Recently, someone who I have treated for several years was in my office and as he described some stress that he had experienced when he was training a new employee and it seemed to me that his level of stress was much higher than it needed to be considering his coping skills and ability to manage training his employees.  I then explored with him his baseline stress level when he has nothing happening that he feels stressed about. As we discussed this it became clear to me that he was having flashback type reactions and being triggered by events to recall past stresses. These are centered around stressful events related to his struggles with concentration and attention. I concluded that he was experiencing PTSD symptoms because of events connected to his problems with concentration and attention span.  

I had previously diagnosed PTSD for people with ADD/ADHD but they all had other traumatic experiences that were enough to cause the PTSD. This time the traumatic events were directly related to the ADHD. Importantly, I had not recognized this earlier and I believe that this kept my patient from making more progress letting go of his stress reactions. 

After recognizing my patient's PTSD symptoms I helped him to commit himself to protecting himself from stress and working on calming himself with mindfulness type skills.  I also discussed trying a stronger antianxiety medication to help reduce the number of times that his brain reacts [instantly] to triggers related to past traumatic experiences.  For him I recommended a low dose of aripiprazole.  I have found this type of medication superior to antidepressants, benzodiazepines, propranolol, etc.



Empathy is good and shame is bad.  So why is this a big deal?  It may be because shame is so destructive and empathy is so helpful. What makes shame so destructive? If you have ever experienced shame [and it is possible that everyone has experienced shame] then you know how bad it feels.  Shame makes people feel alone and separated from others.  We have our unique ways of responding when we feel shame and yet certain patterns of response have been identified by Linda Hartling,Ph.D. Director of Human Dignity and Humiliation Studies, that she calls "strategies of disconnection" [from the pain associated with feeling shame] that include: 1. moving away from people by disappearing into ourselves; 2. moving toward others by people pleasing behaviors; and 3. moving against others by anger and fighting back.

What causes shame?  Some people connect shame with traumatic experiences.  So when we feel overwhelmed we feel shame?  Being overwhelmed does seem to separate us from others and likely from ourselves.  This makes being empathic or responding to empathy from others difficult, if not impossible.  What can we do?  Brene' Brown in a TED Talk about shame indicated the importance of being able to identify things that will cause each of us to feel shame.  These triggers, when we are aware of them, can be avoided at times and our awareness can allow us to cut short the shame response before it becomes powerful.  Our awareness can allow us to stop ourselves from responding in our usual and negative way, substituting a self-affirming response.  Sounds good but how do we break a pattern that often has been established over years? 

Dean Smith [long time coach of the North Carolina Chapel Hill basketball] is quoted as saying that if you make a mistake you should "recognize it, admit it, learn from it and forget it." Maybe this could help us deal with feelings of shame.  It also may be related to recommendations for how people who have been traumatized can help themselves [with the support of a therapist] by choosing to think about the past trauma and tell themselves that they don't need to be stressed by the event anymore and why, then move on and let it go [forget it?]. It also helps if we are able to calm ourselves and clear our minds and then choose to think about past traumas.  So, as I have blogged about previously, to help people recover from traumatic experiences research indicates that it is good to combine mindfulness practices [calming ourselves and clearing our  minds]; Trauma Focused Cognitive Behavioral Therapy [like what I described above] and interpersonal therapy [working with someone that you trust so you are willing to risk trying out new skills to let go of worries about past stresses].

So, what about empathy?  According to Brene' Brown, shame can't survive empathy. So, why is that?  Well, empathy connects people and shame disconnects people.  To respond empathically we need to listen to others nonjudgementally and communicate our understanding of what others are feeling. This invites responses from others and creates a sense of connection and support.  To be empathic we need to be present with others and not be reactive or judgemental.  This seems like a good way to relate to others all the time.  




I've had several requests to write another blog about grief.  A number of my patients have lost pets, mostly dogs.  Some have had to make the decision to euthanize their pets.  We have had discussions about how to prepare for the death of a pet.  This includes whether to create a shrine to their pet.  The need for a shrine seems related to worries that we will not be able to remember those that we have lost.  This worry starts before our loved ones die and we seem to worry more the more things we accumulate to remind us of the loved ones, the more worried we become.  So, why does this happen?  It might be that the focus on trying to remember makes it harder to remember.  When we are worried our brains automatically make this a priority.  When this happens it is harder for us to access stored information and this is where we access our memories, including those of our loved ones. Therefore, if we start worrying about our loved ones we can have a difficult time remembering them because of our worrying about them, including worrying about being able to remember them.

You can then imagine what can and often does happen.  Our worries lead us to signal our brains that we are stressed and our brains respond to this stress and then we can't access memories about our loved ones so this intensifies our worries and it is even harder to access memories, etc.  This is one reason that some people decide to make shrines to their loved ones as a way of holding on to memories.  These may help cue some memories and yet this cueing is not needed if we are calm and trust our brains to supply the memories, and they will.  If we trust our brains we might also be able to discover that our loved ones are still with us.  Worries and shrines get in the way of this.  Of course, keeping some photos and a few items can be comforting unless you do this to try to reduce worrying. This is not comforting.  

So, try not worrying and see what happens.  Of course, it is ok to let yourself have feelings and then move on to what is next.  However, it is not ok to use feelings as a way of worrying becauses you know what can happen then.



I've been helped by my patients to see patterns of brain functioning in people who have difficulty concentrating and focusing.  They seem to rely on stress and deadlines to help them focus.  They also seem to be able to focus if they are excited about something and find it novel and stimulating.  So, concentration and focusing are helped by stress and novel and exciting learning opportunities.  However, this type of concentration and focusing is short lived as it is kept in reserve to help cope with stress and to allow focusing in novel and exciting situations.  It is not meant to be used for routine focusing and routine learning.  This then presents a problem for people with ADD/ADHD as they require stress to be able to focus.  Thus their need for deadline pressure to complete projects and assignments.  This alone contributes to a lot of stress and conflict with others who do not understand why they procrastinate [do things at the last minute].  

However, and importantly, with treatment using so called stimulant type medications, concentration and focusing are improved so that it is no longer necessary to rely on deadline pressures to concentrate and focus. This does require that the medication is titrated so that focusing is supported during waking hours to allow the time necessary to complete tasks and to relate to family and friends.  It also is necessary for the individual who is taking medication to support their concentration, to tell their brain that they no longer need to depend on deadlines and stress to focus as the brain is used to this pattern and will maintain it unless repeatedly instructed to change it.  This last is very important.



I recently saw a Michael Jordan poster that pointed out all the shots that he had missed [thousands] including game winning shots that he missed.  It ends by saying that he failed repeatedly and that was why he succeeded. Do you believe that?  Does failure lead to success?

Right after seeing the poster, I met with one of my patients who had just been told that something he had worked on for months would have to be either redone or fixed some how so that it would work. He was discouraged and was trying to talk himself into quitting and not redoing it.  After saying this, he knew that it would not be right for him to quit and that the right thing for him to do was to keep going and make it work. He was also able to reflect on the quality of what he had completed and this helped him to make a renewed committment to keep trying.  

We then talked about the value of persistence as we may need to repeatedly do what we think is right as we run into road blocks.  My patient then wondered what else we would do besides what we felt was the right thing to do and was true to our values and beliefs.  So, what else would we do?  Is it that simple?  

So maybe failing to succeed is really persisting to succeed.  What do you think?

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