Updated: Oct 13, 2022
Easily one of the more common diagnosis I am finding in my primary care practice more recently is ADD in adults, and admittedly, these individuals aren't well. They are overwhelmed. Maxed out. Frozen. Broken. Addicted. Angry and fearful. They are mad at themselves for not being in better control of their lives, for missing appointments, for pushing deadlines, or maybe even behaving somewhat inappropriately, blurting out their thoughts, maybe even being rude and insulting at times. Trivial distractions seem much more attention than the important tasks in their lives.
These individuals have often been mismanaged. Many are unaware their struggles have a name, and certainly haven't considered ADD, but even when well aware and medicated, they still aren't often realizing their optimal state of being.
October is ADD Awareness month so let's talk...
Did you know that 85 percent of psychiatric drugs are prescribed by primary care providers and not psychiatrists?
The diagnosis of adults and children is quite similar with regards to the DSM-5. Any practitioner can utilize this guidance and assign the diagnosis, which essentially requires six or more symptoms of inattention for children up to age 16 years, or five or more for those 17 years and older. These should have been present for at least 6 months and are inappropriate for their developmental age level. Examples would be careless mistakes in schoolwork, failing to give close attention to details, trouble holding attention to play activities, not listen when spoken to directly, not following through on instructions, failing to finish schoolwork or chores, trouble organizing tasks and activities, avoiding tasks that require mental effort over a long period of time, losing things necessary for tasks such as books or their car keys, and also forgetfulness and being easily distracted. Hyperactivity has its own criteria, which helps meet the diagnosis of ADHD.
The unfortunate thing is that most primary care providers are not overly knowledgeable in treating ADD and may misdiagnose or incorrectly treat. There really is no single medical, physical, or genetic test for ADHD. This is a clinical diagnosis based on the clinician's expertise. Checklists may be helpful or standardized behavior rating scales (Copeland Symptom Checklist for Adult ADHD, Wender Utah Rating Scale, & Brown Adult Attention Deficit Disorder Scale), but they certainly aren't required. ADHD should not be diagnosed though from a brief office observation or simply by talking to the client.
Wender developed a set of ADHD criteria, often referred to as the Utah criteria, that reflects features of the adult disorder including the emotional aspects of the syndrome. The hot tempers and angry eruptions are appreciated in this model as significant characteristics of ADHD. Outbursts ranging from euphoria to despair to anger can make the ADHD adult seem out of control.
The Copeland symptom checklist includes eight dimensions: inattention and distractibility; impulsivity; activity level problems; noncompliance; underachievement, disorganization and learning problems; emotional difficulties; poor peer relations; and impaired family relationships. Short-term memory is often impacted. Individuals will have to reread paragraphs to remember what was just read. Some have right-left discrimination problems, motor overflow movements, and sequencing difficulties. Serum lead levels and thyroid function tests can be helpful.
Adults with ADHD do not have a "pure" form of the disorder though, in that having other challenges is more likely to be the rule than the exception. Substance abuse for example is common, whether the chicken or the egg. Addiction can result in effort to self-prescribe because of frustration arising from distractibility, inattention, and impulsivity. Sleep apnea, head injuries, drug interactions, hearing loss, liver disease, and seizure activity should also be considered.
Dr. Amen is a psychiatrist and brain imaging specialist, and Tick Tock superstar. He is redefining #ADD for us all. Dr. Amen's work is really changing the landscape of treatment for individuals with ADD, but know that his work and treatments are not - yet - accepted by the DSM-5. However, also consider that psychotherapist are the only specialist who do not look at the organ they are treating. Right? Think about that; a cardiologist looks at the heart and a dermatologist looks at the skin, but not the psychotherapist.
ADD isn't a one-size-fits-all diagnosis and certainly there are a number of approaches, but his research has really helped us better individualize treatment. Would love to hear your thoughts on the 7 types coined by Dr. Amen in the comments below.
Before-and-after imaging, more often using non-invasive SPECT scans to study blood flow and brain activity patterns, Dr. Amen has found that attention deficit issues are far more complex than we previously appreciated; and that, in fact, there are seven different types of ADD, each with its own symptoms and treatment options. Dr. Amen shares that if he could, he'd add one more and that would be the ADD that results from head trauma or frontal lobe trauma. Even if you never suffered a concussion, your hippocampus will suffer consequence.
Never have I been a fan of the ABA therapy or the behavioral modification approach to #neurodivergent individuals, as I think it's truly dehumanizing to manipulate someone to behave in a way that is easier and makes other people feel more comfortable, but ultimately means you have to mask yourself, make yourself smaller and ignore your primary needs to communicate and move. The #somatic #trauma in these individuals, in addition to all the more obvious trauma they endure really must be profound. My goal has been to remove the barriers that prevent these individuals from being who they really are - their best self.
Attention Deficit Disorder
Dr. Amen lays out in this research and in his best-selling book, Healing ADD: The Breakthrough Program that Allows You to See and Heal the 7 Types of ADD. The book explores how ADD impacts many areas of the brain and the three #neurotransmitters: dopamine, serotonin, and GABA. The affected brain areas are the prefrontal cortex and cerebellum, which control executive functions of concentration, attention span, judgment, organization, planning and impulse control and the anterior cingulate, which helps the brain shift gears and detect errors. The temporal lobes are also impacted, which involve memory, learning, emotional reactions, mood stability and visual processing, and the basal ganglia is involved, which is a large structure deep in the brain that helps produce the neurotransmitter dopamine. Finally the limbic system is also involved with ADD which sets emotional tone and bonding.
The cerebellum is the most hind part of the brain and is very underappreciated. Although it only composes 10 percent of the brain's volume, it holds half of all the brain's neurons which is typically the most active part of the brain. This is also why coordination exercises, like dancing, yoga, tennis, even table tennis can actually making your mind work better. When we activate the #cerebellum, it has connections and activates the frontal lobe.
Think about riding a horse. One has to really balance themselves when on a horse, engaging their core, and this really ignites the brain - increasing your neuroplasticity. Autistic kids have really benefited from horse therapy, but they can be dangerous. Riders do fall and get injured. This is why I am such a huge advocate of yoga and all types of dance.
As mentioned previously though, ADD is specific to particular areas of the brain and what Dr. Amen has learned from his brain scans is although two people can present with the same symptoms, we don't know until we look at the brain whether they are suffering with too much activity in the brain or too little. Those would too little would clearly benefit from a stimulant, but give a stimulant to an individual who has too much activity and they often become suicidal.
As we look at these, keep in mind that dopamine is for #focus and motivation. Serotonin regulates mood, sleep and shifting attention. GABA calms the brain. Also know that you may identify with more than one type, and yes, you may have more than one type. Let's dive in a bit to the various types of ADD as identified by Dr. Amen and then we can talk about what's next.
These symptoms are being inattentive, distractible, hyperactive, disorganized, and impulsive. Maybe you relate? However, if you're thinking, "No, I can be very focused when I am interested," Ding! Ding! Ding! That's the key! When interested these individuals can really dig in and play their games or work on projects for hours on end, but when not interested, almost nothing can keep you engaged.
The attention required for the regular, everyday activities is the challenge - homework, paperwork, chores - the things that make life work. The things which are new, or novel, or highly stimulating or frightening, people with ADD can pay attention to just fine. Those activities with their own intrinsic dopamine are those which these individuals do really well. These are the kids with one or two As, and one or two F. Right? They do well in those they really enjoy and poor in those they don't.
These are also the individuals who confuse their words in conversation. They are also the individuals who need love to pay attention, and pay a great deal of attention when they fall in love, but then, when the relationship becomes normal and routine, they lose attention.
Another intriguing thing about these individuals, and their brains, is normally people can block unimportant information out of their brains. For example, we put on our socks and shoes this morning, but haven't thought about them since. Those with ADD have difficulty weeding out this information which is why they are so sensitive to noise, light, even touch - their clothes have to be just right. These are the little ones who always take their clothes off and run around naked.
Their rooms and desks and their filing is a bit of a mess. They tend to be late. They don't even start to get ready until they are late, because they need that "Oh shit" moment to give them the dopamine they need to get going. Individuals with ADD have lower heart rates, lower sweat gland activity, and lower activity in their frontal lobe function. They almost need to get upset to get anything done. This means they are also excitement seeking, conflict driven behavior. Living with them can be stressful.
Procrastination is serious. They don't move until someone is mad at them. Paperwork is due at 5pm. They will turn it in at 5:10pm. Then you tell them, "Look, next time you're fired if you turn it in late." They turn it in at 5:05pm. The threat and anxiety has to be significant.
These individuals also have impulse control so that they say the first thing that comes to mind. Is it helpful when we say everything we think to our partners? They do tend to be restless and hyperactive. Watching movies with them can be tough. "What'd they say? What'd they say? What'd they say?"
When at rest, these individuals have normal brain activity, but when trying to perform tasks that require concentration, their brain activity decreases because they suffer from a dopamine deficiency. They also have decreased blood flow to the prefrontal cortex and cerebellum, as well as basal ganglia, which helps product their dopamine.
Treating these individuals, per Dr. Amen, is most often successful when stimulant medications are offered, such as Ritalin, #Adderall, Vyvance or Concerta. Stimulating supplements may also be offered such as rhodiola, green tea, ginseng, or amino acid, L-tyrosine, which is a building block of dopamine. Dr. Amen has proprietary blends which are incredible - soft Ritalin. These individuals also do well when they are more physically active, eating low simple carbohydrate diet with high protein and high fiber can be super helpful. Sugar boosts serotonin in the brain or foods that quickly turn to sugar, so all the simple breakfast foods like cereal, waffles, donuts, pancakes, and poptarts boost insulin, which boosts our precursors for serotonin and ultimately lower their dopamine. Interestingly, we do this with our kids and then tell them thirty minutes later to focus on their school work!
Avoid low fat diets. Our brains are 60 percent fat! Low cholesterol has been linked with autism, homicide, suicide, and depression. You don't want your cholesterol under 160; this hormone is the mother or backbone to all other hormones.
Okay, so supplementing with fish oils higher in EPA than in DHA is also quite helpful. Most of us are abundant in omega 6, which are pro-inflammatory because our processed foods are full of them. These need to be in balance with our omega 3s though, so supplementing with these which are anti-inflammatory (salmon, tuna, and anchovies). DHA doesn't seem to be as helpful for mental health though.
These individuals have a short attention span, are easily distracted, disorganized, they procrastinate, may daydream and be introverted but are not hyperactive or impulsive. This type impacts girls as much or more than boys and is caused from #dopamine deficiency due to low activity in the prefrontal cortex. It often goes undiagnosed, because their behavior isn't as difficult.
The unfortunate scenario is the primary care provider who misses this one, and prescribes an antidepressant which increases serotonin and further decreases activity in that frontal lobe. When this happens, these clients might feel good initially but what they discover is they are completely inhibited so if we get these meds wrong, you can go to jail, you can lose your job, lose your marriage and lose your kids. This is really important.
Treatment here is also stimulant-based with medications such as Adderall, Vyvance or Concerta, or stimulating supplements such as amino acid L-tyrosine. A high-protein, low carbohydrate diet is important, as is regular exercise.
These people have the core symptoms of classic ADD, but they also have trouble shifting attention, going from thought-to-thought or task-to-task, and can get stuck in negative thought patterns and behaviors. They notice everything they hate about themselves and other people. These people worry, hold grudges, and when things don't go their way, they get upset. On the surface, it appears selfish, but rather, they are rigid. These individuals are oppositional and argumentative. Their first words are "no," first phrase is "no way," and first complex sentence is "You can't make me do it." If something is sad that rubs them the wrong way, they will replay it over and over in their heads, then not being able to pay attention to anything else that is said. Dr. Amen says these people don't just hold grudges, they beat it to death or even into the afterlife.
These individuals have both dopamine and serotonin deficiencies, and have over-activity in their anterior cingulate gyrus which makes flexibility difficult. They also have family members who just get stuck and when this one is diagnosed, we look for a family history of #addiction, especially alcohol because what alcohol does is calm down your brain.
Supplements such as L-tryptophan, 5-HTP (dietary supplement used as an antidepressant), saffron, and inositol (naturally occuring nutrient used to boost alertness, focus, mood, and mental clarity) can be helpful, but some do need pharmaceuticals, which are more often Effexor, Pristique, or #Cymbalta. They may even be best served with a combination of Prozac and Ritalin, or Lexapro and Adderall; however, there are botanical combinations that can serve this purpose too. These individuals should avoid a high-protein diet as this can trigger mean behavior. Neurofeedback is also helpful with this type of ADD.
Temporal Lobe ADD
Again, the core symptoms of classic ADD are present, but also learning, memory, and behavioral problems, such as being quick to anger, aggression, and mild #paranoia. There are abnormalities in the temporal lobe and decreased activity in the prefrontal cortex in these individuals.
The amino acid GABA can be supplemented to calm neural activity and inhibit nerve cells from over-firing or firing erratically. This should be done first. Then add something to boost dopamine to help focus if still struggling at work or school. Magnesium can help with anxiety and irritability. And interestingly, due to the involvement of the temporal lobe, also associated with seizures, anticonvulsant medications can help with mood stability and gingko or vinpocetine to help with learning and memory problems. Higher protein and healthy fat diet.
This type of ADD, type five, expresses the core symptoms, but also low-level sadness although not necessarily depression. These are the glass-half-empty people. They can be moody, have low energy, and often have a feeling of helplessness or excessive guilt. They experience chronic low self-esteem. They are more socially isolating and often have poor appetite. There is a great deal of limbic activity in these individuals in their limbic brain (the mood control center) and decreased activity in their prefrontal cortex, whether concentrating on a task or at rest.
Here we use stimulating supplements or medication to boost the brain and enhance mood. These individuals do well with DL-phenylalanine (DLPA) supplementation, L-tryosine, and SAMe, but can also be benefitted from #Wellbutrin or Imipramine. Sometimes when they are significantly struggling with life, it can be helpful to think of these folks as in a state of triage and treating this way, and then working back into a more lifestyle and supplement approach. Fish oil and diet modifications do make significant impacts as does exercise. Yoga!
Ring of Fire ADD (or "ADD plus")
These individuals are sensitive to noise, light, and touch. They can be mean and demonstrate nasty behavior and are fairly unpredictable. They speak fast and have high anxiety and fearfulness. All eighteen symptoms of ADD can be seen in them, in fact, including moodiness, they are easily distracted, have too many thoughts, and are overly sensitive.
A ring of hyperactivity around their brain is what separates these individuals from the rest. The entire brain is overactive with too much activity across the cerebral cortex and other areas, whereas ADD is more often an underactivity in the brain.
Stimulants alone can make these people worse. Rather, begin with an elimination diet. If allergy is suspected, neurotransmitters GABA and serotonin are boosted through supplements, such as GABA, 50HTP, and L-tyrosine. Don't skip on the fish oil. Medication may be necessary and so, begin with anticonvulsants and the blood pressure medications, guanfacine and clonidine, as this can calm overall hyperactivity. However, they really aren't always necessary.
This final presentation, type seven, presents with all the core symptoms of classic ADD but they are anxious and tense, with symptoms of physical stress such as headaches and stomachaches. They always see the worst and freeze in anxiety-provoking situations, especially if being judged. They would rather get an F in a class, than get up and talk. These individuals have the exact opposite activity in their brain as those with classic ADD in that they have high activity in the basil ganglia.
Stimulants alone may make them more anxious, so these people need therapy that focuses on grounding and calming their anxiety. Meditation and yoga are great adjuncts. Deep breathing techniques are also very helpful. Increase dopamine and GABA levels. Supplement with L-theanine, relora, magnesium, and holy basic to enhance a sense of calm. Tricyclic #antidepressants Imipramine or Desipramine can help lower anxiety, depending on the individual. Neurofeedback can also be helpful to decrease anxiety and calm the prefrontal cortex.
Complex & Combinations
It is certainly possible to have more than one type of ADD. If you identify as Ring of Fire or Temporal Lobe ADD, these are treated first so start with GABA. If you start with serotonin in these two types, they can suffer worse symptoms. Error on the side of protecting the brain. Then the next most important symptomatology is what we would address.
Another consideration is differentiating between #bipolar, particularly in kids, and ADD. Treating children with serotonin for what is thought to be depression or ADD when in fact the underlying issue is bipolar can cause a manic episode, even suicide. This really is an important consideration, but one that is fairly easily recognized in that ADD is a daily struggle. We don't have ADD one year and not the next; if you have ADD, you have it all the time. Individuals with bipolar though have very normal periods. They then have down times and up times. Those with Ring of Fire ADD are not bipolar because they have these issues all the time. It doesn't go through wild fluxuations.
Here's the other thing though, if you think your child has bipolar, get them on an elimination diet. My preference is #MRT & #LEAP. Then get a brain scan, because a lot of what we diagnose as #bipolar is actually brain injury. They fell off their bicycle, fell out of a tree, or even fell out of your bed as an infant or toddler, maybe out of their highchair and they damaged their temporal lobe. Now they have mood instability, irritability - all temporal brain problems, and we're diagnosing them as a lifelong mentally ill person, but in fact, many of these kids have a condition that could be rehabilitated with the right treatment. How do you know, unless you look? Imagine what could be discovered if we scanned those with trauma, particularly war veterans. Many times this is a traumatic brain injury and concussion protocols could be implemented rather than sedation or #addiction.
The future of psychiatry is looking at the brain. The only speciality that doesn't look at the organ they are treating is psychiatry, right? Everyone who goes to prison should get a brain scan. Everyone in residential treatment should get a brain scan. Anyone who turns 50 years, should get a brain scan; #Alzheimer's starts in your brain 30 to 50 years before you even have symptoms. We scan our bones, our colons, our breasts, our eyes, ears and teeth - why not the brain?
This is psychiatry treatment in 25 years, but wouldn't it be awesome if this were our approach today? Brain scans are being done on 2800 different conditions and 100s of thousands of clients have had their brains scanned as part of their psychiatric treatment plan, and it completely guides their healing, but this hasn't become the professional recommendation yet because there aren't gold-standard random control trials that meet criteria. These are almost always absent prior to implementation of standard practice because they just aren't always practical. They are essentially void entirely in maternity care and women's health, yet we implement a theorized approach and evaluate those who were subjected to these more novel approaches because we know waiting may deprive them of the care that truly may benefit their lives. Without imaging, we are simply guessing about what is going on in the brain.
What Does a SPECT Scan Cost?
A single photon emission computed tomography (SPECT) scan is a nuclear medicine procedure used to study the heart, liver, bones, thyroid, and/or brain. It is designed to depict the brain flow and activity patterns inside the brain, allowing clinicians to observe which area of the brain is working well and which parts may be over or under active. Typically these are ordered when a seizure may be suspected, with a stroke, for dementia, head trauma, or even with suicidal behavior.
On average these cost about $4,000 if paying out of pocket. There are some places that one can obtain a SPECT scan for as low as $1,000 and as I am aware, Dr. Amen's clinic charges $3,500 which he not only utilizes in his treatment for ADD, brain trauma, anxiety, and dementia, but also obesity. They are also offered at the Mayo Clinic, Mayfield CLinic, and Cedar Sanai Medical Centers, but their prices aren't posted.
Certainly speak with your provider about potential diagnosis which may be assigned to a SPECT Scan order and then inquire with your health insurance about preauthorization. These may be covered, but often times are not. If paying out of pocket, ask for an early payment, cash discount. This is often half or even significantly less than the quoted price, and hey, go with your bestie and see if you can get a two-for-one package. Doesn't hurt to ask.
What Happens in a SPECT Scan?
There are two parts to the SPECT scan, the injection and the scan itself. The first scan is known as the concentration scan, which takes about twenty minutes. During this portion, your attention and focus are measured. Then a baseline scan is performed, and you'll be asked to sit back and relax while the imaging radioisotope solution is injected inside your veins via a small intravenous line. When the solution enters your system, which can take about a half an hour, you will be taken to the scan machine where cameras will rotate around your head, taking pictures of your brain. These are then converted into 3D images for interpretation by the experts. The entire process is about 90 minutes.
While an "expert" will read these scans and identify areas of weakness and strength, reading these as a radiologist and as a neuropsychiatrist trained in ADD such as Dr. Amen are two very different things, not to mention the understanding of your primary care provider regarding either brain scans or those results specific to ADD. Even in the best clinics, this can alone isn't diagnostic, but it can help explain how your brain is functioning.
For the most part, a SPECT scan isn't overly risky, in that you can have a reaction to the radioactive tracer. These aren't safe of course, for women who are pregnant, or even those currently breastfeeding. There is also a small amount of radiation exposure.
Brain Body Connection
Listen, this is important, but this isn't all. You have to get healthy. This is a complete lifestyle overhaul. Learn to eat well for your body, and eat clean. Discover the best movement for your body. Work on somatic healing because you won't have ADD without some level of trauma. Clean up your environment and relationships. Sleep well. Rest. Create a healthy gut microbiome. Consider talk therapy. Join us so we can help you implement the best strategies for your body, needs, and epigenetics. We are successful in these efforts. We'd be happy to work with you.