Driven to Distraction (Revised)

by Edward M. Hallowell

  7. Understand mood changes and ways to manage these.

  8. Expect depression after success.

  9. Learn how to advocate for yourself. Adults with ADD are so used to being criticized that they are often unnecessarily defensive in putting their own case forward.

  10. Learn to joke with yourself and others about your various symptoms. If you can learn to be relaxed enough about the whole syndrome to be able to joke about it, others will forgive you much more easily.

  In addition to making the diagnosis and offering education and practical tips, I also referred Sarah to a psychotherapist in her part of the country and agreed to serve as a consultant via the telephone should the need arise. After she went home, I made an adjustment to her medication in search of the right regimen. I had originally started her on the antidepressant desipramine because, unlike the stimulants, it only needs to be taken once a day creating an effect that is often more even than that of the stimulants, which have to be taken several times a day. I started her on a very low dose, 20 milligrams (mg) per day, but that had little effect. There is some controversy as to what dosage of desipramine one should give. The usual dosage for depression is between 100 and 300 mg per day. However, I have found that considerably lower doses are often effective for ADD. Since lower doses produce fewer side effects, I usually start at a low dose—10 to 20 mg per day. I raise the dose gradually. When I increased Sarah’s dose to 40 mg per day, she noticed considerable improvement, which she discusses below. Once the medication was set and Sarah had been in counseling for a while, I got the following letter.

  Dear Dr. Hallowell,

  I would like to fill you in on how the medication has been helping me.

  The adjustment you made with the medication has produced much more noticeable results: In general, I feel much more relaxed, more positive, and more on an even keel emotionally. I am also less confused. I didn’t know that I was confused before, but I think that that was one of the reasons that I avoided conflict and have been tense in social situations. I couldn’t think or respond quickly under stress. I feel now that it is more possible to engage with people, and that in conflict situations, I have more of a chance to know and say how I feel. This is not to say that I am great at it, but it is definitely better.

  I am less threatened by erratic and unpredictable people.

  My desk and work areas are not as messy, and it is easier for me to put things in order. They still are not what they should be, but at least I’m making some progress.…

  I have more energy in the evenings and am able to think more clearly. In general, I am having more fun.

  My husband says that I am more steady, less jumpy and controlling, and more involved in general conversation.

  The only side effect that I have noticed is that I don’t sleep as soundly. I don’t stay awake, though, so I can live with it.

  The tips on nonmedication management have been very helpful in keeping me on track. I reread them every so often.

  I have been thinking more about the issue of my father: the last I wrote to you was that I couldn’t imagine wanting a relationship with a father. Since then I have noticed that I have a desire to relate to some of the older “father figures” in my life, ones that are somewhat of a kindred spirit to me. And, probably, as I rethink it, my father, his sister, and my sister have ADD or something like it.

  A while back I dreamed I was in the house I grew up in. I was furiously angry at a woman who has been somewhat like an older sister to me. She is a very efficient person who can keep track of ten things at once. I think that she represented my mother, who cared for me but didn’t understand me.

  Perhaps the greatest benefit that has come since discovering that my husband and I have ADD is that we can understand each other. Previously, I felt that my friends understood me much more than he did. Since finding out about ADD and getting treatment, he is much happier, more productive, more accepting of himself, and easier to talk to. He used to be like a machine that tried to give answers; now I feel that he is the person who understands me the most.

  As in children, ADD in adults occurs on a wide spectrum. There are severe cases of adult ADD, where the individual can barely function at all due to rampant disorganization, or uncontrollable impulsivity, or a complete inability to follow through on anything. In addition, the person may be disabled by secondary symptoms of low self-esteem or depression. On the other hand, there are very mild cases of ADD where the symptoms are hardly noticeable at all.

  Mild cases can go undetected even by people who know of the disorder. The symptoms can be quite subtle, or they can be masked, as we will discuss in the chapter on diagnosis, by other symptoms, or the individual can have adapted so well that there appears to be no problem.

  I have treated a number of cases of adult ADD where I only discovered the disorder late in the treatment of some other problem. For instance, I had been seeing a highly successful businessman for five years in supportive psychotherapy before realizing that he had mild ADD. Bernie had been seeing me once a month or so to discuss worries and concerns that would come up in his busy life. He used me as a confidant, bringing up concerns with me that he wanted kept confidential but lay outside the purview of a business consultant. The matters had to do with his perceptions of his competitors, how he sized them up, how they treated him, what his thoughts were about the business world in general, and what his fears were in particular. Our work together seemed to have nothing to do with ADD, nothing to do with focusing attention, or regulating impulses, or containing restlessness, or dealing with procrastination or disorganization or any of the other usual concerns one hears from people with ADD. What we had set up was an unusual, but in Bernie’s case effective, model for getting some psychological support. It was only when we were talking about one of his children, some five years into our relationship, that I mentioned what the symptoms of ADD are. We looked at each other for a moment and had the same thought: Have we been missing something?

  Although he was not disabled by ADD, Bernie did indeed have symptoms of distractibility, impulsivity, and moodiness that bothered him. He would frequently tune out at meetings, find himself unable to listen to a telephone conversation even when he wanted to, tangle himself up with patterns of procrastination and overcommitment, and find himself getting angry and irascible without provocation. Once he got started on stimulant medication—Ritalin, 10 mg, three times per day—these symptoms abated. His level of productivity soared, leaving him shaking his head in amazement. “I get more done in a morning now than I used to in a week,” he said. Since he was an intuitive and resourceful man, he had been treating his ADD without knowing it by the strategic use of structure and by delegating to others what he hated to do, or could not do. “But,” he said, “now with the medication I feel more focused and organized than ever before.”

  I felt rather foolish, a specialist in ADD, not noticing the symptoms of ADD in a man I saw once a month for five years. My problem was that I had closed my diagnostic book, so to speak, on Bernie. As we settled into our regular conversations, I stopped thinking diagnostically. Only the mention of the symptoms of his child luckily reopened the book. It was a striking lesson to me of how what we see depends so much upon the context. Here I was, a professional highly and specifically trained to notice the symptoms of attention deficit disorder, sitting with a man for years who had many of those symptoms, and I didn’t see them. It was because I wasn’t ready to notice. The context in which I saw Bernie defined him as someone who did not have ADD. So, even though the symptoms were staring me in the face, I didn’t see them. I wager that I wouldn’t see them in a close friend, or even my wife, again due to the context.

  Most adults with ADD need the fresh look I withheld from Bernie for so long because I’d already made up my mind about him. That’s the problem with being an adult: people have already made up their minds about us; we’ve even made up our minds about ourselves. That makes it terribly difficult to get the radical reappraisal that
something like making the diagnosis of ADD requires.

  Most cases are more severe than Bernie’s. But at the same time, most people who have adult ADD aren’t floundering. Many successful people have it. It is particularly common among creative people—artists, actors, writers—scientists, people in high-energy or high-risk jobs, and people who work on their own.

  I recently treated a physician, let’s call him Joshua, who came to see me for the treatment of depression. He was a man in his fifties, a tall, burly gentleman with a salt-and-pepper beard and a hills-of-Tennessee accent. I didn’t know what that was, until he told me. “You sound southern,” I had said.

  “Hills of Tennessee,” he said. “One of the many southern dialects.”

  He was a warm, friendly man, trained as a general surgeon, but now practicing as a consultant. “When medicine stopped being medicine and became paperwork, I got out,” he said. “I’m doing fine professionally. And my marriage is good. I’m just not living the life I know I could. I’m not on top of things. I’m not being as creative as I want to be. Maybe I have no right to be, but I think there’s more to me than has come out so far. I don’t know if you can help me or not. I’m depressed, but then I’ve been depressed on and off my whole life. I was alcoholic for a long time, but I quit twenty-one years ago.”

  “How did you quit?” I asked.

  He smiled, as if humoring all the various movements that purport to help people with addictions. “The only way that would work for me. Cold turkey. I just stopped one day. I could see it was going to kill me—or worse, kill one of my patients. Can’t say I don’t miss it, but I’ll never drink again. Anyway, the depression got a little better after I stopped drinking, but I still have these moods. Black, interminable moods where all I can think of is what a rotten, worthless man I am.”

  “You start in on yourself,” I said.

  “Boy, do I ever. I’ll just have at me, call myself every name in the book and then some, go over and over all my failings, and show no mercy. You know, I can talk about it now like I’m talking about a symptom, but when I’m in it, I’m death. I’ll just brood for hours, even a day. I can still function, I can still work, but there’s this relentless voice carping away at me inside. My wife can’t make it stop, nobody can. I’ve seen a number of psychiatrists, and I’ve taken just about every antidepressant medication there is, but nothing works. Maybe it’s just my Southern Baptist roots come back to haunt me and I’ll have to live with it.” He raised an eyebrow as if to put a question mark at the end of his sentence, where his tone of voice had left a period.

  “I don’t know,” I said. “Let’s try and find out more about these moods.”

  After taking a lengthy history, I realized there was more to the story than just the problem with bad moods. Joshua’s dark periods were not typical of depression; they were not full of listlessness, hopelessness, and pessimism. He did not lose sleep or stop working or withdraw from the world as so many depressed people do. Rather, he actively brooded within himself, carrying on an internal monologue like a preacher from the pulpit about the extent of his sins. He never thought of suicide, nor, even, did he lose hope for the future.

  On the other hand, he gave ample evidence of ADD from childhood on, compensated for with structure and determination. “You know,” I said, “I think it might be useful to look at your depression from another vantage point. Let’s consider it as a kind of pernicious variation in your way of paying attention. You lose perspective. Instead of paying attention evenly, you hyperfocus on everything negative. This happens subtly, but profoundly. The next thing you know some mad preacher within you has started to harangue at you and you can’t stop listening. What this adds up to in terms of a diagnosis, combined with everything else you’ve told me, is that I think you may have the adult version of attention deficit disorder.”

  “You mean what hyperactive kids get?” he asked skeptically.

  “Yes,” I said. “But you have the kind that especially affects mood. You organize around a bad mood and you don’t let go. You hold on to it for dear life. You don’t dare give it up for fear that chaos will replace it.”

  Something I said caught his attention. His eyes focused on an upper corner of my ceiling, and he mused, “I organize around a bad mood. Interesting idea. Say more.”

  While the earlier example of Laura centered around anxiety as the chief symptom, in Joshua what was most troubling was the perseverative, negative thinking. I explained to him about ADD with anxiety and depression. It made sense to him. “You mean,” he said, “my mind may fall into one of these ruminative cycles, as you call them, like a muskrat walking into a trap? Snap! The trap shuts, and the muskrat can’t get free. That’s how it feels to me, because I’m struggling all the time. I’ve been calling it depression because it hurts so much, but it’s more of a fight than a depression, now that you mention it.”

  “Exactly,” I said. “Usually, you organize around a task or a schedule or some other logical schema. But when you happen into one of these traps, you organize around worry and self-contempt. If you can ignore the content of the ruminations, hard as that may be to do, and look instead at the process of ruminating, it may become easier to wriggle free of the trap. Instead of engaging in the argument, instead of answering back to the preacher in the pulpit, you need to ignore him. And the only way you can do that is by leaving his church. Go for a run. Call someone on the telephone. Write a letter. Turn on loud music. Whatever works to shift your focus off of this sermon of self-hatred and onto something else, do that. When you’re in one of those moods, it is not the time for introspection. Beware the preacher because he is beguiling. Because you’re intelligent and you like words, and you grew up in a strict moral framework, when you hear arguments mounted against you you can hardly resist answering back. But once you join in, the preacher has you. You cannot win. The preacher will always have the last word. In those moods, you can never stare him down.”

  “You’re right,” my patient said, then added with a wry smile, “you speak so convincingly about it that you sound like you’ve been there yourself.”

  “Well,” I said, “let’s just say I’ve heard an awful lot of people talk about it.”

  “And the other symptoms, what are they?”

  “Well, you mentioned your history of drinking, and you talked about how much you procrastinate, how you usually have too much going on, how you can’t get organized, how you overwork as a way of getting stimulated, how much you are putting off, your writing for example, because you can’t get started—these could all be due to ADD.”

  Once we had the diagnosis confirmed, we agreed upon a course of treatment. After we started medication—Ritalin—and had a few more sessions to develop insight into his situation, he improved remarkably. He found that he started to really like his work. He noticed what was going on. Most of all, the black moods ceased. He could still feel unhappy, but not in the bone-crushing way as before. “I’ve learned how to walk out of that preacher’s way,” he said. “I can see the scowl on his face and I laugh.” He used the concept of organizing around depression and anxiety as a means of fighting his tendency to do so. The medication helped both with focusing and with his moods. As focusing and organization became less of a chore, he found that work became more settled, freeing him up to start some projects he had been putting off. Like many people who discover in adulthood that they have ADD, he became excited about this new understanding of himself, and about the effectiveness of the treatment. “You know, I came in here not expecting much. But what has happened is amazing. I’m a new man. My wife is overjoyed. The world really should know about ADD.”

  While I share Joshua’s enthusiasm, I should temper it. The initial phase of treatment for ADD, the time of discovering that you have it, of making use of the insight this brings, of finding out that the medication really works, this phase of treatment is exciting. It can indeed transform one’s life. New realms open up to the individual. For some it is as dramatic as sud
denly being able to speak a foreign language they’d never been able to understand before, or swing the tennis racquet that had always felt like a pickax in their hands before, or get the books and papers and projects filed and organized that had mounted like heaps of refuse in their minds before.

  On the other hand, after the initial phase of treatment, the struggle usually does not end. For some lucky people it does, but for most people ADD continues to pose problems daily. While the treatment helps with the symptoms, it does not eradicate them. The ADD does not go away. It cannot be surgically removed. If one has it as an adult, one has it for life.

  People in treatment for ADD usually still struggle with issues of organization, impulse control, and distractibility. But more difficult than that, they struggle with the secondary symptoms that years of living with undiagnosed ADD created. These are symptoms such as impaired self-image, low self-esteem, depression, fearfulness of others, mistrust of self, skittishness in relationships, and anger over the past. These wounds heal very slowly.

  * Paul Wender, Joseph Biederman, Rachel Gittleman-Klein, Gabrielle Weiss, Russell Barkley, Kevin Murphy, Ronald Kessler, Lenard Adler, Stephen Faraone, and Bennett and Sally Shaywitz, to name a few, have now all written about ADD as it occurs in adults.

  4

  Living and Loving with ADD

  ADD IN COUPLES

  In couples where one or both partners have ADD, life can list and yaw from day to day. As one member of a couple said to me, “I never know what to expect. I can’t rely on him for anything. It’s really a circus.” The syndrome can disrupt intimate relationships and leave each partner exhausted. However, if the situation is subtly regulated, both people can work together, instead of being at odds.

  When ADD is at the root of a marriage in stress, the diagnosis is often overlooked because the couple’s problems can look like those of any couple. A husband comes home and immediately starts reading the newspaper, has trouble paying attention especially when talking about feelings, drinks too much, and struggles with self-esteem while ignoring his wife’s repeated attempts to get close to him. Or a wife daydreams chronically, feels depressed, complains of never having reached her potential, and feels trapped at home. These symptoms, in both instances, are consistent with ADD, but few people would think of ADD because the complaints are so commonplace.