ADHD is a personality type that is determined mainly by genetics.  Survival of the group is enhanced by variability of its members.  We wouldn’t want everyone to be the same.   Ancient tribes for example, needed a look-out person who could patiently maintain watch in case something happened.  That wouldn’t be an ADD person.  The ADD person needs much more stimulation.

The diagram shows the range of stimulation within which everyone functions.  You are excited at the higher end and relaxed at the lower end.  Everyone also has a level of stimulation below which they are bored and above which they are overstressed.  People with ADHD tend to have a problem at both ends.  They need higher stimulation than normal people and are stressed more easily.  They have trouble separating important from unimportant and tend to have too much on their mind. 

Stimulants help both problems.  They turn on the brain to enable concentration on the lower level stimuli.  They also allow focus on one thing at a time, which helps the ADD person to be less hyper and more relaxed. 

If a kid with ADD is playing baseball and you put him in the outfield, when the ball is hit to him you may ask – where is he?  The kid with ADD can’t pay attention in case something happens.  He may be digging a hole, or playing with stuff in his pocket or visiting with someone on the side-lines.  This inability to focus and separate the important from the unimportant is also seen in schoolwork (and in the case of adults, paperwork). 

Boredom with routine is related to inadequate dopamine levels in the part of the brain that controls drive and motivation.  Easy distractibility is related to inadequate norepinephrine in the brain cortex.  Impulsivity is related to inadequate dopamine in the cortex.

ADD people focus on things that are interesting rather than things that are important.  They need action.  They are often the explorers, innovators and challengers in our world.

www.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/

Psychopharmacology is the study of the use of medications in treating mental disorders. The complexity of this field requires continuous study in order to keep current with new advances. Psychopharmacologists need to understand all the clinically relevant principles of pharmacokinetics (what the body does to medication) and pharmacodynamics (what the medications do to the body). This includes an understanding of

• Protein binding (how available the medication is to the body)
• Half-life (how long the medication stays in the body)
• Polymorphic genes (genes which vary widely from person to person)
• Drug-drug interactions (how medications affect one another)

Since the use of these medications is to treat mental disorders, an extensive understanding of basic neuroscience, basic psychopharmacology, clinical medicine, the differential diagnosis of mental disorders, and treatment options is required. Psychopharmacologists also must be skilled in building and utilizing a therapeutic alliance with the patient.

Who Qualifies as a Psychopharmacologist?

In a generic sense, any physician who treats patients with psychotropic medication is a psychopharmacologist. Physicians who have completed residency training after medical school have a high level of understanding and expertise in pharmacology, including psychopharmacology. Psychiatrists (who have completed four years of advanced training after medical school) have an even higher level of understanding and expertise in psychopharmacology.

The term “psychopharmacologist”, however, may also be used in a more specific sense to mean a physician with training in advanced psychopharmacology. That is, some psychiatrists specialize even further in psychopharmacology through academic education, Continuing Medical Education (CME), or self-study.

Physicians who are certified by the American Board of Medical Specialties have demonstrated a high level of understanding and expertise in pharmacology and other areas of medicine. Only board certified medical specialists are eligible to take the ASCP’s Examination in Advanced Psychopharmacology. This rigorous exam covers all areas of psychopharmacology and requires a thorough understanding of the latest science that has relevance to clinical practice. The exam must be taken every 5 years.

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Recently, one of my pharmaceutical reps asked me a question she’d been asking other doctors.  "If you only had 5 medications to work with, which ones would you choose?"  For me it was easy.

1. Adderall XR

Has the best batting average.  Batting average = how often patients say, "This med is great.  It changed my life and has no significant side effects."  And they’re still saying it after a year.

2. Alprazolam (Xanax or Niravam)

Helps people take back control of their lives.  Was the most prescribed med for stress last year.

3. Ambien CR

Safe sleep medication which gives you normal sleep.  Normal sleep = foundation for health.

4. Effexor XR

Has the most flexibility (SSRI at low doses, dual agent at higher doses), works the fastest, and has no significant drug/drug interactions.

5. Abilify

Best mood stabilizer.  Was the 1st of the new generation of atypicals.

I no longer take insurance.  To be successful I have to use the meds that work the best.  My goal for each patient is to find "the right medication at the right dose."  All of these "Top 5" have alternatives that I often use.  The bottom line is that with these meds I have seen the best long term results.

Click here to see how Dr. Jones determines "Best Meds"

Stimulants are without a doubt my most successful medications.  All except Provigil require a triplicate prescription, which is ironic because stimulants are seldom abused when properly prescribed. Approximately 10% of adults will abuse prescription medication but what they abuse is primarily pain medications, especially Hydrocodone (4 to 1 over stimulants and tranquilizers 2 to 1 over stimulants). Ironically, pain medications and tranquilizers are much less regulated and can be called in with refills whereas stimulant prescriptions have to be written each time. In what way does this possibly make sense? To paraphrase an old Bullwinkle cartoon, “are you familiar with government intelligence?” “It sounds like a contradiction in terms to me sir.”

The single most important thing for all ADHD patients on stimulants is ALL DAY coverage.

AMPHETAMINE PRODUCTS

Adderall XR primarily and Adderall tablets to a somewhat lesser extent rank #1 in my practice. Adderall is a type of amphetamine. Amphetamines have been studied in patients since 1936. The fact that we have more years of scientific study and clinical experience with this type of medication than any other we use in psychiatry is reassuring to me and many of my patients. There is no evidence of long term problems with Adderall or other amphetamines.

These medications help with staying calm and focused on what one chooses, not just what’s interesting. Adderall also tends to improve mood. It doesn’t usually decrease appetite but helps control weight because eating impulsively due to being bored or stressed is reduced. It is usually the best long term treatment for Bulimia-sometimes combined with an SSRI. The primary indication for Adderall XR and Adderall tablets is Attention Deficit Hyperactivity Disorder (ADHD).  Adderall was the first stimulant approved by the FDA to treat adult ADHD.

Adderall helps people to think about one thing at a time and to single out the important from the unimportant. The XR formula usually allows for once a day dosing although some people, especially those that want 16 hours of calm/focus and productivity, may take it twice a day. It has a low abuse potential because it takes 6 hours to reach maximum blood level, (3 hours for Adderall tabs). Abuse potential correlates highly with rate of onset of action.

Dexedrine is similar to Adderall and may be as effective for boredom or low motivation, but isn’t as calming.

Desoxyn (see below)

METHYLPHENIDATE PRODUCTS

Methylphenidate may be better than amphetamines for hyperfocusing. Moodiness may be a side effect, but it is less likely to affect blood pressure or erectile functioning. We have over 50 years of scientific study and clinical experience with methylphenidate and have no evidence of long term problems or loss of efficacy.

Daytrana patch is the most flexible and potentially longest lasting stimulant – up to 15 hours if removed at 12 hours or if left on for up to 24 hours.  It has a smooth onset of action and wears off 3 hours after it’s removed.

Concerta usually lasts 12 hours.   For patients who would do best on a methylphenidate product but who don’t like or can’t tolerate patches, Concerta is the best choice. 

Other forms of methylphenidate:

Ritalin and Methylin last 3-4 hours and rebound can be a problem. Methylin comes in chewable and liquid forms for children and adults that have trouble swallowing pills.

Focalin is the primary active ingredient in methylphenidate and may be better tolerated by a few patients.  It lasts 4-6 hours.

Focalin XR lasts approximately 8 hours and was the second stimulant approved by the FDA to treat adult ADHD.

Metadate CD is 30% release initially and 70% in 4 hours.  Ritalin LA is 50% immediately and 50% in 4 hours.  Both last around 8 hours.  Some people have a preference for one or the other.

WHY START WITH AMPHETAMINES?

Some people prefer methylphenidate and some prefer amphetamine products. In one study that compared methylphenidate to amphetamines, about 40% said either worked fine, 15% preferred methylphenidate, and 30% preferred amphetamine.  If the percentages are the same as the study and with no other factors to guide the decision, I feel patients are better off starting with Adderall XR. It will work well in at least 70% of people. If Adderall does not work, I would next try Daytrana.  This will get the success rate to 85%.

Pediatricians usually start with a methylphenidate product because they’re milder.  This is probably true.

There are a few patients that don’t tolerate Adderall, Dexedrine, Concerta, or other methylphenidate type stimulants. The most common side effects they complain of are nervousness and irritability. For these people Desoxyn (methamphetamine) usually works well. I have 15-20 patients who can’t tolerate other stimulants but who lead normal lives on this medication. Unfortunately, it is now only available in short acting tablets. It lasts 4-6 hours and is very expensive. Because it is the most likely of the stimulants to be abused it has to be monitored more closely. We have 60 years of clinical experience with this medication and there is no evidence of long term problems or loss of efficacy.

Provigil is a different type of stimulant. It does not require written triplicate prescriptions and basically has no abuse risk. Provigil was originally marketed for excessive daytime sleepiness associated with narcolepsy and has since added formal approval for daytime sleepiness associated with shift-work and sleep apnea.

Provigil primarily increases alertness but may also improve cognitive functioning and learning. In a study in mice, Provigil enabled old mice (equivalent to 70 year old humans) to learn a maze as fast as young mice. Without Provigil the old mice took twice as long to learn the maze.

Provigil is very well tolerated but occasionally causes headaches or dizziness when first starting. Dose reduction usually solves this problem. It doesn’t work on boredom or low motivation. There are studies showing benefit for ADHD in some patients but it’s not on the order of magnitude of benefit we see with Adderall XR or methylphenidate. It is sometimes added to other stimulants or to antidepressants. It is also useful for chronic fatigue from physical causes such as fibromyalgia. It is pricey and insurance companies frequently try not to cover it. But it is very safe and effective, and many patients find it useful. Although it has only been on the market for a few years, we have no evidence of any long term problems.

Click the link below for latest info on new drugs:

www.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/

We received an email recently about a patient who was suffering from significant distress and got nothing but the run-around from her doctors. She had undergone extensive testing but was not given any clear feedback or results, and was basically let go with no explanation or significant treatment. Her son was very distressed and wondered, "What’s wrong with the system?"

My staffs’ response was, "We hear stories like that on the phone every day." Recently, I was lying in bed, feeling under the weather, and I had this flash – "What if I really got sick?" I suddenly felt the need to say to my wife, "If I’m ever unconscious, and you can’t wake me up, don’t call an ambulance. I would rather take my chances here."

On more than one occasion, I have said to a patient who was sick, “I don’t know any doctors in your area. You’re safer staying home than seeing a doctor at random.” The number of horror stories and irrational medical treatment that I have heard is staggering. While medical science is growing exponentially, satisfaction with medical care seems to be on the decline. What is going on?

There are undoubtedly many factors contributing to the problem. When I first started treating patients in the 60’s, patients presented with symptoms, and doctors did whatever tests they thought were necessary. Once a diagnosis was established, treatment options were discussed and the best treatment for that patient would be initiated. Follow-up would be determined according to each patient’s needs and treatment response. The insurance would cover whatever cost they were contractually obligated to cover.

Over time medical costs grew and insurance companies began to balk. A monitoring system was established as a new entity that would regulate medical care (aka “managed care” but really “managed cost”). They would take 20-25% of the medical dollars available, and in return, cut cost to both insurance companies and employers. Meanwhile, the employee/insured had 30% or more taken away from them in medical reimbursements and coverage.

Insurance 101: Did you know that there are people in this country today who believe insurance companies exist to help you? They exist to make money. They make the most money by collecting as much as possible in premiums and paying out as little as possible in claims. Insurance companies now have the most power. “The tail wags the dog.” Of course, they make a lot of money and contribute generously to politicians. It’s the “golden rule” – “Him with the gold is him who makes the rules.”

A case in point – I evaluated a young woman who ironically worked for a large insurance company. She was severely depressed and although not needing hospitalization, needed a lot of therapy along with antidepressant medication. Her insurance only covered “approved therapists” on their list. I said fine but I would like to see the list so I could suggest a therapist that I had a relationship with so we could coordinate her care. They would not share the list. They informed me that therapists were selected who had more of a short-term therapy approach. How was this established? Well, how many times would a patient go back to see them … if they saw them only once – that would be the most effective therapist. If the went back 12 or more times, they obviously were not short-term oriented and would be presumably dropped off the list. You get the picture.

How does this impact the treatment of a given patient by a given doctor? Most doctors who do procedures that can be very costly have to deal with insurance companies. Myself and other psychiatrists and few other doctors have opted out of insurance plans because medical care of patients is often adversely affected by restrictions in time, frequency, type of appointments, etc. I still have to deal with insurance companies at times to get prescriptions approved, and that can be a nightmare. Recently, I had a patient who had excessive daytime sedation and was in jeopardy of being fired. The only medication that worked for her was Provigil. She couldn’t afford it. The insurance company refused to cover it despite the strong letters of appeal.

Insurance companies may be quick to pay $1000’s for highly technical procedures but won’t pay for 15 minutes for a doctor to counsel a patient about weight, smoking, etc. They frequently won’t pay a primary care doctor for services related to treating anxiety, depression, and insomnia even though they provide the bulk of this treatment.

One of the most harmful consequences of this shift to insurance company domination is that by gradually reducing what they pay physicians, physicians gradually decrease the amount of time they spend with patients. Medical office overhead is very high, and doctors have to generate a lot of cash flow to cover all expenses. I’m not talking about super-specialists with very expensive surgeries or procedures – they’re doing fine.

Recently I was speaking in a primary care clinic, and I asked a doctor how he evaluated for depression. He said, “I used to have them fill out a check list of symptoms for depression, but now I don’t have time. I just note whether they’re tearful or look depressed.” Unfortunately, only 70% of people who are clinically depressed report feeling sad, down, or depressed. 30% have other symptoms, especially loss of interest, motivation, or pleasure (85-90% of depressed patients). I guess they’re out of luck.

Doctors don’t have enough time to adequately evaluate or counsel a patient. Insurance companies usually won’t pay for a clinical assistant to help. The system is broke! I’m not sure what the solution is, but I’m sure it’s not the government.

People have to take more individual responsibility to research their symptoms, diagnoses and treatments. They have to network and do everything possible to find a physician who takes the time to listen and address their concerns and then provides either adequate care or refers them to someone else.

All fields of medicine are going to get increasingly complicated and expensive. I’m afraid things are going to get worse before the pendulum begins to swing back.

As May 1968 approached my feelings were mixed. I was proud and excited to be graduating from medical school. For the rest of my life my name would be followed by M.D. I was also nervous (o.k. scared) because I was now going to have primary responsibility for patient care. I would at times be the only doctor in the emergency room or maybe even in the hospital where I would be a medical intern and where I would moonlight every Monday night for 3 years. I would literally have life and death responsibility. But I was also confused and concerned about the war in Viet Nam and the draft. Most medical school graduates had to go into the military one way or another. I didn’t believe in the war and I had no intentions to be sent there – I said l would move to Canada rather than go to risk my life for a war I didn’t and still don’t believe was right. But it’s cold in Canada. What about Mexico – I took Latin and German, no habla Espanol.

Fortunately I applied for and got permission to complete all my training and then go into the Air Force for 2 years. The way we were compensated for 12 years of advanced education was to be given rank. So I became Major Wayne Jones. Of course career military officers who had spent years climbing up the ladder were really pleased with me and my fellow physicians getting to start with rank. I actually made myself even more conspicuous my first day by putting my gold leaves on backward. I had requested assignment in San Antonio where they had 2-3 Air Force bases including a teaching hospital atmosphere.

It was a mixed blessing that I was assigned to Sheppard Air Force Base in Wichita Falls, Texas. At Sheppard we had the largest psychiatric hospital facility in the world with 120-150 beds. It turned out to be a great learning experience – especially long interviews with prisoners of war released when the war ended. Some of them had spent over 10 years in solitary confinement.

On the other hand, Wichita Falls, shall we say, is not a tourist attraction. One of my favorite memories is sitting in one of the best restaurants in town – Kings’ Quest. It had linoleum floors, vinyl table cloths and a wine selection that included a $150 bottle of wine – needless to say I never tried it.

After 2-3 days of basic training, yes, "days", I reported to duty as the officer and physician in charge of a 30 bed unit. Several times per week we received new patients from acute psychosis to behavioral problems. We had to keep things moving but our task was made more difficult because of administrative obstacles.

In medical training I was driven by 2 goals – the highest level of scientific understanding of symptoms, illnesses, and treatments and the most practical ways of helping people make their lives and stress symptoms better. In the Air Force the overwhelming emphasis was on the practical administrative options.

My first morning I met my head nurse, Ray. He was short, somewhat overweight and very friendly. He would become my greatest ally. To him we were like a large family. He believed in the community approach to psychiatry. For the next 12 months we would be like two parents with a very large family. Ray and I had a few things in common – we were both conscientious and had a sense of humor – although I was more inclined to the dramatic or occasionally the outrageous. He was also a Major but he had earned his rank over a long Air Force career. I never felt that he resented me getting instant rank and I always felt the appropriate respect as the medical "captain of the ship". We mostly complemented one another. He was more sensitive and I was more practical. He had a more maternal, cooperative, communication oriented personality, I was more typically paternal, competitive, decision making, and performance oriented. We shared pride when one of the "kids" shaped up or grew up and went on to do good things. We shared a sense of failure when one made bad choices and ended up in some not ok outcome. He wanted patients to say how they felt. I wanted patients to improve their thinking and behavior. Not that he was too soft nor I was insensitive. We of course played "good cop bad cop" on occasion.

My first decision was to move morning rounds from the nursing station behind closed doors to the day room where everyone would participate. Getting input from everyone was especially helpful in an atmosphere where a lot of patients were not there by choice or they had a very specific agenda, e.g., getting out of the Air Force. Patients learned that if they shot straight with me and helped me understand what was going on with others in the milieu that I would go the extra step in helping them. On the other hand, if they were primarily negative, manipulative, dishonest, or splitting they would learn that I could make their life miserable – I had the "power of the pen".

During our larger daily family meetings I was able to use skills I learned in doing group therapy. If the group was mainly attacking someone verbally I would be supportive of the patient. If the group was enabling or being supportive of inappropriate behavior I would be confrontive and tough. The balance usually worked out well.

I would frequently give mini-lectures during our morning "family" meetings. This helped to train the staff – nurses and psych techs (corpsmen) and to teach some basic principles to the patients. It was then that I discovered my passion for teaching. I also learned at the risk of sounding immodest, that like Geena Davis said after her first holdup in "Thelma and Louise", "I think I’ve got a knack for this shit".

One of the most useful ideas I came up with is that there are 3 types of thinking:

I felt sad when I read this week that Joan Kennedy, former wife of Senator Edward Kennedy, was found lying on a sidewalk in the rain. She had suffered a concussion, a laceration on her forehead, and a broken shoulder.

The story goes on to say that her son has been trying to get appointed as her legal guardian, so that he can ensure that she cooperates with treatment for chronic alcoholism. She has been through several rehab programs after a series of arrests for drunken driving. She obviously has unlimited financial resources and political connections and has undoubtedly had the best treatment available in the world, and yet here she is basically lying in the street like a homeless person.

Why can’t we help her? One reporter described Mrs. Kennedy as shy and reserved, unlike the other strong Kennedy women. Apparently her major problems with drinking started after her husband’s scandal.

Two general principles are demonstrated by Mrs. Kennedy – using alcohol to cope with stress and social anxiety. In one study 60% of alcoholics were using alcohol to help reduce social anxiety.

Understanding Addiction

The good news is that addiction is easy to understand. There are only two symptoms: “denial”, and “dyscontrol”. Addicts lie to themselves, “I’m not really an alcoholic, I just drink too much occasionally”, or “I just drink socially”.

One of my favorite all time books is titled, I’ll Quit Tomorrow by Vernon Johnson. That title tells you everything you need to know about how an addict thinks. Two other great book titles on addiction are: The Craving Brain by Ronald Ruden and The Selfish Brain by Robert Dupont.

Addicts also lie to others – “I only have one or 2 beers a day” – unfortunately they buy 2 cases per week, and there’s never any left and they always drink alone. The math doesn’t work.

Dyscontrol means it controls you, you don’t control it. The first step in AA admits to being powerless over ________ (fill in the blank). But of course, it’s not just alcohol.  It’s food, drugs, gambling, work, sex, etc.  Even people who pull out their hair or cut on themselves are addicted to the body’s response to bodily injury – it may be as simple as causing a release of endorphins. These are chemicals released by the body that act like morphine or heroin in low dose.

A great prototype for addiction is smoking. Addiction means compulsive behavior in spite of negative consequences. People who smoke die 13-15 years earlier than nonsmokers on average. How negative is that? Of course the smoker rationalizes “I didn’t want to be an old person anyway.”

Do you have to drink every day to be an alcoholic? No. The rule that I have used in diagnosing addictions over the years is, “does the behavior result in harm to health, jobs, grades, or relationships?”

What causes addictions?

The single strongest factor is genetics. The part of the brain that learns what substances or actions lead to pleasure or escape from pain is genetically less reactive to normal life pleasures or serves to help reduce pain.

There are two primary goals of addiction – getting high, especially when bored and getting numb when feeling overwhelmed.

Why would someone jeopardize their marriage or custody of children just to get drunk? They don’t actually make a conscious decision, “I’m going to get drunk and I don’t care what the consequences are.” It’s more like self-manipulation. They forget to take their medication or they set themselves up to desperately need a drink – of course just one, or maybe two larger ones. For some people, their judgment is soluble in the first drink.

There are actually 2 subtypes of alcoholics. The first type starts usually in the teens and the goal is to get high. People who inherit this form have a high tolerance even when they first start drinking. The second type starts later, 20′s or 30′s and is primarily to treat chronic anxiety. Some people are unfortunate and have both types.

What about treatment?

Addicts, especially alcoholics are masterful at alienating everybody and using alcohol as their primary or only relationship. They can make people so angry with them that they get no social support. But effective treatment requires an alliance with the person against the problem – you have to separate the person from their addiction. It has to be you and them against the addiction.

The worst form of “pseudo” support is enabling. This is basically making it easier for them to continue with their addiction. The opposite of enabling is “tough love”.

Treatment ideally needs to include the significant other(s). In the movie When a Man Loves a Woman, the potential benefits of AA and Alanon were well depicted. Early in the movie the characters, played by Meg Ryan and Andy Garcia, seem like a normal healthy family. In retrospect we could see that the husband encouraged his wife’s drinking because she was more fun when she was drunk. I thought the treatment program in the movie was seriously flawed. Instead of involving the husband and children in couples and family therapy the treatment was mainly with her peers in the program. When she got out she continued to rely on her peers for all her social support and it almost destroyed her marriage.

Any couple dealing with an alcohol problem or other serious addiction should see this movie. It shows the secrecy, deception, and subtle way alcohol takes over one’s life. It shows how alcoholism is a family illness and everyone is effected. It ends by instilling hope – it’s possible to take back your life.

Since addiction is denial and dyscontrol, recovery is getting honest (with self and others) and getting control.

AA provides many tools like “one day at a time, sometimes one hour or one minute at a time”. Addicts should ask for help and may need medication.

What about medication?

Antabuse is often helpful. It’s not a medication that keeps you from drinking. It’s a medication that is taken in the morning and helps protect you from drinking impulsively later in the day. Antabuse interferes with the metabolism of alcohol and will cause you to get very sick – as in vomiting through your eye sockets. There has even been an occasional death resulting from drinking a lot of alcohol when on Antabuse.  Also, the longer you take it the longer you have to be off before you can safely drink – it means you have to premeditate your drinking up to a week in advance. Of course alcoholics don’t usually think, “I’m going to stop it so I can drink this weekend” – more like, “I don’t need it anymore”, and then oops!

One of the myths about recovering from addiction is that you have to want to do it and do it yourself.

Studies have shown that Antabuse works better when a loved one hands it to you every day. Treatment programs also work better when ordered by a judge.

One of the most annoying things about some programs is their negative attitude about medication. One alcoholic young man told me he liked taking Antabuse because he didn’t have to worry about drinking at night. But he was ordered by a judge to attend a program – the program wouldn’t let him attend if he was on any medication. Brilliant!

Just recently another medication has become available in the U.S. – Campral. It has been used in Europe with some success for 10 years. Early results here look promising. One disadvantage is that it has to be taken 3 times per day, two tablets each time. It apparently lowers craving by having one of the actions of alcohol in one part of the brain without itself being habit forming or having any reinforcing properties. It is not clear how well it will work if started while drinking, but getting people to stop drinking first is a major challenge – as in good luck!

Another treatment for alcoholism that has been around for several years is Revia. It works by blocking receptors for endorphins. In studies, 1/2 of alcoholics didn’t drink and 1/4 of alcoholics markedly decreased their drinking. The main draw back has been cost and insurance companies refusing to pay for it. It has been helpful for a few patients.

Since many times addictions are a self treatment for an underlying disorder, being able to diagnose the underlying problem and provide adequate treatment is often helpful. This is especially true when ADHD is the problem. Putting patients on stimulants has often significantly reduced or eliminated addictive behavior.

The TImberlawn Foundation did a study once of former cocaine addicts. They asked why and how they quit. The responses were vague and not especially convincing. But when they asked when did you quit and what was going on at the time they almost always found that addicts had gotten involved with something outside themselves. They became less self centered. Some became actively involved with a church or in other cases fell in love. They found a substitute. They found something that could help them achieve a “natural high”.

In other cases effective treatment of post traumatic stress disorder resulted in the addict no longer needing to get “numb”.

So we are left with the image of a woman of status and wealth, loved by her family found in her exclusive Boston neighborhood lying on the sidewalk in the rain with a concussion and multiple injuries. This was presumably a consequence of alcoholism – a medical illness that does not discriminate against any gender, race or social status. But as we learn more and more about the science of addiction and as we get better treatments there is much cause for optimism. Sadly, for some it may be too late.

Practice paced breathing

Proper breathing is very important for control of anxiety and panic.  It is also the best relaxation technique for control of nervousness and panic.  Underbreathing (slow/shallow) increases carbon dioxide retention.  This triggers the suffocation response in panic prone people, leading to compensatory overbreathing.  Conversely, overbreathing (hyperventilation) decreases carbon dioxide and causes feelings of depersonalization (feeling detached from oneself), dizziness, numbness, and confusion.

When anxious or tense, it is easier to breathe out first:

• Step one:  Slowly exhale through the open mouth making a “s h h h h” sound.  Listen to the sound, or feel muscles relax, letting go of tension.
• Step two:  Breathe in through the nose slowly, (mouth closed) and count, 1—2—3—4
• Step three:  Hold to count of  1—2—3—4    
• REPEAT STEPS

Find distractions

Focus attention on something outside yourself.  This might include listening to music, going for a walk, or calling a friend.

Use conditioned relaxation response

Make relaxation a part of daily routine.  Set aside time to practice your favorite relaxation activity.  This might be working out, playing sports, games, cards, movies, listening to music.  When relaxation is regularly practiced, the body forms a memory of what it feels like to be relaxed.  This memory is a tool you can use when you feel anxious.  Practice relaxing in anxiety provoking situations.

Earl Campbell (football legend) was in his truck driving to Austin, Texas. He was stopped at a light in the small town of LaGrange. All of a sudden and for no reason he felt chest tightness, racing pulse, and shakiness. He panicked. He thought, “am I having a heart attack, dying, or going crazy”? This is a classic panic attack!

Panic attacks are physical reactions associated with an inappropriate adrenaline response in the body and excessive noradrenaline release in the brain. Though brief, they are terrifying, especially because they come on for no apparent reason or precipitating cause. Panic attacks can be thought of as a “false alarm” in the brain. There is some evidence that two types of panic attacks exist. One relates to hypersensitivity to increased CO and the other to hypersensitivity of the inner ear. Symptoms are acute and intense and vary for each individual. Agoraphobia is usually caused by panic attacks. What the agoraphobic fears is panic or panic related symptoms. He or she may begin to avoid certain situations because of panic attacks.

Although they come out of the blue, panic attacks are almost always preceded by increased stress within the recent few months. Stress includes any significant life change (good or bad), and any loss, as well as conflicts and life demands. The worst stress is associated with a feeling of being helpless to control factors that affect an individual’s life.

Stressors are cumulative and additive. Symptoms tend to occur when the amount of stress in life is greater than stress management (exercise, recreation, relaxing activities, laughter, positive relationships).

Treatment includes patient education, desensitization (behavioral techniques to reverse the phobic process), relaxation techniques (especially proper breathing), and cognitive training. Frequently medication is necessary to aid treatment, or used to shorten the treatment by accelerating the recovery process.