Over Thinking

Over thinking is a part of anxiety, generally long term rather than recent.

A brief on anxiety: Some anxiety is caused by over expecting past bad things to happen again. Some anxiety is caused by past compensating behaviours being poor for a stable environment. Some anxiety is caused by situational problems that may need addressing. Most long term anxiety is caused by biology, most commonly your neurotransmitters aren’t well balanced, leading to your brain misinforming you.

Graphic text says:

"If you're happy and you know it, overthink.
If you're happy and you know it, overthink.
If you're happy and you know it,
give your brain a chance to blow it.
If you're happy and you know it, overthink."

Graphic picture shows a renaissance female with a hand on her face looking like she is "over it".

Back to overthinking.

Uncertainty

Over thinking can be a behavioural response to uncertainty

– The easy fix is to make a decision on the thing you are thinking about, then when you think again about it chant to yourself “nope, solved that <insert 1 sentence fix/decision>”

– If you go on to think “but what if”, respond with “I’ll solve that if it comes up”; unless it is highly likely to come up. First do a “likelihood of occurring” assessment (is it really likely, or just scary?), and if it is, make a decision now about what will likely work.

– Remember, you’ve survived this long, your emergency decisions have always succeeded at keeping you alive. You can fix an imperfect survival decision’s consequences later if you have to.

Toxic Environment

Over thinking can be a response to the most common condition I come across that should be in the DSM and ICD, but isn’t: “surrounded by A holes, but not knowing it/not knowing what to do about it”

– Sorting this out takes some specific knowledge about your situation and advice to get out of it, and how to change your thinking pattern.

– There are articles on our website jomida.com regarding toxic and abusive people as a primer

Biochemically driven

– Our brain has 1 primary goal “keep us alive”. It does this by trying to predict what is likely to happen that could be a problem and solving that ahead of time. It should only work on the most presenting risk in the near future. The further away the risk thing is, the bigger it has to actually be in order to spend valuable “now” resources to solve.

– If our brain’s neurochemistry is out, it misreports what threats are, or threatening they are, and how much resource should be spent on resolving them

– Take a look at how other people are responding to the same issues. If most people (perhaps 80%) are not worried about them, or only a bit concerned and have a basic plan of what to do, then you are indeed overthinking it. If you only occasionally sink lots of resources into a single problem, then perhaps you’ve seen something they haven’t – but if you often do this, then you are likely over reacting to risk.

– If using the above “I’ve got an answer” isn’t working and your brain keeps coming up with new problems, or ignoring your solution, you likely have a neurochemical problem. Biological problems require biological solutions.

= That means antidepressants. They start at modifying Serotonin, which works for about 1/3 of people. When that doesn’t work, it is important to look at the adrenalin system, often norepinephrine, which could be high, low or over-reactive. There are further explorations after that, but at this level you need an expert.

= You may also be experiencing anxiety and over thinking secondary to something else, like poorly managed Autism and or ADHD etc. This needs to be factored into your management of this too.

= Medication is generally only a part of the solution, addressing how you think is very important too.

Anxiety and the fight flight response, a quick guide

Anxiety – it can be tricky.

Below is a quick and basic guide to addressing long term anxiety.

For a deeper dive on Anxiety [Link]

The graphic below says "How do I teach my body that my fight or flight response is supposed to be for life or death situations, not answering an email", 11:56 AM 8 December 2022 from @ _chismosa_

It starts with some CBT (Cognitive Behavioural Therapy), where we look at a combination of the thoughts and behaviours around the triggering things, in this case emails.

If there are only a few triggering things, then you may have had an adverse event that has led to a heightened response to things that seem similar to that bad event. We can do some de-escalation and mood regulation exercises around those triggers to take the power out of them so that you can overcome that fight / flight response.

If there are a few more triggers than can be explained by a simple adverse event or two, then we need to look at some of your boundaries around people. This is often around when it is fair that someone is angry versus when it isn’t, and what your share of responsibility is towards that person who may or may not be justly angry. These core values may need some tweaking if they are set to “self sabotage” mode. That combined with some of the de-escalation and mood regulation, reinforced with boundary ascertion, possibly getting away from toxic environments, and some timely mantras to remind you that you have rights as much as they do often does the trick.

If this fight or flight response feeling is pervasive, then either we are dealing with a trauma response (PTSD style) or a neurotransmitter imbalance.

PTSD style first.

If you know the traumatic event(s) that created this anxiety, and your anxiety doesn’t pre-date the traumatic event, then we can do some trauma therapy around this. Trauma therapy has a few parts:

– ensuring the neurotransmitters are okay; which might mean some medication, exercise and dietary adjustments to correct

– mood education; so you can understand what your feelings actually are and are actually trying to tell you – and importantly when they are wrong

– mood regulation skills; to get your mood back under control so that your mood informs you and you choose your actions, rather than your actions are chosen by your mood

– understanding toxic behaviours and how they can manipulate you

– and finally, if and when you have a good handle on all of the above, stepping through what you know of the traumatic memories, mapping out timelines, separating facts from story, decompressing events and working out what the event(s) mean to your older you now vs your younger self

* sometimes even then the event(s) are too stressful to process directly, so we can use a distraction method to decrease the feeling of intensity such as eye movements, textured items, building lego objects, drawing and so on

If you can’t remember the trauma, then it isn’t trauma.

If the anxiety predates trauma, or isn’t explained by trauma, then we are looking primarily at neurotransmitter problems. That often starts with SSRI medication. If SSRI’s don’t give an adequate relief, likely switching to SNRI or a Beta Blocker medication depending on certain traits/symptoms. If that doesn’t work, then a more comprehensive assessment needs to occur to figure out what is going on, which exceeds what this quick guide can do.

Importantly, while SSRI is often a good place to start, it isn’t the end of the medical line; just often the end of what the GP is likely to trial. At that point you really want a therapist who is informed about medication and probably a psychiatrist. This will help work out the actual likely diagnosis for mental health and the likely medication that will help that medical problem.

Biological problems require biological responses. You can’t will power your way through diabetes, heart conditions or neurotransmitter irregularities.

The Five Phases of Trauma Therapy

Trauma is a term that is often very misunderstood in Mental Health. While PTSD (Post Traumatic Stress Disorder) is a serious condition, far too many people misdiagnose PTSD when in reality the situation was merely uncomfortable, regretful, confusing or better attributed to another condition. Trauma is often uttered as an explanation for odd cognition or behaviours, without either an investigation of whether a traumatic experience truly is the source of these thoughts or behaviours, or any attempt being made to do something about the cognition or behaviours.

Phase 0: Understanding Trauma

Phase 1 – Balance Neurotransmitters

Phase 2 – Stabilise Environment

Phase 3 – Stabilise Self

Phase 4 – Mood Management

Phase 5 – Trauma Therapy

Basic drawing of a brain and a person in a chair looking at it with a question mark above their head indicating questioning.

Phase 0: Understanding Trauma

While I did say that there are 5 phases to Trauma Therapy, this is on the assumption that Trauma Therapy is actually warranted.

Trauma is a medical term that refers to the damage left after an incident has occurred. A doctor might describe that their patient has “a rupture caused by blunt force trauma”, where “blunt force” is the nature of the “trauma”, and the “rupture” is the damage to the body from that blunt force. Body trauma can have a range of consequences, from short term to long term. Most trauma will heal in a short amount of time, often tracelessly. Sometimes there are some signs of healed damage that linger such as a scar, and importantly, this does not cause any serious long term consequences. Sometimes the consequences of the traumatic incident affect a person for the remainder of their life, some in minor ways and some profound.

We are not just physical beings.

A traumatic incident that affects our bodies can also affect our minds, both the hardware of the brain and the wetware of the thoughts and behaviours we exhibit. This can be brief, such as a minor burn to your hand on some cooking equipment prompting you to be cautious of how hot the kitchen ware is; moderate such as a romantic break up prompting you to greive, or long term.

PTSD is an initialism for Post Traumatic Stress Disorder, and while the concept was a rebranding of prior names names that describe the psychological damage to soldiers who survived war, it is also applied to any person who is having a range of specific ongoing consequences to an incident that they define as strongly traumatic after 4 weeks from the incident.

Even if your experience isn’t technically PTSD, some experiences can be very unsettling. We can experience lesser traumatic events, which can be a single incident or a series of linked or semi-linked events, that still affect us. Talking to a therapist can be helpful to understand what has occurred, what was fair, what is within the range of “normal” (even if it is unusual), and how to adjust to that and similar situations. Ideally you will exit the therapy with a greater understanding of the incident, some positive changes you can make from something that was likely out of your control, and a plan for if such a thing were to happen again.

It is important to note that the above is important if the behaviours and stress are only due to the incident identified as traumatising. I would estimate that upon proper investigation, around 80-90% of the people that come to see me for their Trauma discover that their behaviours and distress (most often anxiety) pre-date the incident/event identified.

When you are holding a hammer, all problems look like nails.

Too often people and therapists decide that this series of behaviours must be a trauma based response. When I expose that the behaviours existed prior to that event, they go looking for another trauma to heal, even going as far as “repressed memories” and “early childhood trauma”. We have excellent evidence where people suffering from clinically diagnosed and in-the-process of being treated for PTSD have had an accident that has caused an amnesia (loss of memory) that includes the traumatic events. These people have stopped experiencing the PTSD symptoms and no further treatment was needed. What we have learned from this is, if you can’t remember the incident, you aren’t traumatised by it.

This does not give you leave to go out and try to get amnesia!

In the cases where the problems that have brought a client to therapy predate the hypothetical incident, and no actual triggering traumatic event appears to be a starting point to the symptoms, we need to consider that we are dealing with a mental health or neurodivergent situation and shift gears to deal with that instead.

It is time to Put the Hammer Down.

Where the situation is either ambiguous or clearly trauma related, we need to look at Trauma Therapy. The gold standard for Trauma Therapy is a modified Cognitive Behaviour Therapy – Trauma CBT (sometimes tCBT, or TF-CBT [Trauma Focused CBT]). This should be in conjunction with other therapies for a holistic treatment plan. Specifically, a medical expert who can prescribe relevant medications, the therapist performing the Trauma Therapy on the backbone of CBT, other therapies to help target specific mal-adapted behaviours and or neurodivergent traits that are uncovered, potentially a relationship counsellor, domestic violence counsellor, home support and so on depending on what may be de-stabilising the client. In my case, I do all of the bits listed after the medication and I’m not shy about making recommendations for which medications types I think are most likely to help.

There are 5 important phases to Trauma Therapy

Phase 1 – Balance Neurotransmitters 

Many of my clients come to me either self medicating, on the wrong medication or no medication. While not all people require medication, many do – either short term or long term. Often much of their current struggle is an exacerbation of lifelong undiagnosed conditions. It is hard to think clearly and behave as you want when your brain is misfiring, and hard to know what to do if yoru brain is misinforming you, and or pushing you towards certain behaviours.

This needs to be stable enough for phase 4 and 5  to be possible.

Phase 2 – Stabilise Environment

While Maslow meant for all of his hierarchy of needs to be met, the baseline housing, nutrition, physical health and social safety are fundamental to good mental health.

This needs to be stable enough for phases 4 and 5  to be possible.

Phase 3 – Stabilise Self

The most common trauma that I see is relationship violence [Extensive list: Link]. This leaves the client with a destabilised sense of self, feeling over responsible for everyone and everything, and poor to no personal boundary definition or defence. People who have had non-relationship trauma (for example, a motor car accident) can lose these as they try to survive their understandable reaction to a traumatic event.

As the medication side is being explored, the therapist begins to rebuild the person’s core principles and helps build a scaffold for the person’s identity and boundaries to be tied to. This needs to be self-referential rather than tied to an external person, as if that person is no longer available, the scaffolding will fall, leaving the client even more lost. 

While progress will seem slow in the absence of medication (if needed) or environment stabilisation (if needed), once these previous two phases have progressed enough, the client will begin to enact the new core ideas and behaviours.

Phase 4 – Mood Management

This begins with some education on identifying what it feels like to have each of the major mood categories, and how to correctly assess the levels of those moods. This will then progress through to understanding the biological and social purpose of moods and how to tell if your emotional reaction matches the environmental cue. Checking on this is learning to note when your mood exceeds a mild level, giving you time to make decisions rather than just reacting.

A choice that is important to be able to make is to calm your mood back down. You can’t make a choice if you don’t know you have a choice to make, nor the skill to implement it. This leads to upskilling on how to manage your mood – but remember, this can only work temporarily to get you through a short term interaction. Long term mood dysregulation often points back to phase one.

[We have covered mood management before Link]

Phase 5 – Trauma Therapy

While it may seem like a great deal of pre-work to get to the actual therapy for the trauma, without a properly (or as best as we can manage) working brain to comprehend and make wise choices, without a stable environment to go to after therapy, without a sense of who you are and growing to be; and without the skills to recognise your mood and stabilise that – it is very dangerous to explore an event that was so traumatic that it damaged all of these things.

It is not uncommon that my clients don’t actually need this final step. What they thought was trauma related mental ill health was actually their brain using a traumatic memory to drive the mood to produce neurotransmitters to try to balance their brain, frequently on a background of unstable home life. When these are stabilised, it becomes apparent this was the actual problem.

If it is still relevant to continue with trauma therapy, a range of techniques are employed, depending on the nature of the trauma, the nature of the effect of the trauma and most importantly the individual client. The most common elements are:

  • Unpacking the trauma, noting falsely conflated events, facts vs assumption
  • Unpacking the narrative, seeking the best objective reality understanding
  • Desensitisation to specific triggers
  • Regaining Power and Choice

Our New Office has just Opened!

I’m excited to be starting my new location in our New Office – Midland, Western Australia. I’ve been working towards this for a while now, and we signed the lease 10 days ago and opened our doors only 1 day ago!

We have 3 rooms available for sub-leasing to Allied Health Clinicians, whether Social Workers, Psychologists, Clinical and or Mental Health Nurses, Occupational Therapists, Speech Pathologists or more.

Our goal is to actively help people with Mental Health difficulties, Workers Compensation, Neurodiversity (eg Autism, ADHD), physical disabilities and Life Crisis issues. We can help with a range of struggles, including:
-Identity
– Psychiatric
– Gender
– Substance use
– Mental ill health
– Family conflict
– Workplace conflict
– PTSD
– Anxiety
– Depression
– Domestic violence
– Anger management
– Parenting support/education
and more!

We see people
– Privately
– MHTP (Medicare’s Better Access Initiative via a Mental Health Treatment Plan from your GP
– NDIS Plan (Therapy via funding 15)
– eligble for Insurance rebates (if your company supports)
We can discuss other options too!

So, if you are looking for support for yourself, contact us!

If you are looking for a clinical room, contact us!

Feeling Antisocial

While humans are social animals, not all people benefit from these social interactions. Often there are some changes that can be made to address this, sometimes it is valid to just be alone.

Humans evolved long before what we recognise as civilisation existed. The ancestors that branched off from the other Primates 6 million years ago were not very big, strong or scary in comparison to the animals who thought of us as food. Humans who existed on their own did not live for very long, while those who cooperated with other humans for mutual survival thrived.

Benefits from social cooperation include safety from predators, greater hunting and gathering ability, collective access to people’s strengths, communal joining of effort, collective support for people’s weaknesses, and more efficient use of resources. To be in the group, you need to be a part of the group. When times are lean, there is a risk that the group may need to downsize, and those who do not contribute enough, people who are redundant or people who are not liked are the most likely to be kicked out. If that is you, then you are on your own.

When you are on your own, you are at risk of predation. While you may be safe enough while you are awake, you have to sleep at some point, and there is always a predator hunting for meat – you are, after all, made of meat, and we are very vulnerable when we sleep. Without a group to support us, our personal strength is the limit of what we could achieve. Even if you were the strongest person in your old group, you are not as strong as the whole group’s combined effort, so your effective strength is now reduced. There is no one who can compensate for your weak areas, and that can be fatal. To survive the old times for long, you need a group.

This is part of the terror of being alone, and part of what drives social anxiety and social phobia. Our biology recognises that we are at risk if we are without a group, so we will put up with much to keep it.

We evolved mechanisms to work well in groups. Tuning in to your group allows you to know when to act without having been told. Imagine that you are with a group hunting an animal. There is a good implicit time to act that helps to catch the prey, and a bad time to act that scares it off before people are ready. Tuned in people will act in support of each other, without having to explicitly hand wave or yell. A more modern example of this tuned in cooperation is moving furniture. Trying to lift and move a heavy bit of furniture is a vastly different experience with someone you are tuned in with versus someone that you aren’t.

Feedback mechanisms exist to help guide us in the group.

We evolved to take on characteristics of the group to further knit us into it. When we belong, we implicitly get a feel for what the rules of the group are, we take on some of the same dress fashion, we pick up speech mannerisms, adopt behavioural mechanisms and pick up group habits. This is what peer pressure actually refers to in psychology – the personal pressure to pick up the behaviours of our peers, not the pressure of others to conform.

Perceiving negative signals (generally feelings) in others indicates we are making the wrong assumptions. Perceiving positive signals in others helps us feel at home, safe and nurtured. Negative signals push us to invest energy into changing and conforming, while positive signals reward and recharge. How we perceive our group can change whether we feel drained or recharged by the encounter.

We are not the only factor in this relationship. A group of toxic people will have constantly changing rules such that you can never win, always perceiving negative signals and always feeling draining. They will misinform you so you always perceive negativity and they will take advantage of the drive to invest energy and conform. An incompatible group will always feel wrong, even if the people themselves are nice enough, you’ll feel like you are in a group, but not of the group. A group of compatible peers will feel safe, comforting and invigorating. An incompatible or toxic group will have you acting out of fear or anger, driving you to change, hide or do actions you don’t really want to. A group that is good for you will inspire you to grow and be greater. Look for the people who inspire you towards being more, avoid the groups that drive you.

Sometimes we are toxic to our own minds, where either due to bad experiences or biology, our perceptions are distorted and we can’t pick up the true signals. Therapy and reality checking can help this.

Humans are very malleable. We can flex in lots of different ways to fill the niche and adapt to and overcome the problems we come across. In a stable and nurturing group, this grounds us and guides our growth in healthy ways. In a toxic group it can teach you terrible habits and badly damage your self-esteem. Toxic groups push you to do things you think are wrong, and then claim they are the only ones who will now accept you. Toxic people lie. There are fundamentalist ideological groups who have some very strange beliefs, and people who are immersed in those beliefs can take on those values and errors. After surviving toxic people for a while, one can develop quite an aversion to people.

People who are on their own for too long start to lose track of what is important to them, of the framework that helps to guide their lives and strange beliefs can start to emerge. There is a reason why isolation is used as a punishment and torture. We humans do not do well on our own.

Mostly.

There are some people who do not feel refreshed and recharged after interacting with others. This isn’t necessarily due to a history of trauma, or just not finding compatible people. It is just a difference in mental mechanisms from the norm. A divergence, if you will. That isn’t to say that all neurodivergent people fundamentally struggle with feeling rewarded and recharged from good socialising, but some do have this trait. While many neurodivergent people do struggle to find their niche group and there is a strong representation of people with traumatic pasts to overcome, most neurodivergent people do find their niche group, their village.

People who still find no significant reward in their village can struggle to justify why they should expend the energy to socialise, since it only costs them and doesn’t benefit them. There is a truth to this idea, it is mostly just cost. There are some benefits that are harder to see though, that these hermits need to consider and add back into this cost benefit analysis. Two important parts of having a good social network are that when you do need help, it is good to have people who will come; and a good social network helps you not to become too strange from isolation. The challenge is to find the correct ratio of enough energy invested in social to allow for these benefits that does not cost more than these benefits can give.

When every social interaction costs you, or even if just many of your social interactions cost you, it is very important to give yourself non-social recharge time. Social batteries are an excellent metaphor for allowing them to recharge again before expending them.

While most in this group of people who find no significant reward in their village will find an equilibrium between enough social for protection of self and not too much that it is too expensive, there are some who find it better to just be alone. In those situations, this is valid. When you need village support, there are professionals who will do this. To keep yourself from drifting too much from yourself, there are mechanisms to account for that too.

Mental Health and Medicine

I am frequently fascinated and sometimes a bit horrified by the explanations that my clients give me to explain their feelings, thoughts and behaviours. The vast majority of these concerning explanations are steeped in a belief of ‘personal failure’, misattribution to ‘trauma’ and blaming ‘bad parenting’. While insufficient effort to change, traumatic experience and poor education can contribute to poor mental health, these are rarely the cause for someone to see me. It isn’t my client’s fault though. It is an artefact of how therapy has evolved. I see these same mistakes being repeated by therapists, online advocates and text books. They are all missing the key feature – biological causes require biological solutions.

Mental health evolved separately from most medical science. Running in parallel to cognitive therapy is medication and neurology. Dr Steven Novella, a neurologist, stated that “If we know what neurons are involved, it’s called neurology. If we know what medications help in the absence of the neurons, it is psychiatry. If we don’t know what medications help, nor what neurons are causing it, that’s called psychology”. Interestingly, neurological problems aren’t called mental illnesses, while both psychiatric and cognitive problems are. More on the medical side a bit later. First we need to understand what doesn’t work.

The evolution of treating “Mental Illness” in the absence of medicine started with religion, an morphed through “you have angered the gods”, “you are wrestling with your demons”, “you have a moral failing of your character” and “those who work hard get rewarded, those who don’t get punished – what did you do?” The solution was prayer, inner self searching and working harder. Failure to “heal” was defined as a problem with the patient, not the therapy. This holdover sounds like “I caused it/it’s my fault”, “I’m not good enough”, and my favourite “I’ll just try harder”. There is an element of truth to this, if you don’t want to change, I can’t change you with therapy. However, if you are trying and it isn’t working, then the method is wrong – work smarter, not harder.

Therpay couch
Talking therapies are most popularly done from a couch

Treating “Mental Illness” then went through blaming parents, sexuality, society and your own baser unconscious desires. Psychobabble was born to help confuse the patient so they didn’t realise that the therapist had no idea either, while a failure to progress was again put on the patient. Again, there is an element of truth here, bad parenting and societal rejection can create problems. These are fairly easy to correct for, so if a few months of effective therapy doesn’t help, it isn’t likely that.

Effective talking therapies, such as Cognitive Behavioural Therapy (CBT) and Trauma Therapy, are excellent at challenging erroneous beliefs and upskilling the person to improve their mental health. This only works if their mental distress is caused by a faulty idea, maladapted behaviour (the wrong lessons), or ignorance of a good solution. Additional features of good therapy include helping the person explore their experience and solution, education, upskilling and the actual support of the therapist.

As a therapist, learning to recognise when a person’s experience is caused by biology is really important. A biological cause needs a biological solution. No amount of talking therapy will fix the focal distance of your eyes, help your pancreas to produce more insulin, fix a murmur in your heart, heal a fractured bone, or balance the neurotransmitters in your brain. While talking therapies can help you manage these a bit better, they won’t give you a good health outcome without a medical component.

But what happens when CBT doesn’t help? What happens when challenging your core beliefs does not shift those same ideas that drive your behaviour? What if all of your behaviours are correct, and you have the core rational and logical helpful beliefs about yourself and society, yet you are still mentally distressed?

Therapists have tried many different models and theories to try to supersede CBT. Most of them don’t work, because they are just rehashing religion/ideology, victim blaming and psychobabble to pretend that they know what they are doing, while having no actual impact on why the person is struggling.

The “alternative therapy” models that do work are basically CBT Purple Hat Therapies. A Purple Hat Therapy is where something flashy and distracting is done, such as “please wear this Purple Hat”, while the real therapy is performed (such as CBT). You are then told that it was the Purple Hat that healed you. You only really notice the Purple Hat because it is different to what was expected and miss the real therapy you did. These do not perform any better than raw CBT.

Over the last century and a half, various medications have been found to help some very specific symptoms and “Mental illnesses”. Over time, investigations into what these medications do to our brains and bodies has revealed direct and indirect information about what is the biologic cause behind many labels of “Mental Illness”.

This should shift the category of these particular conditions (such as anxiety, depression, autism, adhd, schizophrenia, voice hearing, bipolar affective disorder and many more), from Psychiatry/Psychology to Neurology. But it hasn’t. These are still considered to be “Mental illnesses” rather than divergent neurology (Autism and ADHD) or a neurological condition.

With the recognition of what many of these medications do, and which medications work for which symptoms, we now know that many labels of “Mental Illness” are just the presentation of symptoms of some basic neurotransmitter imbalances. Anxiety Disorder, for example, is one of the symptoms of either too little of the neurotransmitter Norepinephrine (most of the time), or too much (some of the time). Other symptoms for the same biological cause (Norepinephrine imbalance) can be Aggression, Impulsiveness, Self-Harm, Suicidal Ideation, Rejection Sensitivity, OCD, Mysophobia (fear of germs), Social Anxiety, Sensory Hypersensitivity, Meltdowns and Hyperactivity to name but a few. While Norepinephrine isn’t the only thing that can cause these symptoms, in my experience it is the most common.

Despite our new knowledge, these symptoms continue to be given a “Mental Illness” label and are treated with talking therapy or the wrong medication. I have a client who has been through trauma therapy around 10 times with various therapists for their social phobia. Their treatment outcome was a belief that he wasn’t trying hard enough and thus he is to blame for not getting over his trauma. That really isn’t helpful. His GP treated him with the typical anti-anxiety medications, which don’t actually address the base cause. I identified that he was doing the right things as outlined by Trauma Therapy, and therefore his ongoing symptom was likely biological. With the cooperation of his doctor (his psychiatrist didn’t believe the model), my client began a biological remedy (medication) to treat his probable biological condition with a significant positive result. That is, it works. We are now trying to tweak the medication to give him 24 hour positive results instead of only 12 hours.

I can already hear the counter argument forming in some people out there. Let me address the most likely arguments.

What if he could just learn not to be socially anxious, isn’t no medication better? Yes, it would be better, if his anxiety was based on an idea and maladapted behaviours. It isn’t, it is caused by biology. We know this, because “educating” the client did not change their experience, so it wasn’t a lack of knowledge. If a neurotransmitter medication could give you that knowledge, I want to try the one that tells me how to do Kung-Fu.

What if he just wasn’t trying hard enough? Anyone that says “you aren’t trying hard enough to get over your anxiety” is arguing from a privileged position of never having experienced real anxiety. Laziness, willpower and effort is not the problem.

What if the medication is concealing rather than treating? Certain sedatives can block and conceal the route course of something like anxiety. This medication is not a sedative. It is actually treating the route course. Explaining exactly how that medication works is beyond the scope of this.

If all mental illness is just a biological problem, then why don’t we just give everyone medicine? For a start, not all struggles that people see me for are classified as mental illness. Secondly, for the same reason we neither give everyone insulin treatments (as not everyone has diabetes), the same insulin treatment (every person is an individual with diverse needs) and insulin treatment in the absence of education about what diabetes is and how best to treat it.

I’m going to say this again, for the people up the back who weren’t paying attention throughout this monolog.

Talking therapies are fantastic to help correct maladaptive behaviours, erroneous core beliefs and upskill ignorance. I use it frequently with my clients for when their mental distress is due to one of these. Learning smarter solutions to problems that have defied the person’s current skills is excellent and the base point of talking therapy. Good therapists are excellent at helping you keep on track and providing additional support when you need it. When this is all that is needed, well done, your job is done.

As a therapist, learning to recognise when a person’s experience is caused by biology is really important. A biological problem needs a biological solution. No amount of talking therapy will fix the focal distance of your eyes, help your pancreas to produce more insulin, fix a murmur in your heart, heal a fractured bone, or balance the neurotransmitters in your brain. Once the biological condition is stable, now you can see if further talking therapy is needed and get on with that. Then your job is done.

So please, stop victim blaming people for failing to will power their way through a biological condition.

Autism Parents

Text below
The usual answer is semi-right, but simplistic and stigmatising

“Why can’t parents talk about their experience with Autism?”

‘Because unless they’re Autistic parents,
they’re not talking about their “experience with autism”.
They are talking about their observations of their Autistic child,
filtered through their own non-Autistic perspective.’

The common response

Actually, it’s more complicated than that.

We know that most parents of Autistic kids are also Autistic (85%+).

Due to historical poor understanding of Autism, the parents of Autistic kids have often grown up thinking they are neurotypical, and to survive, they have tried to be as neurotypical as possible. This means being enculturated in the anti-Autistic
social stigma.

This skews their views on what they are actually advocating for – and unfortunately that is often regurgitating the societal dogma.

That isn’t what is best for their kids, and what is “good for Autism”, despite their best intent.

ADHD Primer Part 3 – Autism and ADHD Comorbidity

If a person has sufficient traits of Autism and sufficient traits of ADHD, then that person should be diagnosed with Autism and ADHD Comboridity. “Co-morbid” is the medical term for co-occuring for the same person. The question, though, is how common is a comorbid diagnosis in society, and how common should it be?

[Link to ADHD Primer Part 1, understanding the history of ADHD and looking at what that might mean]

[Link to ADHD Primer Part 2, understanding what medication tells us ADHD is]

Before we can look at the overlap of Autistic and ADHD people, we need a quick and dirty primer on Autism.

Much like ADHD, Autism is a neurological divergence from the neurotypical brain. Autism’s inclusion to the American DSM (Diagnostics and Statistical Manual of Mental Illnesses) was, like ADHD, a mixed bag. While it helped many medical professionals gain a better awareness that Autism was a thing to factor into their diagnosis and understanding of people, it changed how medical professionals, and thus how public perception, categorise Autism. The inclusion in the DSM erroneously re-categorised Autism from a neurological condition to a mental illness.

Autism is not a mental illness in and of itself. Like ADHD, Autistic people can experience mental illness. Often this is a result of external problems, such as societal stigma, exclusion and traits that are not well managed. Autism is not a disability in and of itself. Like ADHD, Autism can be disabling. Autism does not mean the person has an intellectual disability. Like all people, Autistic people can have a comorbid intellectual disability.

Much like ADHD, Autism is poorly defined in the two basic diagnostic manuals, the American DSM and World Health Organisation’s ICD. In simple terms, the first criteria for diagnosis (according to both the DSM and ICD) approximately says “has difficulties with being social”. The latest Text Revision of the DSM 5 is particularly heinous in stopping right there – no other factor is considered. The ICD has a secondary test, which is checking to see if the person has classic odd behaviours in patterns and or special interests. The ICD prioritises the social difficulties over the other symptoms – the “has no friends” false stereotype.

I have literally had a GP tell me the person I would like assessed can’t be Autistic because they have friends. Firstly, are those friends also Autistic? Secondly, for Autistic people to survive this society, many of them learn to mask. Masking is where you try to give other people the social signals that they would expect from a neurotypical person – it is exhausting. If you find being around most people is tiring, then you are likely masking. Thirdly, the reason the name was changed from Autism to Autism Spectrum Disorder was to highlight that there are a range of traits that an Autistic person may have, in different strengths and showing in different ways. Social difference is just one of those traits, not the only trait. To emphasise, you can be Autistic and have friends.

Ok, I think that is enough of a quick Primer on Autism.

Prevalence is the medical term for indicating how likely a thing is to be found in a random, or specific, group of people. Interestingly, any “condition” that is considered to be higher than 1% of the population is considered to be just a part of being human. For example, the prevalence of Left Hand Dominance is between 9-11%, thus being a Leftie is both common and a normal part of being human, rather than a disorder. Being a Leftie can be disabling in some circumstances, but it is not a disability in and of itself.

Unlike being Left Hand Dominant, assessing Autism and ADHD is unexpectedly challenging. Part of this is the poor definitions given for each condition. Another issue is whether the government agrees that ADHD and or Autism is an actual condition or not; and if so, how is that defined, tested and treated. This leads us to some wildly fluctuating international numbers for both Autism and ADHD.

Let us focus more specifically on Australia. 

Deloitte estimated that the range of prevalence of ADHD in Australia is between 1.8% to 5.8%. Deloitte explains that accurate estimates for ADHD in Australia are difficult due to shifting criteria, poor definition and variable access to diagnosisticans. Deloitte also points out the contradiction of various officials claiming that ADHD is both over and under diagnosed. Surely both can’t be right?

The same story exists for Autism. Australian prevalence estimates for Autism vary widely, from 0.67% (1) to 4.8% (2) in youths alone. Autism and ADHD are brain types you are born with, so you don’t “grow out of” them. 

These estimates are so varied in range, they become untrustworthy. Even so, the rates are clearly higher than the 1%, so much like being left-handed, both Autism and ADHD are just a part of being human.

Back to our first question – what is the comorbid prevalence? That is, how many Autistic people have comorbid ADHD, and how many ADHDers are Autistic?

We don’t actually know.

Autism Spectrum Australia (3), in regards to Autism and ADHD Comorbidity wrote “Estimates of co-occurring ASD+ADHD vary widely. Generally, it is considered that the majority of individuals with autism also have ADHD symptoms. However, in some studies the proportion of children with autism who also have clinical symptoms of ADHD is reported to be as low as 14% while other studies report it to be up to 85%. Similarly, clinically elevated levels of autism symptoms have been noted in 18% to 67% of children with ADHD.”

Those are some mighty big error bars. In any hard science field, these results would be laughed at. 

Science has failed us. 

If we can’t trust the existing science, then what is my clinical experience?

Out of all my clients that I have recommended seeking assessment, those clients who have persisted through waitlists; additional referrals; expense; and have been assessed by a professional who has the authority and expertise to provide a diagnosis – all of them have been confirmed to have ADHD and/or Autism. This indicates that my ability to assess Autism and ADHD is very accurate. I am not claiming to be foolproof though, so take the following speculation with a pinch of salt.

My experience matches what Autism Spectrum Australia found. In my opinion, all of my Autistic clients show sufficient traits to qualify for an ADHD diagnosis, and most would benefit from access to ADHD medication. In my experience, all of my ADHD clients show sufficient Autism traits to qualify for an Autism Diagnosis.

Yet very few of my clients have a dual Autism and ADHD Comorbidity diagnosis.

It is important to understand that the struggle to get just one diagnosis is quite hard. To get the second diagnosis is even more difficult. That might be hard to understand if you have not had to navigate the gauntlet of gaining a diagnosis for either one. It is ridiculously hard, but explaining how hard is beyond the scope of this. If you only have the resources to pursue one diagnosis – either Autism or ADHD –  my common recommendation is to get the ADHD diagnosis. An ADHD diagnosis will get you access to restricted medication that helps both conditions – don’t fall for the erroneous opinion that “you can’t medicate Autism”.

In my experience, it isn’t just an Autism and ADHD Comorbidity… Autistic people and ADHDers are the same people, and so share the same experiences. With two camps flying under different banners, this has led to both camps describing these specific similar experiences with different language and flavour, falsely attributing the traits/behaviour/experience as unique to their category.

This, combined with very different diagnostic criteria, has erroneously led to the historical belief that Autism and ADHD are so unrelated that it is only possible to be diagnosed with one condition. In Australia, this error has led to the role of diagnosing people for ADHD and Autism to generally be done by two separate systems and professionals, adding to the struggle to get properly assessed, diagnosed, and where relevant, treated.

What of the traits that are not unique? Surely that is where this shows that Autism and ADHD are not the same, right? For example, Autistic people love pattern and order, while ADHD love chaos – checkmate Joshua, checkmate.

Some Autistic people love pattern and order. They find the patterns comforting, the efficient elegance and find order cheaper to maintain. Some Autistic people are incredibly messy, because they see that there is no true system, and trying to maintain any kind of system is very fatiguing. Some ADHDers can’t maintain a system to save their life, while others like a very simple black and white system because it is easier to maintain and this way they don’t lose their keys all of the time. Hopefully you have noticed that I have described the same behaviour range twice, just with different language. Remember, spectrum means that traits exist on a range.

In my opinion, the Venn Diagram of Autism and ADHD is not quite a circle, but it is darn close. Perhaps it is a circle.

One might ask if there is such a high overlap of Autism and ADHD Comorbidity, is there really a difference? Personally, I speculate that ADHD may actually be a trait of Autism, and hope we will see increased understanding of the overlap within the scientific and health communities in the near future.

Venn diagram offering an overlap of Autism and ADHD, OR just Autism/ADHD called AuDHD
Venn Diagrams – Are Autism and ADHD separate with Autism and ADHD Comorbidity overlap, or are they the same thing, called AuDHD?

References:

(1) “Autism in Australia”, Australian Government, https://www.aihw.gov.au/reports/disability/autism-in-australia/contents/autism

(2) “Autism Spectrum Disorder Prevalence in Children Aged 12–13 Years From the Longitudinal Study of Australian Children”, Wiley Online Library, https://onlinelibrary.wiley.com/doi/abs/10.1002/aur.2286

(3) “Autism and ADHD”, Autism Spectrum Australia, https://www.autismspectrum.org.au/uploads/documents/Fact%20Sheets/Factsheet_Autism-and-ADHD_20171113.pdf

ADHD Primer – Part 2

TL:DR – ADHD is mostly about Dopamine. Norepinephrine is also often important. Understanding how Dopamine and Norepinephrine affect our feeling is key to understanding a great deal about ADHD.

"Out of Dopamine Error" style error alert - Fix button does not appear to be working and is greyed out.
“Out of Dopamine Error” – Fix does not appear to be working

Last time we covered that ADHD is a neurological condition that is poorly defined, but does affect a fair percentage of the population. The name means Attention Deficit Hyperactivity Disorder: where on observation, some ADHDers do seem to have trouble with attention. We will see that the conclusion is simplistic, and that this method for defining the group of ADHD is misleading.

We established that certain types of medication can really help. What these medications have in common is their ability to increase a chemical in the brain called Dopamine. I also stated that there is frequently a problem with regulating another chemical called Adrenaline.

We will be covering here what that is about, what it tells us, what the consequences to the individual can be, and what you can do about it.

Originally, methylphenidate, commonly called Ritalin, and a classification of medications called Amphetamines, were observed to help people who fit the description of Hyperkinetic – that is, they move too much, which was a precursor to the name ADHD. Amphetamines are categorised as a medication called “stimulant”. Ritalin was classified as a medication to modulate blood pressure. One would think that giving a stimulant to a person who has trouble sitting still would make it even harder for them to do so – but the reverse happened. These people found it easier to sit still. More importantly, they found their concentration vastly improved, and often, their mood easier to regulate.

This tells us that Dopamine is a key component to the category of ADHD. Dopamine is a chemical our body uses in various ways for various things. It is classified as a Hormone (like testosterone, oestrogen and insulin) and a Neurotransmitter, a chemical specifically involved in how signals are sent and received around the brain.

We need to do a quick side track about mood, which will help us understand both neurotransmitters and some important ADHD aspects.

ADHDers often find their mood dysregulated in the absence of medication. First, what the heck is mood?

We feel in response to an occurring or expected event. The feeling is the result of a super quick assessment of the situation and that feeling comes with some default actions. Those actions can vary in strength from suggestions to commands. The common biological feelings that give us a quick assessment of the situation are fear, anger, disgust, surprise, sadness and joy.

If that feeling persists, it becomes our mood. When we show that internal state to others, it is an emotion. I don’t have to show others how I feel, but sometimes showing that feeling helps them respond to the situation or me better. My emotion doesn’t have to match my feeling or my mood.

So, feelings are quick, moods last and emotions are feelings or moods that we are signalling to others.

Even though they are technically different, be aware that both socially and frequently in scholarly literature people interchange feeling, mood and emotion. A mood disorder can be more about feelings than moods, moods than feelings, or a balance of both. Emotional disorders are almost always about feelings and moods rather than communicating those feelings and moods to others.

Our fundamental feelings evolved far before civilisation, and are integral to our survival system. As such, they are strongly tied to our freeze, flight and fight reflex. Freeze, flight and fight are more or less controlled by a chemical called Adrenaline. When we detect risk, we assess the situation, get a report in the form of a feeling, get a default action in the form of an urge, and release Adrenaline to prepare the body for action depending on the strength of that urge.

Adrenaline has a few forms. An important one is Norepinephrine, which is classified as both a hormone and a neurotransmitter. In the brain, we make Norepinephrine made from a different hormone/neurotransmitter called Dopamine, the chemical at the heart of many of the ADHD medications. Norepinephrine empowers our getting on with tasks and is part of regulating our state of alertness – sleep, relaxed, alert, anxious and panicked.

The feelings most closely tied to the neurotransmitter Norepinephrine are pain, fear, anger, disgust and surprise. While Sadness is also related, it is complex to describe and beyond the scope of this quick exploration. As part of your survival mechanism, each of these feelings has evolved to help you avoid damage now or in the future. They aren’t inherently good or bad per se; they are good if they are doing their job and they are bad if they aren’t.

In the same vein as the previous feelings, Joy evolved before civilisation. Joy is the feeling we have when we have done an action that promotes our wellbeing, such as eating food, acquiring goods, connecting socially to people, succeeding at tasks and so on. Joy is connected to the neurotransmitter Dopamine. When we do one of these activities, Dopamine is released and we feel good (a form of joy), and it will reinforce us doing this activity again. Much like the other feelingings, Joy isn’t inherently good or bad. This cycle is great for our survival when in balance, but when out of balance can cause havoc.

We can co-opt the Dopamine reward release to power up the Executive Function. More on that a bit further down.
To review, so far we have experiences that trigger feelings, which will then trigger certain Neurotransmitters to be released in our brains, which can then power certain abilities such as solving, freeze, flight and fight. These feelings will then affect the decisions and actions that we take.

It is important to note that you don’t need an experience to have a feeling. On the one hand, we humans have active imaginations, which ideally help us plan and solve problems before they happen. However, our imagination can also trigger the feelings, which can then trigger these Neurotransmitters. On the other hand, sometimes our brain can randomly misfire; we can have a reaction to a food, drug, illness, medication; or other physical occurrence can also trigger the release of these Neurotransmitters. These erroneously released neurotransmitters will then trigger feelings that are not connected to the usual kind of stimulus (real life event).
The point of this side track is both to understand how our feelings and these Neurotransmitters are tied together, and to recognise that they work in both directions – feelings trigger the release of certain chemicals, and the release of certain chemicals can trigger feelings.

When we humans have a feeling that doesn’t obviously correspond to an experience, we search for an experience to connect it to. If we find one that will almost work, we will generally distort our perception of that experience to match our feeling. In the absence of an experience that fits well enough with the type and strength of the feeling we have, we will make something up that can fit how we feel. So far as our brain is concerned, this is a nice and tidy bit of accounting – the feeling is now tied to an experience, so we can act on it. The problem is that the faulty allocation of a “reason” for our weird feeling often leads us to make awful decisions. For example, if you suddenly feel fear due to a body chemical mistake, and failing to find a real world thing that might reasonably explain your fear, you will create a reason to explain that fear based on the situation you are in. This made up reason is not real. Your next action to address that fictitious fear is wrong and likely to cause you problems.

I keep talking about these Neurotransmitters. We need to take another side journey to understand those a bit better, and why they are so important to understanding what ADHD actually is. I’m going to focus on the big three for a moment – Dopamine, Norepinephrine and Serotonin. I am also going to add in a bonus Neurotransmitter, Melatonin. Please keep in mind that this is going to be a quick approximate tour.

Dopamine, Norepinephrine and Serotonin are related chemicals. I’m not going to go into every step, although it is very fascinating. Each of these chemicals becomes another, with a distinct chemical formula and traits.

Firstly, when you eat protein, your digestion turns it into base amino acids. One of these amino acids is called Tyrosine. Tyrosine is used to make various different parts of your biology, which aren’t relevant here. The one that is relevant is called levodopa (L-Dopa). Levodopa can pass through your blood brain barrier and is the first point at which what you eat becomes the base product of this series of neurotransmitters that your brain needs. After a few transitions (each of which are used for various brain functions), it becomes Dopamine. While your body also makes Dopamine elsewhere in the body, this Dopamine can’t pass the blood brain barrier. Dopamine powers the Executive Function and is a Reward hormone that helps you feel good. Dopamine is then turned into Norepinephrine, which empowers both getting on with tasks, and is part of our defensive feeling system. A few more steps and Norepinephrine becomes Serotonin. Serotonin is often ascribed to regulating and affecting all of the things that I’ve described for both Dopamine and Norepinephrine, and I think that this description is overly simplistic, often mis-ascribed, but still a part of a complex picture. A few more steps and Serotonin becomes Melatonin, often used to indicate to your brain that it is time to sleep.

Dopamine is used in various parts of your brain for various tasks, such as regulating muscle movement, memory storage, memory retrieval, comprehension, problem solving, prioritisation, sleep, learning, lactation and more. Some of these are very relevant to ADHD. Effectively Dopamine powers your Executive Function.
Yet another side trip to explore the Executive Function. In this context, the Executive Function is a network of parts of your brain that plans tasks that improve our chances of survival. It tells us what are the priority tasks right now, how to do them, gives us temporary memory storage (working memory) to facilitate that solution (like doing mental math instead of having to write it down), finding clever solutions to problems, activating us starting on those problems and then keeps us on track. It is an integral part of our ability to do several tasks in quick succession, a basic kind of multitasking.

This all sounds fairly standard and normal, unless you have an ADHD brain, in which case some or all of these things are literally hard to do. When we give a medication that increases the available Dopamine in the brain by just a tiny bit, the ADHDer finds each of these much easier. That tells us that ADHD is fundamentally a problem getting Dopamine to the parts of the brain that do these functions.

If the availability of Dopamine is low, your brain will be reluctant to use it for something as mundane as solving non urgent problems. This makes it hard to make sensible plans, hard to remember details, and hard to anticipate what is next. The ADHDer will also often feel disconnected from the world and disassociated as Dopamine being used by the motor cortex becomes minimised to conserve remaining Dopamine resources for potential crises.
Next along the pipeline, Dopamine becomes Norepinephrine, one of the forms of Adrenaline. Norepinephrine is integral to our defensive feelings and fight/ flight and fight reactions. If there isn’t enough Dopamine, then there generally isn’t enough Norepinephrine, which means that a person is going to feel very down, “emotionally” numb, and unmotivated. This will also often feel like being “out of energy”, which prompts actions to conserve energy. This is quite easy to mistake for a condition called Depression.

Our brains are primarily geared towards survival, and without enough Norepinephrine, it is very hard to power up the system that makes a quick and accurate assessment of the situation. If your brain detects that something is going wrong, it tries to fix it, and in the failure of fixing, compensate. In this case, it notes there is not enough Norepinephrine, so it tries to convert Dopamine and substitute Epinephrine (regular Adrenaline, the next chemical down the pipeline from Norepinephrine). Epinephrine is not used much directly in the brain (other than some very fascinating memory storage action when combined with glucose), so it is often available, prior to moving further down the pipeline towards becoming Serotonin.

While your brain will be reluctant to use limited Dopamine for such mundane tasks as planning a possible future, a sufficient crisis will override this caution, and allow the Dopamine to be converted to Norepinephrine.This allows you to be present to the moment, but with reduced intelligence. That is, you can do something now, but because it is viewed through the filter of crisis, solutions are often very black and white, very now, and often look like freeze, flight and flight.

If you recall, earlier we explored how feelings can trigger chemical release, and that chemical release can trigger feelings. If our brain convinces us that there is a problem, it can trick the hindbrain, that is, the part of the brain specialised in survival, into thinking that we are in crisis, and therefore taking crisis action which includes releasing Adrenaline. This is experienced as anxiety (the freeze and flight reaction); and or aggression / anger problems (the fight part). Again, misdiagnosis is something to be aware of.

Crises are not that common, so your brain will have to either create one, or bring you to one. Some common mechanisms to trigger the anxiety is that either fool you into thinking that something is horribly wrong out there, perhaps everybody hates you, exercising negative self-talk such as “I’m a loser and can’t get anything right”, or prompting a fear of something common and everywhere such as germs or cockroaches. Some common mechanisms to trigger the anger are thoughts like “everyone is against me”, “it is me versus the world”, “everyone is just getting in my way” or designating key people in your life as the enemy despite any real evidence.

It is important to understand that Adrenaline based thinking is emergency based thinking. In an emergency, we don’t have time to solve problems, when the problem is here and deadly. This makes it hard to assess how much time is passing, how much time a task will take and when actions should actually be done. It also makes it hard to plan, because the stakes of failure seem so high. We also feel like we can’t actually do any kind of reality check, because everything feels so darn urgent.

If your brain doesn’t use this crisis mechanism, then it won’t have enough Adrenaline to substitute for Norepinephrine. This will often be mistaken for Depression. This kind of “depression” feels like you wanting to do things, you even have a plan… you just can’t actually do it for some odd reason. It feels like something is in the way, like something is stopping or blocking you. It feels like an insurmountable barrier that can only be solved by escalating how you feel. This can lead to two very concerning behaviour patterns. I’ll outline the main three.

The first concerning behaviour is using lots of stress, fear or negative self talk to drive yourself to break the barrier. While you can sometimes get things done, it feels absolutely awful. This can really affect your self-esteem and confidence.

Another concerning behaviour is to reframe your life such that nothing matters anymore. If you can’t get anything done, and nothing seems to help you feel good, you stop wanting to do anything. Change out of this becomes very, very hard, because it seems like there is no point. This can devolve into anhedonia – an absence of joy. While there are other mechanisms that can get a person to anhedonia, this is one of the more common mechanisms, and it is frequently overlooked.

The other pathway is both dramatic and dangerous. To break through the lack of Norepinephrine, and in the face of failure to create enough anxiety or anger to substitute Adrenaline, your brain will go down a path of self harm. Either actions that harm you psychologically, social, or physically. This can lead to thoughts and actions to directly harm your body, or taking your own life.
I’m going to pause here for a moment and state that one of the first things I do when a client comes to me with thoughts or actions of deliberate self-harm, and or thoughts of taking their own life, is check to see if I am actually face to face with someone who is an undiagnosed or untreated ADHDer. The risk of death is both real and high for people who cannot get help. No one talks about self harm and death for long without something being wrong. Anyone who has accidentally hurt themselves can appreciate that self-harm hurts – and someone who tries to do this “for the attention” won’t try it for long, because it hurts and has little tangible reward. So someone who is repeatedly self-harming is someone who needs to trigger the Adrenaline that this harm brings to function. So please, take the call for help seriously and get a proper assessment.

Unfortunately, in my experience, most public hospitals are not good at assessing long term help. They are focused on getting people out as fast as possible, so they are motivated to patch up and kick out. If you, or someone you know, is going through this, please see an ADHD informed and trained professional. While your brain may not be an ADHD brain, the professional should be well trained in Self-Harm and Suicide, and be able to help out. You are looking for a therapist that understands the neurotransmitter side of mental health, and medication.

It is also important to recognise that some ADHDers do not actually have a problem with a lack of Norepinephrine. Some have excess. This can lead to very odd thinking anxiety and or aggression. The mechanism isn’t clear, but essentially with a lifetime of either using anxiety or anger to trigger the Adrenaline response, or having experienced enough traumatic events, your brain becomes locked on to crisis mode. This quickly depletes Dopamine to keep the Norepinephrine and Epinephrine levels high.

I estimate that of 20 ADHDers, 5-7 will have very low Norepinephrine levels, most will have low to moderate Norepinephrine levels, and 1 will have high Norepinephrine levels. ADHD medications not only increase your Dopamine, they also increase your Norepinephrine. For the 5-7 in 20 very low ADHDers, while ADHD medication will help the feelings of Anxiety and Anger, it won’t be enough. For most, this boost is good enough. For that 1 in 20, the experience of Anxiety and or Anger will significantly rise. There are medications that can help offset both outer outcomes, taken additionally with or instead of regular ADHD medication.

Serotonin is the next major neurotransmitter of interest down the pipeline. It is of interest only because it is the target of the most common mental health medications. It is mostly not directly important to ADHD. That pipeline analogy comes into fruition here though. If you block up part of the pipeline, then everything blocks up a bit, slowing the flow down. As Levodopa is continuing to cross the blood brain barrier, it continues to create more Dopamine, and then subsequently more Norepinephrine. As these can’t really go too much further because the Serotonin section is a bit full, the overall availability of Dopamine and Norepinephrine is effectively higher. This is why we think that some Serotonin medications have a small but positive effect on ADHD. Some of these medications work better than others at affecting this chemical pipeline. Some are next to useless.

Finally, a few more steps down the pipeline, Melatonin is created. The longer you are awake, the more Melatonin accumulates. A mechanism that our brain uses to determine if enough wake time has elapsed that we should now go to sleep is to check how much Melatonin has accumulated. If your brain finds that there is lots, it triggers the “tired now, go to sleep” mechanism. While you are asleep, Melatonin is flushed out.

Melatonin is one of the few Neurotransmitters that can actually pass the blood brain barrier. Many ADHDers struggle to sleep well, possibly due to insufficient Melatonin production, often due to an excess of Adrenaline overriding the sleep mechanism. Fortunately, Melatonin is also a medication you can be scripted. Melatonin medication is not a sedative, per se. It merely helps your brain realise that it is time to sleep. Excess Adrenaline can negate this signal, so it is important to learn how to either calm this down, or discuss with your doctor medication that can help this aspect.

ADHD Primer, Part 1

As October is ADHD Awareness Month, we will be taking a detailed look at ADHD – what it is, what it isn’t, what it means, and what to do about it.

ADHD is an initialism that translates to Attention Deficit Hyperactivity Disorder. It’s a terrible name that only describes the behavioural characteristics of a few percent of the people who are or can be labelled with ADHD. That is, the initialism is based on a description that is very out of date.

Consider that ADHD was first noted in medical literature about 250 years ago. German physician Melchior Adam Weikard, wrote the first known medical textbook description of a disorder with the hallmarks of what we would now call ADHD in 1779, in a chapter titled “Mangel der Aufmerksamkeit”, (literally “Lost Attention”), in his fourth volume in his series “Der Philosophice Artz”, pages 114 to 120. This wasn’t the first reference to ADHD, just the first modern medical reference. Hippocrates (460-375 BC), considered the father of modern medicine, described patients who had “… quickened responses to sensory experience, but also less tenaciousness because the soul moves on quickly to the next impression” approximately in 493 BCE.

Picture from the page of Der Phisophice Artz, Vol 4, 779, Melchior Adam Weikard, page 114

Every 50 or so years, various European medical texts have re-described the behaviour patterns, often with new names. None of these diagnostic descriptions persisted until 1902 when Sir George Frederic Still, considered the father of British Paediatrics, described some struggling children. He described mostly boys, and how they seemed to move too much. He called this category of people “hyperkinetic”. Hyper means “above the average” and kinetic means “movement”, that is, they move too much.He described it as “an abnormal defect of moral control in children” and that these children “couldn’t control their behaviour the way a normal child would” even though some of “these children were intelligent”. Thankfully we no longer try to use the idea of “moral control” as a medical description!

Medicine evolved and so did the name. Hyperactive/Hyperkinetic Syndrome, Maladjusted Children, Minimal Brain Dysfunction and ADD (Attention Deficit Disorder) are some of the names that ADHD has been historically called in the past. 

Up until relatively recently, ADHD had been recognised as a neurological disorder. It was thought to be “untreatable”.

This changed when Leandro Panizzon, an Italian Chemist in the employ of Swiss pharmaceutical company Ciba, now known as Novartis, synthesised a new chemical in 1944 called methylphenidate. He named the compound Ritalin after his wife Rita (short for Marguerite). Methylphenidate was found to help blood pressure and performance. It was also found to help calm down the hyperactive children such that their movements were muted, their concentration improved and there behaviour improved. This was the first medicine that reliably helped hyperactive people who fit Sir Still’s behavioural description. This first medication was followed by an amphetamine treatment in the early 1960’s, originally compounded to treat breathing difficulties.

We now know that both of these medications work in different ways to produce a similar effect – they increase the available chemical Dopamine in the brain. This gives us some clues as to what we are really dealing with. More about that later.

Even at the point of these medications being discovered to work, ADHD, currently called Hyperkinetic Syndrome, was a neurological condition.

It wasn’t until the American Manual for Mental Disorders’ second release, the DSM II, that the condition and treatment entered mainstream medicine awareness.

On the one hand, this inclusion meant that people struggling with ADHD could be recognised, diagnosed and given some kind of medical treatment. On the other hand, it recategorised a neurological problem into a mental illness in both the medical and social perception. Even with this greater awareness, ADHD was frequently not diagnosed, and due to Sir Still’s early perceptions of it being a boys disease, it was even less likely to be diagnosed in females.

The medical definition for ADHD is very loose. “Attention-deficit/hyperactivity disorder (ADHD) is marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development” [source: https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd]. That describes what to look for in some people, but not what ADHD is or why people have ADHD brains. Worse, it also fails to include a larger number of people who don’t show this trait/symptom.

Recall that the original reason for ADHD behaviour was considered to be a moral failing of the patient. This idea continues to persist in messages like “try harder”, “focus more”, “write lists”, “you are just lazy”, or “stop using ADHD as an excuse”. The more modern inclusion of ADHD in a list of mental illnesses has a new twist, – people think they are crazy and are often gaslit into thinking that they are just mentally ill. “Well, I can’t focus well, because I have a mental illness”. This completely ignored the many ADHDers who live fully functioning, high quality and fulfilling lives.

While ADHD can be disabling, it is not in and of itself a disability. Many people use the creativity and energy of their ADHD to accomplish many great things. Take a look at the entertainment industry – most of that is powered by ADHD. Take a look at the emergency services – again, mostly powered by ADHD. There are pros and cons to ADHD.

The modern take on ADHD is that this is still a neurological difference, as it was first classified after medicine started to let go of the moral aspect of disease. I’m using the literal definition of disease here – dis – ease. When things aren’t right, and you can’t be at ease. The ADHD community identified as Neurodivergent from the mainstream Neurotypical population. Much like left handed people, different but not broken.

The poor medical definition of what ADHD is, and how it works, has led to very badly designed studies. This often confused exactly what the scientist is actually testing, measuring and understanding; which then frequently leads to erroneous conclusions and people using scientific contradictions to handwave that “ADHD isn’t real”, “it is just a label for naughty people”, or other excuses to be negligent in helping or disenfranchising a decent percentage of the population.

Speaking of a percentage of the population, because the definition of inclusion for ADHD is so vague, it is next to impossible to get a rational scale of prevalence for ADHD in the world population, or country populations and genetic populations. My estimate is about 10 to 15 percent of all humans are ADHDers.

So what is ADHD?

Currently, ADHD is diagnosed based on behaviours that persist for more than 6 months and look either inattentive, and or hyperactive. That’s it. Most countries will include that the behaviours must have been noted before the age of 12 years of age (which can make a late adult diagnosis tricky when the professionals didn’t notice or record relevant difficulties), but not all countries. Some countries refuse to consider that ADHD is even a thing at all! This poor medical and scientific definition has led to the inclusion of anything that can lead to attention struggles, such as acquired or congenital brain damage, metal toxicity and other neurological conditions. This makes international prevalence, diagnosis and treatment comparisons like trying to compare apples and bananas. Yes, they are both fruit, but that’s about three only point of similarity.

In my opinion, this is very wrong. We have tests for those other conditions, and while ADHD medication may help those conditions too, methylphenidate also helps blood pressure, and that clearly isn’t ADHD.

In my professional opinion, ADHD is a very strongly heritable congenital neurological difference characterised primarily by low dopamine supply issues not otherwise described by other better forging conditions, and a secondarily related adrenaline imbalance in most ADHDers. The Dopamine issue can present as brain fog, struggles with Executive Function problem resolution, dissociation and eating disorders. The adrenaline issues can present as anxiety, aggression, extreme moodiness, self harming behaviours, sleep problems, kinesthetic hyperactivity and impulsivity.

Stay tuned for a more in depth explanation of all of this.

Stay tuned for a more in depth explanation of all of this.

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