ADHD Diagnosis: ADHD or Just a Bad Person?

by Dr Charles Parker on June 3, 2009 · 6 comments

Avoidant ADHD looks so malevolent, so negative, so disrespectful – maybe they really are bad people?

.

I don’t think so…

Watch this video and tell me what you think. No, the avoidant ADHD crowd aren’t hyperactive but they could be, and oftentimes no, they don’t admit to cognitive anxiety, the subset we posted recently here. In fact they often meet no specific criteria for ADHD… but in fact look like ODD – Oppositional Defiant Disorder.

Yes the Avoidant ADHD folk hate speaking about their ‘issues,’ don’t want to see anyone remotely psychiatric, and simply need to be left alone. Decreased variables [limited activities], manageable structure [not going anywhere], – all quite predictable, because they aren’t doing anything.

My book ADHD Medication Rules deals with this subset of ADHD in considerable detail.

Please drop a comment here to tell me what you think about this different wrinkle on ADHD diagnosis.

cp

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ADHD Diagnosis: ADHD or Just a Bad Person?

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Tagged as: ADD and ADHD, Add new tag, ADHD and Depression, Attention-deficit hyperactivity disorder, Avoidant ADHD, avoidant personality, Child and Adolescent, Disorders, Health, Hyperactivity, Mental health, Negativity, Neurodevelopmental, oppositional defiant disorder, Oppostional Defiant Disorder

  • Erik

    Hi Dr. Parker,

    First off, I’d like to thank you very much for your excellent Web site. It has been invaluable to me (and I’m sure to many others) who are learning to cope with their ADD diagnosis and find their way forward.

    I’m in my late 30s and was finally diagnosed last Fall with inattentive ADD (after being in denial for many years). I’ve been struggling to settle on the right medication, but after trials of Adderall, methylphenidate, and Concerta, I have finally done well on 40 mg of Vyvanse for the last couple of months (thanks to your great advice on dosing).

    It has done wonders for me with cognitive anxiety (I can finally speak clearly and remember what I was saying during conversation!) as well as aid in concentration and focus. My productivity has gone up at work and at home, and I feel I have begun to finally assemble the pieces of the puzzle.

    However, the puzzle isn’t complete yet. Vyvanse hasn’t helped as much as I would like in dealing with the Avoidant aspects of my ADD. I’ve struggled to articulate this for a long time until I came across this video. I grapple every day primarily with the Avoidance of Projects. If at all possible, I’ll tackle the most simple item on my to-do list first (which I can now actually focus on due to the Vyvanse), rather than deal with the big project that I should be working on, etc. Anything to avoid tasks with lots of variables and requiring sustained thinking and attention. So while I’m getting more done, it’s just not always the things I should be getting done.

    Although Vyvanse has helped somewhat, I also still struggle with Avoidance of People (I prefer email over phone whenever possible, and avoid interacting with people, particularly strangers). I don’t have the Avoidance of Self issue so much, although I do deal with the Avoidance of Close Relationships (always thought it was an issue with intimacy, but it seems to fit the general avoidance theme).

    I have also been struggling with some depression (which seems to have been amplified by the Vyvanse), where I’ve gone through periods of apathy and just feeling down in the dumps. My wife has been concerned by that, as well as some irritability issues that tend to come up (particularly in the pm).

    Anyways, to make a long story short, I printed out your Web page and brought it to my p-doc to help explain what I’m feeling. He seemed to be a little unsure about the avoidant subsets (hadn’t heard anything like that before), but did agree that we should try an anti-depressant to help with my co-morbid depression and irritability. Based on your experience, I attempted to convince him to prescribe Pristiq (or at least Effexor), but he preferred Wellbutrin first based on positive results he’s had in the past with pairing a stimulant with Wellbutrin for ADD.

    I have a couple of questions:
    - Will the anti-depressant (either Wellbutrin or the others) typically help with the avoidant issues or just with the irritability and apathy/depression?
    - Is there any chance that Wellbutrin will pair well with Vyvanse in this regard? I’ve noticed from your previous postings that you prefer Pristiq (or Effexor). I just took my first 150 mg dose of buproprion today, and while I know it will take a few weeks before any determinations can be made, I’d rather not waste any more time if this is a bad long-term combo for my particular situation.

    Thanks in advance for any thoughts you might have. I appreciate it!

    Erik

    • http://www.CorePsychBlog.com Dr Charles Parker

      Erik,
      Big compliments on getting your own assessment closer to the mark. Completely agree with adding the antidepressant – seems like you are up against a less informed doc with the Wellbutrin, but no prob. I would encourage you to stay with that recommendation for a trial, and then move on if it doesn’t work in 2 weeks. SSRIs do the job better, Wellbutrin is less likely to do the job. Mastering the depression will very likely solve the avoidance – just have to stay with the politics of the moment, he’s the medication guy, and then use the Kelsey scale to assess improvement on your clearly defined parameters.

      Well done! Watch for my book [ADHD Medication Rules: Paying Attention to the Meds for Paying Attention] launch week of July 4 – I can see that you will appreciate it!
      cp

  • http://www.CorePsychBlog.com Dr Charles Parker

    Jackie,
    You got it! Yes that is the point of understanding the complexity – no silver bullet will do it, only a complete appreciation of the entire picture, with specific treatment objectives for each subset of issues.

    Your son’s symptoms, not having seen him, do sound like he has all three subsets found in these recent videos. Some have all three, some two, very few have only one. Executive function seems to hit so many aspects of our lives. If the avoidant person is really avoidant they are successfully removing themselves from realities that will spin them into thinking or doing too much. Many suffer from the thinking too much and avoidant subsets, and show no impulsivity – these folks are often overlooked until adulthood, and could have been easily corrected as children preventing the years of shame and the travails of not doing well.

    Yesterday I just completed a 2 hr SPECT eval on a very interesting single person who is 40 yo, never diagnosed, and simply can’t manage a job or relationships due to his unmanageable cognitive abundance. Very fixable guy. Would have been even more fixable if identified with the symptoms he showed in the 2nd grade, in the 6th, in the 9th and in the Fresh year of college. Surprisingly, he is free of the substance abuse often seen as a method of coping with these cognitive issues, and is well motivated in spite of having recently lost his job. Yes, he does not know who he is. He is avoidant, and stuck relentlessly in deep thought, – stuck in his own mind with no way out.

    Depending on other variables [sleep, breakfast, metabolic rate, response to low dose meds] your son sounds like he doesn’t need more than an antidepressant with a stimulant [my current favorites are Pristiq and Vyvanse all other $ matters being equal]. Lamictal may be needed for greater mood dysregulation.

    Check with your doc, do not use Prozac or Paxil with AMP [see this post from almost 3 yrs ago]

    Cymbalta has few problems, tho a bit of 2D6 slowing, – if your medical team prefers that one, just watch for backup with Vyvanse way down the line. I do like the SNRIs as first line, absolutely – efficacy is greater if they can take them.

    Thanks for the question, – best with your guy.
    cp

  • Jackie

    Dr. Parker, this is fascinating.
    I wonder if you could comment on the possibility that several of these functional problems could exist together. For example, I am thinking about an adolescent who has some cyclothemic anxiety/depression going on; acts without thinking in social situations; obsesses, ruminates and hyper-focuses about specific topics and relationships (generally only one at a time); plus also avoids thinking & acting either about herself, more than one person at a time, or projects!?
    And, if you have seen these things occur together — is this the kind of situation where polypharmacy might have to come into play — where a mood stabilizer (such as lamotrigine) and ssnri (such as duloxetine) might be used to help the up and down affective and obsessional pieces, but needs to soon be followed by a dopamine-enhancing medication so that the core ADD symptoms and cognitive anxiety does not run further amok?
    Thanks as always for such thought-provoking fodder!
    Jackie

  • Linda

    My son is 17 years old and has inattentive ADD. Upon viewing your videos, my husband and I realized that you have honed in on an aspect of our son’s behaviors that we didn’t understand. We suspected it was ADD related, but not sure how.

    He definitely does a lot of “thinking without acting”, but avoidance of projects is a huge part of what he does as well.

    He somehow manages to get things done, but it’s always at the last minute. He puts off thinking or planning for situations, commitments, projects, deadlines, etc., especially if it involves problem solving or unknown components. When we try to remind him that he needs to plan or think about an event/test/task, he shuts us down and dismisses it as something he’ll work on later. He often states that he’ll think about it, but action doesn’t come until it’s almost too late. He asks to be left alone, but in the meantime does nothing to work on solving the situation. What follows is a lot of stress.

    Also, I’ve noticed a pattern of just having one friend at a time. Even if the friend doesn’t call or isn’t as interested in the relationship, he won’t put himself out there with others. We never understood why he’d just sit and wait for this one friend to call him, rather than call other kids. Perhaps avoidance?

    On the other hand, he does some group activities, is a great student, is liked by teachers, etc. It’s interesting that he has this internal struggle going on that people are unaware of.

    He takes 40 mg. of Vyvanse. Is there any further treatment or coping skill for this aspect of his ADD?

    • http://www.CorePsychBlog.com Dr Charles Parker

      Linda,
      Glad the video helped you recognize these cognitive subsets – the avoidant was the last of that series I discovered and simply is the hardest to see.

      Three points:
      1. Use those targets as objectives for treatment – they should improve if the meds are effectively dosed for specific metabolic rates and specific diagnosis.
      2. Dial the Vyvanse in for a DOE of 12-14 hr with your doc. If the DOE is less than that, the dose is almost always insufficient to correct the cognitive challenges. Search ‘DOE’ for multiple posts. And see the previous YouTube Video for a quick explanation.
      3. With Avoidant ADHD always watch for the Clint Eastwood depression. If the stimulant meds increase apathy or amplify negativity or sadness treat the comorbid depression. [See the posts on 'Clint Eastwood' - a video will be out there soon on that presentation]

      Thanks for commenting, – excellent points for our readership, and I hope helpful for your next steps.
      cp

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