted by fachad on September 3, 2002, at 11:25:57
Fachad wrote:
>>> Just to let you know, I was not prescribed stimulants from the start. I tried a lot of different ADs and my pdoc and I got to know each other pretty well in the process. <<<
I've been working with one pdoc for the last two months - and we're getting nowhere at an ever accelerating pace.
I've now got an appointment scheduled with another pdoc whose area of specialty is ADHD. I'll try to present him with my best facts to win that coveted ADHD silver star. No grade school report cards to bolster my case, but I do have personal recollections as well as descriptions of family members' own ADHDish behavior. This pdoc is known to someone in my family (unlike the first guy to whom I was a complete & total stranger) who could perhaps offer backround info on my drug & addiction free life, if that would help allay any controlled substance paranoia on the part of this pdoc. Whether such a "personal reference" would be considered or even accepted is another matter.
In any case, I have neither the funds nor the patience to go though a long "courtship" with this new pdoc. Thanks to you & Sudhira and the Babble archives, I believe I may be able to discuss with him my situation from a much higher knowledge base than I was able to with the first gentleman. If the prospect of a fast & friendly "horoscope reading" appears dim, however, then it's down to Old Mexico asap.
>>> When the time came that I asked for a stimulant trial, I was not just "some guy" asking for speed. The fact that we had worked together for some time helpled him feel comfortable with the trial.I don't know if there is any quick way around that; in defense of pdocs, they really do have to be careful or they may have professional difficulties. <<<
They have my full sympathy and understanding.
Query - do I have theirs?
>>> Here are a few links of prior posts on stimulants for depression:
Stimulant Monotherapy for Depression
http://www.dr-bob.org/babble/20020215/msgs/94717.html
****
Re: Dexedrine Tolerance? A Theory
http://www.dr-bob.org/babble/20020215/msgs/94906.html
****
Ritalin for SSRI Induced Apathy Anergia
http://www.dr-bob.org/babble/20020307/msgs/97130.html
****
Ritalin is not marketed as AD
http://www.dr-bob.org/babble/20020307/msgs/97442.html
****
Marketing Hype and Specificity of Drug Treatments
http://www.dr-bob.org/babble/20020408/msgs/103154.html <<<It's great to have all of these shrewd and informative essays indexed in one place. Thank you very much, Fachad.
-trial&error
This is the end of the thread.
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