WHY I AM GLAD THAT I DON'T KNOW ANYTHING

Recently I received a call from one of my patients who told me that he was running out of his aripiprazole [Abilify] medication.  I had recently increased his dose fom 7.5 mg to 15 mg and I remembered feeling surprised that he was requiring a dose above 7.5 mg.  He told me that he was running out of the medication because he had accidentally increased it to 30 mg and was feeling much better with a significant reduction in his anxiety symptoms.  This patient has PTSD and I realized that I was acting like I knew that he would not need a dose higher of aripiprazole and of course I was wrong.  I try to keep my mind open and not predict the future.  By predicting the future I mean that I am concluding things before I find out about them.  Such as concluding that my patient would not need a dose above 7.5 mg when he actually needed 30 mg.  So that is why I am glad when I don't know anything. I am more able to help my patients when I am open to see what they need and not closing my mind by thinking I know what they need before we actually find out.  

I believe that this is what Socrates was talking about when he said that he had finally figured out why the god Apollo said that he was the smartest person in Greece.  It was because he knew that he didn't know anything. He was able to keep his mind open to possibilities.  If I am able to keep my mind open to possibillities I am more able to be open to help my patients assess what they need for a successful treatment.  This means any aspect of their treatment, not just the medications that I prescribe.

CONSUMING FEAR OR CONSUMED BY FEAR?

After the terrorist attacks in Paris, I heard a priest give a sermon where he said that we are being consumed by fear, that we are like vultures, and the fear is like carrion. This sounds like we are consuming fear and can't get enough of it.

My patients have shown me that their fear makes them like the carrion and they are being being consumed by the vulture of fear.  If it seems that we cannot get enough of fear, it may be that is because we feel compelled to expose ourselves to stressful events over and over.  An example might be the TV news that seems focused on reportiing stressful events over and over. Maybe we keep exposing ourselves to stress in the hope that it will change and be ok and no longer a stress. Some of my patients saw the planes hit the twin towers thousands of times.  I saw it twice and I was upset with myself for choosing to see it a second time, as that was not necessary and only increased my stress level.  It also seems that stress is related to worries and that worries are almost reassuring in that if you worry a lot you will always know what is going to happen...you will be worrying.  

So, why is it so hard to stop worrying?  As I've mentioned, being able to know what was going to happen each day may be reassuring enough to keep us worrying.  I also wonder if our brains recall past stressful events and bring up a memory of this event as a way of asking us if we are still stressed by this but we think our brains are making statements, telling us to be stressed and worried.  So why don't our brains tell us they are asking questions?  This might have to do with the fact that it is our brain and we are supposed to be in charge and make the decisions that then tell our brains what to do.  This may not sound like the way your brain works, or mine.  Yet this is important as it reinforces the importance of the choices that we make and that it really is up to us.  

So if it is really up to us why does it seem like it isn't?  What do you think?

YOU CAN BE YOUR OWN RESEARCH STUDY

When I was on the faculty at the University of Pittsburgh School of Medicine, some of my research regarding the effectiveness of medication for ADD/ADHD utilized a single subject research design.  This design uses each person in the study as their own control.  This helps eliminate the uncontrolled variables in large n [number of subjects in the study] studies.  It does require that the treatment or intervention be reversible quickly. Medication treatments for ADD/ADHD are quickly reversible.  

So why have I been talking about this?  I have seen how my patients can assess their responses to medication treatments using a single subject research design. They can compare their symptoms before and after treatment.  They can then compare their responses by changing the treatment by either changing doses or stopping and restarting the medication.  This can be valuable in helping assess the efficacy of medication treatment. It also empowers patients to be more responsible for their treatments and shows them that their input counts.

This methodology can also be used by patients to help them to assess their responses to other forms of treatment such as relaxation and meditation, some cognitive interventions, diet changes, etc.

WHAT IS TREATMENT ALL ABOUT?

One of my children asked me about how I help people who come to see me.  I began reflecting on the different ways that I provide support and encouragement for my patients. I was able to identify a number of different things that I attempt to do.

I believe that my first effort is to help my patients feel that they can trust me to listen to them and value their participation in their own treatment.  Their treatment is a collaborative effort and I need their input to be able to help them. I believe that my willingness to take the time required to listen to them, helps to develop the trust that is required to be able to help them.

After listening, I will ask questions to try to further define the specific nature of their symptoms as they experience them.  I also will be sure that I ask about any stressful events in their lives and what they remember about them as well as whether or not they think about them now. I also carefully go over all of their experiences with medications and supplements.  I will then go over their responses to checklists that I asked them to fill out before beginning our time together.  

After I have a beginning understanding of some of their symptoms and stresses as well as how they cope and their strengths, together we will talk about possible diagnostic understanding and options for beginning treatment. 

I feel that it is important that any initial diagnostic understanding be linked to specific symptoms they are having and the treatment I suggest is also specifically targeting some or all of their symptoms.  We then discuss how they can use their coping skills to reduce their symptoms and to improve their quality of life.  We also discuss new skills that they can develop and what symptoms they are focusing their skills on reducing.  

At every appointment, we review progress in reducing symptoms and improving their quality of life.  I listen carefully to what they report about how they are doing and I am careful to encourage them to pay attention to everything they are experiencing regarding their treatment as I have often seen that even things like unintended missing medication doses can represent their brain telling them something important about their medications.

I also write down suggestions and possible ways to use specific coping skills that we have discussed and give this to my patients at the end of each visit.  

ADD/ADHD...SO WHAT IS THE BIG DEAL?

I have previously blogged about ADD/ADHD [attention deficit disorder/ attention deficit hyperactivity disorder] and the amount of stress that can occur because of significantly limited amounts of sustained concentration and attention.  I am frequently reminded of this when I work with people with this disorder, especially if they have not had treatment or their treatment was only partially successful.  I have also worked with a number of adults who have ADD/ADHD but were not diagnosed as children or were diagnosed but their parents were reluctant to have them on medication.  Most of these undiagnosed adults in my practice are women.  I have also found that adults who have untreated ADD/ADHD and have had substance abuse problems [studies indicate an above 80% liklihood of substance abuse problems if ADD/ADHD is not treated], do well on medications for ADD/ADHD without a return to substance abuse.

The stress of having untreated ADD/ADHD seems mostly related to the impact of only having shorter periods of concentration or attention available and then only reliably present if the person is facing a deadline or other crisis situation, or if the person is facing a very interesting novel situation.  The brain will release focusing and concentraton for these types of situations so it easier to see why people with untreated ADD/ADHD procrastinate and depend on deadlines and crisis type situations to complete tasks. One can also see how this will lead to daily stressful experiences that can lead to chronic anxiety symptoms as well as depression.  It can also lead to post traumatic disorder [PTSD] symptoms that will then reduce focusing and concentrating even more as the brain automatically orients to the stress reactions and tries to reduce them.  

One way the brains of people with untreated ADD/ADHD attempt to reduce stress is to increase their reactions to minor frustrations so that they will withdraw from other people. This reduces their need to concentrate and pay attention as they are removed from human interactions that require a lot of focusing and attention. You can begin to see how all of this can have a major impact on someone's life and interfere with relationships both at home and at work and at school.  It also interferes with self-image as it requires more sustained concentration and attention to think about our life experiences and gain an awareness of ourselves and how we are living our lives. 

So that is why having ADD/ADHD is such a big deal, especially if it is not treated.  Treatment still centers around medication as very good studies have not found alternative treatments to be effective, although some of the brain wave work seems to be able to allow the person to reduce the amount of medication that they require to concentrate and focus.