ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

March 3, 2013

 

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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2 Responses to “ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)”

  1. graffgift said

    Interesting, but slippery. Are they always linked? How about one without the other ? What about the person who can focus intently for hours on something that fascinates him/her? This same person can work on twenty things simultaneously and will eventually finish them all or those worth finishing.
    By the way, it’s “we physicians”.
    What’s so bad about AHHD? As long as you can keep reorganizing, keep track of your lists and actually get started, it’s great.

    • These are excellent comments and I want to address them in order:

      1) ADHD without Hyperactivity most definitely exists. In fact, it is the most common presentation in females and is also how it presents in a significant minority of males. That being said, the nomenclature is definitely confusing. ADHD without Hyperactivity is classified as ADHD; Inattentive subtype. Furthermore, even a person that presents with Hyperactivity during childhood will typically outgrow it but will continue to have the inattentiveness. I intend to elaborate further about the connection between hyperactivity and inattentiveness in my upcoming posts.The theme of the current post is the functional aspects of ADHD and how we need to look for them in order to make this diagnosis.

      2) I agree that the successful multi-tasker does not have ADHD, and I will re-read my post to make sure that I made this clear. However, a person with ADHD will often hyperfocus on tasks that they find interesting, but will do this to the exclusion of the tasks that he or she may find mundane or boring that are, never the less, important. Examples of mundane but important tasks include listening to the teacher, doing homework in subjects that do not hold the persons interest, calling their mother on her birthday, etc. More about this is forthcoming in future posts.

      3) As always, thank you for the edit. I am changing it STAT.

      4) If it’s great it’s not ADHD; no impairments then not ADHD, which is a subtle point that I tried to make in this post. Depression and Anxiety have symptoms including sad mood, loss of interest, lack of pleasure, fear and worry. The sufferer can describe these and a third party can observe these relatively easily. ADHD does not have symptoms per se. ADHD is only evident by the functional impairments that it causes for the person that has it. However, most people including physicians, do not see dysfunction unless they are looking for it. This explains why 85% of adults with ADHD are not diagnosed or on treated.

      Thank you for your comments. They demonstrate your excellent level of attention and I, for one, benefit from it and appreciate it.

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