Its Uniqueness is its Calling Card

In contrast to popular belief, Attention Deficit Hyperactivity Disorder (ADHD) is definitely not over-diagnosed. With less than twenty percent of the 8 million American adults with ADHD aware of the fact that they have the disorder, it can be argued that ADHD is the most under-diagnosed medical condition in the United States; and the adverse consequences  of missing this diagnosis permeate every square inch of the fabric of our nation. Adults with undiagnosed ADHD are disproportionately over-represented the unemployed, addicted, divorced and incarcerated. Try to name one other medical disorder that when unrecognized will have similar consequences for the person affected or for society; I assure you, you will not able to do it. Therefore, this article will dispense with the common misconceptions and get down to the business of seeing what is right in front of our eyes every day; and until we recognize ADHD we most certainly will not effectively treat it.

When I began learning about ADHD about 15 years ago, one of the first things that struck me was the many ways that ADHD is unique. For simplicity, I will count the unique characteristics of ADHD here:

  1. If you have ADHD, you were born with ADHD- of the entire alphabet soup of mental health disorders, such as OCD (Obsessive Compulsive Disorder), PTSD (Post Traumatic Stress Disorder or BPD (Bipolar Disorder), ADHD is the only one that a person has at birth; all the rest are acquired at a later stage in the life cycle.
  2. ADHD is the most inherited of all the mental health disorders if you have ADHD, there is a 100% chance that either your mother, father or both have ADHD, a 50% chance that your brother or sister also has ADHD and a 50% chance that one or more of your children have ADHD.
  3. If you were born with ADHD but it was never diagnosed or treated, you have nearly a 100% chance of acquiring a second, third and even fourth mental health disorder, such as substance abuse, addiction, Anxiety Disorder and Mood Disorder by the age of 40.
  4. ADHD is the only mental health disorder that has no discrete symptoms; it only has functional impairments, such as academic, vocational and interpersonal failures unlike the Anxiety and Mood Disorders, there is no such thing as an ADHD attack.
  5. ADHD is the only mental health disorder that only involves a single neurotransmitter (Dopamine)-all the other mental health disorders involve multiple neurotransmitters, such as norepinephrine, GABA and the most famous of all neurotransmitters, Serotonin.

By focusing on these five unique characteristics of ADHD, I will show you in my next post how much easier it is to see ADHD; and trust me, this is something you do not want to miss.

End Post

Mitchell R. Weisberg, MD

Internist, Psychopharmacologist and Personal Physician at

Optimal Performance MD

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The Birth of  an Eating Disorder

It’s December and school is out for winter vacation. For one fortunate eleven year old girl, life doesn’t get better than this. In just two more days her family is escaping the Chicago winter and heading to the sunshine state for a vacation. In anticipation she has packed her suitcase since Thanksgiving. In her excitement, the girl dons her first ever two piece bathing suit and comes to the family dinner table where her fifteen year old sister says, “I hope you are not wearing that bathing suit in public”. Until this very moment, this little girl never paid much attention to her body. To her it was nothing more than the vehicle that transported her on, what to this very moment, was a fun and carefree journey; but the journey, in an instant, was commandeered by the luster of her vehicle which, according to her older sister who she idolizes, is lacking.

For the first time in her eleven years, the girl focuses on her physical imperfections to the virtual exclusion of everything else. “How did I get this way?” she will ask herself repeatedly, and only one answer resounds in her adolescent mind; food did this to me! With her enemy identified, her combat strategy is intuitive; evasive action. As the weeks pass, the girl is able to go for longer periods of time without eating and she is certain that she is on the path to victory, until she is ambushed by an invisible enemy called addiction. One day after school the girl comes home to the aroma of freshly baked chocolate chip cookies. Forgoing food since the previous evening, the girl decides she deserves a reward and determines she will allow herself one cookie. Rewarding indeed! Immediately after unconsciously consuming her fourteenth cookie, every one of her 40-trillion previously starving cells experiences a collective euphoria; and just as immediately, she experiences an overwhelming psychological sense of defeat, guilt and self-loathing. However, this only serves to renew her vigor upon her return to the battle. For this, now unfortunate, girl food has become heroin. She cycles between self-starvation, binging, defeat and self-loathing. The major difference however, is that food, far from being a toxic substance, is the only source on Earth from which the girl derives the energy to effectively live her life. Further down the road, distressed over her failure at evasive action, the girl adds a new battle strategy; expelling the enemy.

The message is this; sticks and stones may break bones, but names definitely hurt children; and they can be the essential ingredient in a recipe for disaster, otherwise known as an eating disorder. When we are communicating with our children about their health and wellbeing it is incumbent upon us to be mindful of this strong link between their body image and their risk for developing an eating disorder.

End

Mitchell R. Weisberg, MD

Founder/CEO and Personal Physician at

Optimal Performance MD

 

The Space Shuttle Challenger of Mental Health Disorders

Figure 1

January 28,1986 Space Shuttle Challenger at takeoff

220px-STS-51-L_grey_smoke_on_SRB

Figure 2

Space Shuttle Challenger 73 seconds after takeoff

explosion

Figure 3

An O-ring similar to the one that caused the Space Shuttle Challenger Disaster

Shuttle_O_Ring_1

 

 

How in the world did anyone ever figure this out?

For the details you should look at the following link:

The official cause of the Space Shuttle Challenger explosion

A Presidential Commission ordered the Rogers Commission Report and charged it with investigating the Space Shuttle Challenger disaster. By thinking from function to structure, or in this case, from mal-function to structural defect, the fourteen men and one woman on the Rogers commission derived that the Challenger explosion was the result of a structurally faulty O-ring . They came to this conclusion after watching and re-watching hundreds of hours of video from every conceivable angle of the Challenger’s takeoff, its 73-secod flight path and explosion; reviewing every possible aspect of the flight data; and as they were doing this, the scientists on the commission formed theories that could explain all the potential structural defects that could have possibly led to the Challenger’s catastrophic mal-function and excluded each of them until they found the one theory that explained all the data.

  • How is this different from how we usually think in our every day lives?
  • How is this different from how doctors usually think when they are diagnosing problems in their patients?
  • What does the commission’s figuring out the cause of the Space Shuttle Challenger disaster have to do with how we need to think in order for us to recognize ADHD?

The answer to this last question is that this has everything to do with how we need to think in order for us to recognize ADHD, and our understanding the answers to these questions requires us all to think differently than we usually do. While this is not rocket science, I ask you to bear with me as I elaborate on the cornerstone of scientific thinking; the relationship between structure and function. The reward for completing this mental exercise will be a comprehensive understanding of one of the most common, the most under-diagnosed and the most treatable of all the mental health disorders, which is ADHD. The penalty for not recognizing and appropriately treating ADHD is truly a disaster for the person who has the disorder.

We will begin our examination of the structure-function relationship with thunder and lightning, perceptually two different entities, which are actually two manifestations of a single entity, an electrical discharge between the ground and the sky. Thunder is the sound and lightning is the sight from an electrical discharge. As with the faulty O-ring in the Challenger explosion, the electrical discharge in is not what we immediately perceive; it had to be derived by observing its function, thunder and lightning. Now, let’s consider a sheet of paper lying flat on a desktop (structure). It will function perfectly as a writing surface. However, when we carefully fold this same sheet of paper it in a certain way (structure) it will no longer be a perfect writing surface, but we can fly across the room like an airplane (function). Finally, when we crumble this same sheet of paper tightly in our hands (structure), it is no longer a perfect writing surface nor can it fly it like an airplane, but we can toss it across the room into a trash can (function). Regardless of how many ways we change this same sheet of paper the relationship between its structure and function remains inseparable, or constant. Furthermore, this relationship of an object’s structure and function holds regardless of its scale; whether sub-atomic, microscopic or astronomical. A single proton in its nucleus is all that separates the 118 elements from the element to its left or to its right on the Periodic Table of the Elements. The Carbon atom having six protons in its nucleus (structure) is the exclusive template upon which all life (function) on our planet arose. Jupiter, being the largest planet (structure) in our solar system acts as a gravitational shield (function), protecting planet Earth from catastrophic collisions with debris in the form of asteroids from the solar system’s formation. In essence the astronomical structure of Jupiter allowed the subatomic structure of the Carbon atom to function as the template upon which all life on Earth arose. Thank you Jupiter!

If until now you have not yet pondered the relationship between structure and function, I hope that the preceding paragraph has shown you that we were all just one invisible proton and one massive planet away from never happening; but what does this have to do with recognizing ADHD? We are almost there, but first I need to show how us physicians use the structure-function relationship every day, whether we are aware of it or not, as we try to figure out what is going on with our patients. For unless it was by sheer luck, any physician that ever made a correct diagnosis in his or her patient did so with this immutable structure-function relationship in mindFor example, in a patient that is having trouble breathing, as the patient provides a detailed description of their symptoms, the physician is visualizing the structure of all the organs involved with breathing from the lungs, to the red blood cells to the four chambers of the heart, in trying to correlate the patients symptoms to the malfunctioning of these organs; if a patient that finds it easier to breathe when sitting up as opposed to lying down, she likely has Congestive Heart Failure  as the cause of her shortness of breath where, if her breathing is worse on exposure to cold or dusty air, constriction of her airways, or Asthma is the most likely cause and if she has a fever of 103 degrees and is coughing, Pneumonia is the likeliest cause. The structure-function relationship is cornerstone of all scientific thinking including clinical medicine.

Why is it that physicians fail to recognize ADHD in spite of the numerous occasions they have seen it? The classic optical illusion of The Young Lady or the Old Hag will provide us with the answer to this question. When looking at this picture, depending on the viewer’s perspective they see either the profile of a beautiful young woman or the face of an old hag. Until a person is able to see each image separately, it is impossible for him or her to see both images simultaneously. This is due to the mental effort it takes to switch perspectives. Said another way, we rarely if ever find anything that we are not looking for. During our education and training we physicians learned to analyze clinical information going from structure to function. In medical school, we learn Anatomy (normal structure) before Physiology (normal function); and we learn physiology before learning Pathology (mal-function). Why is this the logical sequence of learning in order to become a physician? The answer is that structure is three dimensional and therefore we can perceive it; we can see, feel, hear, smell it and even taste structure. Function, however, needs to be derived using a distinctly human cognitive ability called abstract thinking.

Now let’s return to our breathless patient. After the patient explains her symptoms, the physician uses those clues while he examines her structurally; measuring her vital signs, listening to her heart and lungs with a stethoscope and getting X-Rays or CAT-scans or the myriad of other diagnostic tests at his disposal which allow him to look at, in detail, the structure of his patient. By correlating the patient’s mal-function with their examination of the patient’s structure, the physician can determine the cause of the patient’s malfunction,  or diagnose his patient appropriately. This is truly an amazing intellectual feat, but how do we resolve a situation in which structure is not perceptible by our human senses, even when aided by CAT-scans or MRI scans? What if we have to resolve a situation in which function or malfunction is the only clue we have to work with? This is the kind of thinking required to figure out the cause of the Challenger disaster or to recognize a patient that has ADHD, and we do not learn how to do it in medical school either.

Recall earlier when I mentioned the Periodic Table of the Elements; no human has ever seen a Hydrogen atom either, yet the human intellect, for better or for worse, was able to split one. Need I say more? Unless physicians examine how patients are functioning,  they will never see a single patient with ADHD. To recognize ADHD, or any other mental illness for that matter, requires that we see both The Young Lady and the Old Hag simultaneously. Unlike the disorders on the mental health spectrum, ADHD has no symptoms; it only has functional consequences.

This is enough to think about for now. There is more to come.

END

Mitchell R. Weisberg, MD

Internist/PsychopharmacologistFounder/CEO and Personal Physician

Optimal Performance MD

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