The Regular Looking Guy


He was in his mid-fifties, quiet and fairly good-looking.  I did suspect he was balding or maybe just plain bald as few men would wear a turn-of-the-last-century newsboy-type cap indoors these days. He sat on my couch and told me he thought he had ADD (attention deficit disorder). I interrupted him right there, as I do everyone who comes into my office thinking they have this disorder. Most people professing this diagnosis who are adults and walk in alone to a psychiatrist’s office are looking for stimulants — the amphetamines and the Ritalins of life. I don’t prescribe these.  I used to — at least as long as it took to get people weaned off them.  But nobody wants to get off them, not ever.  I have seen people who have been on them from earliest childhood through middle age, for no clinical reason I can discern.  Usually they were just being kids and bugging the adults, so they were put on drugs to control them.

Unfortunately, staying on the same dose of a drug indefinitely for any reason is believed by some to be the apogee of modern health care. A quick and easy prescription of a drug someone is “stable” on is considered by public psychiatric clinics as the means to a “quick and efficient” medication management visit.  The patient presumably has already given an “informed consent” — that is, the relevant forms have been signed, so that the patient seems to know the advantages and risks of the drug, and have allegedly been given printed information on the drug.  Of course, it has been painstakingly explained to me that all this is fiction to cover the law and get paid by insurance.

I have never met a patient  a drug regularly who had any idea of advantages and risks, or who read any of the printed matter.  In many cases — had never even been offered the printed mater to read or sign!  Of course this is a violation of federal law that happens every day in almost every public health clinic. At any rate. anyone who comes into my office who claims they are seeking treatment for ADD is informed within less than five minutes that I do not and will not treat this disorder with stimulants. They have my unfavorite side effect, which is a sudden and unpredictable death. Oh, it is seemingly possible to diminish the possibility by doing a “cardiocentric” examination (give a good listen to the chest, preferably by a “real” family or internal medicine type  doctor and not a psychiatrist) but I have never heard another doctor other than me even discuss this let alone get it done. I have done a few, along with an EKG and in some cases, an echocardiogram (ultrasound).

People who should know better play fast and loose with stimulants, which are often prescribed to children who have gotten a teacher mad at them, giving “false positive” screens on both subjective and objective screens for attention problems in teaching. I have walked out of job interviews at swank Hollywood practices where it seemed to me everyone got amphetamine-type drugs, including people interested in high energy, weight control, and some other sought after side effects.

Back to our hero with the cap.  To his credit, he had no interest in stimulants.  Dad and other relatives had died of heart problems. He described himself as an “absent-minded professor-type” who had the idea he could have been more successful in his life if he had been able to maintain focus longer  in school.

In 35 years of medical practice I have seen only one or two cases of ADD that fit the clinical description Carpenter wrote in 1925, based on some of the young patients in his charge at a home for wayward boys .  The patients described have a pardoxic reaction to stimulants.  In other words, stimulants slow them down so they aren’t hyper and they can concentrate.  If stimulants only make them more hyper, then they fail the test for ADD and have another problem (or none — maybe they are just being kids). The same things apply to adults.  I observed my adult patient for obvious signs such as scattered verbal discourse.  He also admitted he had no difficulties following through on long-term projects. He did have a couple of signs of attention problems, reporting rare instances of losing the train of thought — but not more than I would expect from any other adult. Most of these instances seemed to come within the context of his relationship with his woman friend.  She sounded as if she were fairly obsessional and rigid while he had a freer flowing view of life. She had been diagnosed with “some kind of an anxiety disorder.”

Hm.  It may seem on some level as if him having a psychiatric diagnosis and taking something for it may somehow bring this relationship closer together. Even if he had a minimal attention problem, he was in a pretty intense relationship, having lost his wife to a terminal illness a few years ago.  I think the main reason he came to see me was that he was trying to move on in life — trying to cling to his new relationship. I could not even justify the prescription of a non-stimulant treatment for ADD. He had been an architect, finished a university degree in the era before computers were used in that field — which told me already his alleged ADD, even earlier in life, just could not have been that terribly bad. I decided a trial of the best-suited vitamin compound I know was warranted, so I suggested he try it for a month or so, return and tell me how things are going and we could talk then.  He was pleased with this outcome. We shook hands and parted. The next challenge was the billing diagnosis.

I have to give insurance a diagnosis if I want to get paid. An adjustment disorder?  That means for six months or so he adjusts to a change in life. He had been with his woman friend for a couple of years.  The change of architecture from hand drawing-based to computer-based seems to have happened at least a few years ago.  He had been working on computer-aided design and seemed to me as if he had adapted to it mighty well. I told him he was “minimally” attention deficient and he sounded as if he occasionally had some such problems. In the 18th century, this would have been a slam dunk.  I would have diagnosed him as “romantic love.” With current diagnostic manuals, I was pretty much stuck with … ADD.  Minimal. Perhaps, but there is no such qualifier in any manual known to me. Insurance had to pay for him.  He was counting on that, and deserved that.

I had worked hard for an hour.  I deserved to get paid, too. Records are confidential.  At this point in his life, I wonder if anyone is going to give him a questionnaire on a job application that would ask if he had ever seen a psychiatrist?  At least he could say, if all goes well, that he has never required a psychotropic drug. “Normal adult human” is not a diagnosis that anyone would ever pay for.  But how can you know if you ARE one unless you go to see a psychiatrist? I am worrying in theory, not in reality.  We can cross any bridges he has to cross when we come to them. We can keep trying to fix the world, one patient at a time.

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