Let us take up some more examples. Laura came to see me for the most common reason anybody goes to see a psychiatrist: she was unhappy. There was no acute problem, and she was not bitterly unhappy. She did feel chronically anxious, and she complained of a vague feeling of despair. “Despair isn’t usually vague,” I said.
“It’s not in me yet,” she answered, “but it’s out there building, a big cloud. So I thought I’d come see you first. Before it hits.” Laura was thirty-two, a minister in a Christian church, married to a baker. They had two young children. We looked at the most obvious things first. How was her marriage? Was being a minister too draining? How did she get along with her congregation? Were the demands of being a mother weighing too heavily? Were there spiritual problems she’d been pushing aside? None of these questions turned up much to worry about. She loved her husband. They started each day in the bakeshop talking and drinking coffee after the kids had gone off to school. She loved her work and had a loyal congregation. Yes, the work was draining, but she enjoyed feeling so useful. As for spiritual matters, her faith in God was strong; it was her faith in herself that was shaky.
“Well,” I said, “let’s look at the cloud you mentioned when you came in. Can you describe it? What’s it made of? How did it get there?”
“It’s a feeling,” she said. “I don’t know how to put it, exactly. It’s a feeling that my world could collapse. Just fall down all around me. Sort of like the cartoon character who’s run out over the cliff and his legs are still pumping, but he’s only standing on air and he’s about to fall a long, long way down. I don’t know how I’ve done as much as I have, and I don’t know how long I can keep it up. I ascribe my success to the grace of God, but I’m still left with this feeling that it could all be taken away.”
“Is there any reason you can think of that it should?” I asked. “Is there something you feel particularly guilty about?”
“No more than my everyday crimes,” she answered with a smile. “No, it’s not guilt. It’s insecurity. A feeling of being a fraud. Not a fraud, really, because I know I’m not deliberately faking anything. It’s as if I woke up one day and I was at this grand ball, but I don’t know how I got there, and I don’t know how I’ll carry it off.”
Laura and I spent several sessions looking at this feeling of insecurity from many different angles—from her childhood history, from her religious perspective, from dreams and fantasies and whatever other unconscious material we could garner, and we came up with a lot of interesting information but nothing that seemed to explain the cloud she felt on her horizon.
But then we started to look into her educational history and her struggles with academic achievement. She always did very well, was always at or near the top of her class through high school, college, and seminary. That was why she didn’t mention anything about it in our first interviews; she had done so well she thought there was no problem there. But now she told me academics had always been a struggle for her. Just thinking about it brought back fears, fears of failing, of not getting things in on time, of being rejected. Each paper had been an ordeal. She wouldn’t start until the last minute, and she wouldn’t finish until the deadline. She had an abiding sense of having to strain to get it, whatever it was, as if she were nearsighted and had to strain to see the blackboard. “I began to worry about everything,” she said. “That’s where the insecurity started.”
“When?” I asked.
“College. No, high school. Senior year, junior year, maybe. Whenever things got hard.”
Without the perspective of ADD, Laura’s history would make one think of a perfectionist personality, which indeed she did have, and a diagnosis of obsessive-compulsive disorder or some kind of anxiety state. But if she had ADD as the starting point of these problems, with the anxiety and perfectionism occurring in the wake of ADD, that would cast a new light on things.
After she graduated from seminary and found a congregation and got married, she thought the troubling years had been put to rest. But the feelings came back in other ways. Organizing the family became a major task. Her husband helped, but she always fretted she was going to forget something or overlook an important detail. Old feelings of incompetence and insecurity surrounded her. She developed a habit of anxiety that she could not let go of.
“I want to let go of it,” she said, “but I don’t dare. I pray to let go of it, to feel bold and confident, but I don’t dare. I have an image of letting go of it, my worry, as if I were leaning over the stern of a rowboat and watching a big heavy weight sink slowly to the bottom, out of sight.”
“Back into the unconscious,” I said.
“No,” she said. “Gone forever. When I lean over that boat, kneeling on the seat in the stern, I let go of the weight and it is gone forever. I can see it sinking away from me and it feels wonderful. I can let go of it in my fantasy—why can’t I do it in real life?”
“Well,” I said, “maybe you literally can’t. Maybe your brain won’t let you because of the way it’s wired.”
We explored the subject of ADD, and then we got some testing done. While there is no definitive “test” for ADD, what testing can do is help confirm the diagnosis and/or elucidate any associated learning disabilities or other hidden emotional issues. The testing itself involved a few hours of paper-and-pencil tests—tests of cognitive style, attention span, memory, organizational style, specific aptitudes, mood, and a neurological examination. Although testing is not always necessary, when it is done, it usually adds solid information to the often ambiguous diagnostic process.
Based upon her history and the results of the testing, Laura did indeed have adult ADD. “I think what you’ve been doing, Laura, is working so hard most of your life to stave off chaos that you’ve developed a habit of doing it with worry. You use one toxic state to stave off another. You’re right when you say you can’t let go of the worry, of the weight. In a way, it’s been your lifeline. Your brain won’t let it go.”
With treatment for ADD, Laura gradually began to gain a surer sense of who she was. She began to believe that she didn’t wake up at the ball one day, that there was some continuity and logic to her being where she was. The treatment, which included both medication and psychotherapy, did not eradicate the threat posed by the cloud, but it did give Laura greater control over it.
We also worked on letting go of the weight, leaning over the rowboat, in fantasy, in psychotherapy, letting the weight go, watching it fall. Laura would watch, and describe it to me as it grew smaller to her eyes before disappearing into the depth of the water. She practiced being rid of the weight. At first it was scary. We talked through the fantasy over and over again, dozens of times, but gradually the weight did subside and take on proportions that most people carry every day.
The next example involves a man who didn’t think he was seeking help for himself. Douglas and his wife Melanie came to see me for an evaluation of their son, a marvelously imaginative first-grader who had been seriously ill the year before. I thought their son was doing fine, but during the course of the evaluation some problems emerged in Douglas and Melanie’s marriage that they wanted to talk about.
Most of the problems in the marriage, at least as initially expressed, centered around Douglas. He had bothersome mood swings. He drank a lot, perhaps a bottle of wine a day. He worked, as a stockbroker, with great intensity, and achieved significant financial success, making well into the six-figure realm every year. He had trouble with bosses, but he was so good at his job that his bosses let him work pretty much on his own. Before becoming a broker, he was a jazz musician, and he still took to composing with an attitude little short of rapture. He also loved to cook, and would give dinner parties every chance he could. The father of two children, he tried to be as involved as possible with his kids. The time he had left for Melanie wasn’t much, but it would have been enough, she felt, if he were really there during that time. Instead, at any moment, he could disappear, literally. In the time it took to turn o
ne’s head, he’d be gone, gone off in pursuit of some new project, some new idea, some greater stimulation.
Melanie felt that Douglas had a problem with intimacy and was using alcohol to treat his malaise. Douglas felt that he just wanted some space and some freedom to be himself, to compose his music, drink his wine, cook his food, and think his thoughts. He acknowledged he could be difficult, but he said he was working on this.
In going back and taking more history from Douglas, it became clear that, whatever else he had, he surely did have ADD. All the symptoms of ADD of the intensity-seeking type were there: creative male, high energy, restless, distractible, impulsive, seeking stimulation in many ways, engaging at times, at times evanescent, moody, independent, and anxious when left without structure and routine.
After I explained to Douglas and Melanie what ADD was, there was a pause in the room. The couple looked at each other, then broke out in laughter. “That’s me!” Douglas said. “You have me down to a T!”
Melanie leaned over and patted her husband’s knee. “You mean there’s a name for all the stuff you pull? Honey, there’s hope?” Then she looked at me. “There is something we can do for this?”
“Yes, I think so,” I said. “But first, let’s talk some more.”
Such was their curiosity and excitement, the appointment took the time of two sessions. Afterward, Douglas wrote me a letter, which I excerpt here. “A theory of behavior,” he began,
is only a good metaphor as long as it allows you to explain a whole raft of activities as stemming from the theory. I have to tell you that your description of me as “classic” ADD has been a particularly useful metaphor for me. In fact, coming upon it has provided me with one of the most singular experiences of my entire life, because all of a sudden there are an enormous (on the order of 1,000+ instances) number of moments in my life which make sense to me now, and didn’t before, as a consequence of your providing me with this metaphor.
He then went on to write of some of these problems.
I had always done well in English, but I remember realizing one day that I couldn’t “comprehend” what I was reading in one of the lessons well enough to be able to answer any of the questions. I remember going over and over the same bit and not having it stick any better the fifth time than the first. So, for really the only time in my life, I cheated and found the answer sheet.… I can now recall the feeling of complete confusion I felt with the assignments. I have continued to feel that way at various other times in my life. Even now I have an inordinately hard time reading, especially for someone who makes his living absorbing written documents. I have had my glasses and contact lens prescriptions changed at least three times apiece in the last three years in an attempt to “fix” my reading problem, which essentially involves starting to read a page, getting through about three lines with comprehension, then all of a sudden finding myself at the bottom of the page not recalling any of the words I just read.
At the end of my junior year in high school, having never really attended study hall or anything of the sort, and following my third straight year of A+ grades, I made a conscious decision that “if they thought that was good, getting my grades, wait until I really turn on the after burners in my senior year.” I decided to attend study halls and really apply myself in order to insure my acceptance into Harvard. I really did work harder that year than I ever had before, but I got, for example, a 50 percent on my midyear exam in math, having never got less than a 90 percent in my life. I also completely blew history and couldn’t remember anything from any of my lessons, and essentially screwed up the entire year in every course except creative writing. Even now I have dreams which involve finding myself in prep school, and all of a sudden realizing I hadn’t graduated because I had blown all those courses so badly.
I had a similar experience in graduate school in music, where I wrote a lot of music for other students and dedicated the pieces to them. I was asked by a French horn player if I could write a piece for her recital in seven or eight months’ time. In all previous cases I did it on my own time, and invariably got the thing done in less than a month. But in this case the pressure associated with her commission totally froze me. I was never able even to begin to write the piece, much less finish it.
These examples of what I would term “random failure” were incredibly unnerving to me and contributed to a sense I had of myself (and probably still do have) that every success I had prior to that moment was proven, by that moment, to have been a sham, and a fake, and a hoax on everyone including me, which led me to the inevitable question, “Why don’t you just admit that you are of limited intelligence, even less vision, and give up?” For some reason, I didn’t.
I have had any number of subsequent occurrences where, under some sort of pressure, I have, for varying periods of time, lost the ability to concentrate completely, and fallen into fairly significant depressions whose main characteristic is this self-flagellation. My wife, Melanie, finds this behavior the toughest of all my “foibles” to deal with because there is essentially no answer she has been able to find to get me out. I always feel as if describing how I feel and think about myself is too complicated; it’s as if I can hear the whole conversation in advance and I know all of the twists and turns it will take before they happen, so why bother? The effort just isn’t worth it. So, when Melanie asks me in these moods if there is anything she can say or do, she is met with an impatient “Thanks, but no thanks.” As a consequence, she has felt totally disconnected from me for sustained periods of time. I will, in those periods, come home and sit down in front of the TV and watch the news or listen to music late into the night, unable to speak more than monosyllabically with anyone in my family. I always thought my attention to that TV was the result of my intense interest in current events, but it’s pretty clear to me now that when I was feeling overwhelmed, going to sit in my favorite chair in my habitual spot in our living room had a salutary effect on my state of mind—it helped break the state of negative hyperfocus I’d fallen into—regardless of the content of the news that night.
And when I haven’t been depressed during these periods, I have become a stimulation hound. When I was down, I started smoking again, I went out to hear a lot of loud electric blues several nights a week, I drank more, etc. Melanie thought this was all the behavior of a basically decadent person who had sort of lost it, but for me it was very clearly a need to achieve some centeredness by “going for the gusto.”
More recently, I was working as an analyst for a particularly difficult man in New York, and one afternoon, before Melanie and I and the kids were supposed to go off for the weekend, this man, Bob, and I had a very difficult argument, which was simply the latest of a series of serious disagreements. I found this conversation so unnerving that when Melanie came to pick me up I was essentially unable to talk for the entire ride up in the car and for the rest of the evening. That obviously didn’t go over very well with Melanie, who thought that I should just “snap out of it.” The next morning I woke up and we were supposed to go skiing with some friends, and just as I was about to get on the ski lift, I turned to Melanie and said that I had to leave. I didn’t just want to leave; I had to leave. I couldn’t really explain to her or to myself why I had to leave, but I just knew I couldn’t stay there anymore. As usual, she found my behavior completely unacceptable, but also knew there was nothing she could do to stop me. I found a car-rental agency thirty miles away and told the people at the lodge where we were staying that I had a medical emergency back in Boston so they would have one of their young employees drive me to this gas station where they had one car left. I drove back to Boston listening to reports of the developments in the Iraq-Kuwait war and promptly went to my office, which had all of the things I needed to get myself back in a “crisp” or “clear” frame of mind—my computers, my card files, my IN-box, my calendar, etc. As a consequence, I was able to find the peace of mind to think about what I couldn’t think about in the midst of my wife and childre
n and friends.
It was clear to me when I got back to the office having driven all of that way, that that was what I needed, but I couldn’t articulate it. As a matter of fact, I was embarrassed to articulate it, because both my friends and Melanie have always made disparaging remarks about how I work on weekends. But since I have been an adult, first as a composer, then as a professional in the money business, I have always needed to be “at my post,” so to speak, for at least some portion of every day. It keeps me in focus to have a routine to plug myself in to. But since none of my friends or wife or children have such a need, they have long regarded such behavior as changeable, that if I would just relax a little bit, I wouldn’t need to go to the office, I would see more of my kids, and everything would be great. Although I love to see my family and do things together, being a father in the same way someone without ADD is just isn’t possible because it is very clear to me I get into panic situations if I don’t have a pretty strict routine built into my life, which involves a good deal of alone time, not necessarily quiet, but alone time.
Many of Douglas’s symptoms could be explained by other diagnoses—anxiety disorder, alcohol abuse, phobic personality, depressive disorder, obsessive-compulsive disorder—but no single diagnosis explains all the symptoms as well as ADD does. His reading problem in school is quite typical of ADD. He may have had dyslexia as well, but his tuning out a few lines into a page is exactly what you see with ADD. His independence, needing to do things on his own time, on his own schedule, is also typical of ADD, as is his frustration intolerance and his sense of being a fraud. His cognitive failures invalidated all his successes, in his own mind, and his self-esteem plummeted.
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