As I began to share my assessment and clinical insight regarding the need for tolerance/dependence and possible addiction evaluation, he became angry, indignant and insulting.  He demanded to be refunded for the visit.  I noticed a surge of frustration, anger and disgust in myself. This man was insulting and devaluing the very foundation of  the medical diagnostic process. He was making it difficult for a legitimate ADHD-afflicted patient to seek treatment.

Once it became obvious to him that he was not getting his way, he angrily left the office slamming doors, shouting profanities, and frightening the other patients in the waiting area.  He called the office a few minutes later and was verbally abusive to the staff and me on the phone.  For some reason the face of  my tired, innocent medical student daughter flashed through my mind asking me earlier that morning, “Dad, what’s the most common tumor of the salivary glands?”  Enjoy learning the hard science of medicine now, my dear, as the day to day life of a doctor will bring you trying scenarios in dealing with extremes of human behavior!

Mindfulness and awareness are needed here. First, the cognitive distortion needs to be addressed. The usual tendency is to discount the positive and hyper-focus on what went wrong. Next, distancing oneself  from the thought chatter and observing one’s reactions in a mindful state is crucial. If the emotions still do not want to loosen their grip, self-soothing strategies such as relaxation, humor, and psychotherapy can come to the rescue. Don’t give in to the rumination, it tends to want to take root and spoil the present moment. It has a tendency to stop the flow of life energy and create a root ready to grow at the next encounter.

The ADHD brain craves surges in dopamine (the reward and novelty neurotransmitter of the brain), causing many ADHDers to appear as if they have a higher sex drive than others.  They desire more sex.  My clinical observation is that this is an attempt to correct the underlying imbalance in order to gain calm and peace, albeit transiently.  Paradoxically, for many ADHDers an ideal sexual encounter is just a fantasy, and real life sexual relationships requiring commitment and patience are too laborious and boring.  Obsessing about sex fills this gap by providing a displacement/distraction and release with minimal effort.  YourBrainonPorn.com is excellent resource on neurobiology of pornography addiction and sexual physiology with many implications for the ADHD population.

If the sexual libido is persistently elevated, bipolar diagnosis needs to be considered (see Mood Disorder Questionnaire).  The ADHDer focus on sex is more an expression of relieving boredom and seeking novelty.  Preoccupation with an imagined problem and attempts to control it only serve to accentuate the behavior.  Understanding the underlying psycho-physiological processes and being patient with oneself enhances the sense of serenity and acceptance that many ADHDers lack.  Shame, guilt, and labeling a benign behavior as an ’addiction’ perpetuates the stigma and a characteristic self-deprecating attitude!

The unspoken clinical truth is that most doctors with a ”satisfied customer” mentality treat the symptoms without any reference to the core problems. Typical examples are overtreating undefined pain with opiates, ordering unnecessary medical tests, and nonjudicious use of stimulants. These problems in my opinion are not even responsive to traditional forms of psychotherapy.  Spirituality, self-care, personal growth, exercise, and nutrition are often lead to better results in transforming such entrenched dysfunctional styles of coping.

Applying labels such as bipolar, ADHD, and anxiety disorders frequently lead to overdependence on medications and therapists, and perpetuation of the suffering. Imagine the savings in health care costs as well as the improved health of our nation which will result when doctors begin to address these issues without the fear of bad reviews or institutional policies. Let’s all take more responsibility for our health, growth, and personal transformation.

Your family doctor gave you a prescription for Xanax and voila, you discovered a new best friend. It helped all your symptoms calm down; you began taking higher and higher doses. Your family doctor expressed some concerns, but to keep you satisfied and content refilled your prescriptions. You began to take Xanax just to relax before or after a meeting or to tolerate the kids nagging once you came home from the office.

You have developed a dependence on benzodiazepines. This is a very serious condition. Benzodiazepines, in low doses, have a role in short term therapy for certain conditions such as panic disorder, muscle relaxation and seizures. Tolerance and dependence need to be very closely monitored. For the majority of patients they could be life saving and beneficial in short term treatment, and have to be combined with psychotherapy and other more benign tools that do not cause dependence and tolerance.  Keep an open mind and willingness to observe a tapering regimen when you seek consultation with a specialist. You might need a few days of inpatient detoxification to begin addressing the issue. Insisting on having your prescription filled as before quickly classifies you as a drug seeking addict and poses many other challenges. Stopping the medicines suddenly on your own could cause seizures and death. Give it some time, with proper medical care and patience you will regain your balance.

I am often asked whether stimulants are an appropriate choice as part of a treatment program.  Although there are varied views on this topic by the experts in the field, my own clinical approach as an addictionologist is very clear. I advise avoiding any scheduled substances including stimulants and benzodiazepines in this population. I am also much more careful and demand a higher level of thoroughness to establish a diagnosis of Adult ADHD.  A brain injured by chemical dependence needs time and patience to recover.  Rehabilitation and observing sobriety remain the primary goals. There are many behavioral and non-medication interventions that prove quite helpful.  The spiritual joy of recovery, attention to better nutrition, exercise, and group support will promote new and healthy habits with profound implications in daily activities.  Don’t insist on chemical solutions; you have found the solution in your recovery program already!

Life began to unfold; you noticed little problems in the relationship annoying you. His procrastination, inability to complete tasks, impulsive decisions, and restlessness seemed less charming as the months and years went by. You were blessed with two adorable children. After much pain and self-blame, your oldest son needed a behavioral evaluation and was diagnosed with  ADHD. Now you feel exhausted  confused and overwhelmed in your own home. You realized your children are showing many of the characteristics your husband has. You are not as patient any more and feel  betrayed by life for cleaning up after every one.

You are married to ADHD! The qualities that attracted you in the beginning are some of the beneficial qualities of ADHD. It is time to have a serious family consultation.  Everyone needs to come to the table, be educated, assume responsibility, be more giving, and alter personal ways for the good of the family. This is how complex systems adapt and grow. There is too much at stake here. It takes courage, determination and humility to look deep within oneself. It is crucial for the kids to see consultation as a process in action. Do not despair but stand up for yourself. You both need to reignite the positive connotation of the ADHD and manage the negative ones. Proper medical consultation at this juncture is crucial to address the clinical aspects of the problem.

Remember that nice sunny afternoon walk in college all those years ago when the flow of life was light and joyful. That energy is still available to both of you; this is the time to call upon it!

How can we categorize autism, major depression, personality disorder, after effects of trauma, steroid-induced psychosis, and addictions under the generic umbrella of “mental illness”?  Might we not be better off to do away with the term altogether, and address issues with better definitions of such terms as mood, attention, anxiety, or addictive disorders.

What we really need to seriously address is our obsession with the depiction of violence  in our movies, video games, and literature. Study of violence and our cavalier attitude towards its depiction reaches far beyond what mental health is prepared to address. Instead, what we are doing is to further stigmatize those of us who are experiencing disease and discomfort of brain, mind, behavior or relationships.

Somehow the conversation during the session turned to the current hysteria around the Mayan calender and the end of the world prophesies. As she contemplated the ramifications of such a scenario, her affect seemed to rapidly improve!  “You know, Doctor, I just realized that none of my problems can last forever!  They will end at some point just as everything will end eventually.”  I began to worry whether she was conveying thoughts of suicide.  ”Oh no, Doctor, I will never take my own life; I do believe we go on living in our essence and I know suicide is mighty sin against our Creator.” She had realized and reconfirmed an ancient wisdom first conveyed by the prophet Buddha that everything in this world is impermanent and that idea in itself is liberating and paradoxically life-affirming. Maybe that’s why doomsday fantasies have always had an audience.

1. Scientific Materialism or Naturalism: In this most prevalent mode of thinking in vogue today, every phenomenon is reduced to its material components. Overemphasis on material prosperity is only a small facet of this world view. The implications are much more far-reaching. Concepts that do not lend themselves to reduction to measurable elements and are not perceived by the senses are considered unworthy of attention and importance. Much of the current excitement in brain imaging emanated from a desire to explain every aspect of human behavior solely based on its brain function. The positive contribution is to increase our knowledge of the phenomenal world; its negative and potentially catastrophic consequences lead to ignoring the essence of things and taking away the wonder and humility when facing the vastness and mystery of existence. It also removes concepts such as freedom of choice and reduces the essentially human attributes such as honesty and love to mere biological and evolutionary necessities. I personally believe this mode of existence creates purposelessness and emptiness if taken to its logical and honest conclusion.

2. Religious fundamentalism and religious exclusivity: This has been a surprising trend that I believe is a direct response to the materialism of our scientific era, the unmet thirst for spirituality, and the vacuum left by inadequacy of the religious hierarchy. The fear of meaninglessness and unmet psychological needs drove many back to outdated doctrines which disregarded rationality and engendered fear, judgmentality, and a quick path to an imaginary salvation. Fanaticism,  cruelty in the name of God, intolerance, and the practice of traditions no longer fit for a modern world are among some of the consequences of this regression.

3. Moral relativism, postmodernism, and anything goes spirituality: This has been an interesting trend as it tries to combine some helpful psychological practices of ancient religions (such as mindfulness and mental clarity) but disavows itself from any of the original intentions of those traditions. Since it wants to accept every mode of thought, it comes to conflict with itself . The people who hold these beliefs are generally sincere and ethical, but contradictions create a tension that is eventually unsustainable.

4. No philosophy; Ethics for its own sake: This is another category that in my opinion arises from frustration with the other views. Disenchantment with other outdated views led some to correctly put the emphasis on ethical conduct and action. The problem comes with the passage of time; the animating force to perpetuate ethical conduct on its own is not consistent with the way our history has flowed. Our ethical standards and morality are eventually traced back to wisdom traditions and their founders. Without acknowledging them, they will not withstand the passage of time and do not move from one to the next generation.

So, what is the solution? What we are missing when we hold on to any of the above patterns of thought is the fundamental harmony of science and religion.  The first allows us to assess the natural world and apply the knowledge for the betterment of our collective lives. The second provides us with meaning and allows us to see the natural world in the light of a trans-natural reality that informs it. Science and religion should both remain progressive, to be expanded upon as our knowledge and view of both increase.  We rely on our rationality and our scientists to shine light on our understanding of the natural world. We have awe and gratitude to Divine teachers who provide us with an updated view of reality through their Revelation which is renewed and is progressive. This is the view that has informed me as a physician/scientist who acknowledges the necessity for spirituality that has been best enunciated in the writings and discourses of Baha’u'llah, a 19th century prophet and founder of the The Baha’i Faith.