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Dodson Dysphoria and ADHD

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Grumpy Revisited From ’08

I wrote about this Grumpy Guy in my book, New ADHD Medication Rules, but in the context of a fresh discussion over at ADD Connect on Bill Dodson’s new diagnostic subset of ADHD Rejection Sensitivity Dysphoria I thought we should revisit the “dysphoric” Grumpy from about 5 years ago here at CorePsych:

Grumpy Outed In Virginia Beach

Grumpy was one of the Seven Dwarfs in the classic Disney film Snow White [1937]. This week I met his alter ego. In fact, Grumpy arrived at my office in Va. Beach, and we found a new role for him at ~  a real Grumpy Guy ~ 50 years old and counting.

The Original Grumpy

As you may recall, the original Grumpy was named Grumpy because his attitude was short-tempered, and negative about almost everything, – but clearly, in the end, showed a soft heart and saved the day to protect Snow White from the Wicked Queen.

Like the Disney character, our modern/office Grumpy’s attitude covered some uncomfortable life long challenges that often go overlooked under the limited perspective: “that’s just the way he is.”  My positive findings: On the contrary – he can significantly, dramatically, change in a week with the correct diagnosis.

True History, Actual Case Report

At over 50 years old this married Grumpy loves his craftsman job, worked hard for years in military service, and after all of these years of working within character, his wife just doesn’t want him to live as Grumpy any more. She lives on the downstream side of his pervasive negativity and easy irritation. He gets angry too easily, especially when working in his craft, and in spite of his comic costume remains distant, isolated and unable to deal with groups or family. He has an underlying warm heart, but on careful questioning had difficulty separating himself from his character, from the Grumpy character, and quite surprisingly, he had difficulty even seeing his intelligence, humorous characterization, and abiding good will.

Said simply, he presented as caught in character, Grumpy-stuck, with a wish to break out.

We laughed together in this first interview with a psychiatrist, as he elaborated on the role Grumpy has played in his life. Just a few anecdotes indicate that he has 3 Grumpy baseball hats, wears a Grumpy hat everyday, and collected between 12 and 15 Grumpy tee shirts, which go with the whole outfit. In my office he presented as short, robust and muscular in stature, mustache, with a grimacing Grumpy hat, Grumpy tee-shirt and a delightful humorous attitude that belied his actual hopeless feeling of finding himself completely stuck in the Grumpy role. He recounted with great pleasure meeting Grumpy at Disneyland, and missed him on one occasion when Grumpy didn’t show on a trip with grand kids to Disneyland.

Yes, Reductionistic Labels Don’t Work

He clearly thought that seeing a psychiatrist would provide no answers, some further humiliation, – and it’s clear he feared further retribution for his “character disorder.” In short, he presented with a pessimistic attitude about recovery as many of these clients do. [See more Grumpy details in my book New ADHD Medication Rules - Brain Science & Common Sense - with examples and testimonials at this hyperlink.]

The findings are what you might expect: He had defensively taken on the Grumpy role as he has suffered for years with an underlying treatable depression based partly upon his limited achievements in high school, wherein he was no longer able to keep up, – after leading the class in grade school. In the military, he performed outstandingly well as a leader, rose through the ranks taking on the difficult jobs, and reached an officer status from originally signing on as enlisted.

His ADHD presentation was less than obvious: He wasn’t Inattentive or Hyperactive, he was ADHD Avoidant, procrastinating on the unpredictable, mastering the predictable, and suffering with abundant Cognitive Anxiety – an abiding ‘obsessional’ attempt to correct his own uncontrolled self-critical attitude. Grumpy has for years been grumpy largely with himself, and makes a joke of his attitude to soften the blow for others.

The Interesting, “Happy” Science Findings

Antidepressants recently started by another physician made him more Grumpy, as selective-serotonin agents [SSRI like Prozac] characteristically down-regulate dopamine and aggravate underlying ADHD. [See multiple references with peer-reviewed notes here on SEARCH at CorePsych for multiple articles on this common problem.] With a greater sense of futility that last interpersonal door with his wife, that last opportunity at self-realization, was swinging shut for the rest of his life.  His real thoughts: “Psychiatry doesn’t work, I shouldn’t have gone in the first place, no one can deal with Grumpy, I might as well go off by myself to watch the remaining years go slowly by.”

Psychiatry doesn’t work for the wrong diagnosis leading to the wrong treatment.

The simple solution: This intervention strategy is not at all complicated – treat the untreated Adult ADHD and the abiding depression simultaneously.  His cognitive, ADHD mind, can find relief from obsessional worry, and his depression did dissolve in less than one week.

“Character disorders with depression” result more from biology than is often appreciated. See more here on Clint Eastwood’s ‘Stranger’ in High Plains Drifter, and the vet in Gran Torino, and then this Grumpy guy – why men and some grumpy women simply don’t get in for psych review.

The good news: this Grumpy guy will be wearing his Grumpy outfits with a different sense of humor and self discovery… he’s been a great guy all along. He probably still blushes when kissed by Snow White. Together we enjoyed considering how the rest of his life might work out as Happy, that other cool dwarf.

Grumpy is fixable – but the problem is neither straight depression or straight ADHD – it’s a combo of both. See this:

Video Explanation 4.5 min

My Comment at ADD Connect

Much as I respect, indeed admire, Bill Dodson as a thought leader, clinician and determined fellow partner on the path to grow ADHD understanding – I do disagree with this fresh label and the conclusions he reaches. I appreciate your bringing it to my attention.

Dysphoria is: “a state of feeling unwell or unhappy; a feeling of emotional and mental discomfort as a symptom of discontentment, restlessness, dissatisfaction, malaise, depression, anxiety or indifference” – from Wikipedia.

Every synonym here is a word that describes serotonin related issues, that respond well to various serotonin related products [SSRIs, SNRIs] most of the time.

The problem we face as clinicians is simple: We’re confusing the fact that depression has clear *cognitive dimensions* on several levels, and arises for the most part as several important, different presentations:  an Affect [down], a Cognitive condition [apathetic/negative] and a mixture of Both with anger and cognitive depression thrown in [Gran Torino].

See this article from almost 5 years ago: http://www.corepsych.com/2008/11/grumpy-outed-add-and-depression-for-a-lifetime/

Bottom line: dysphoria, and ADHD need treatment together, simultaneously, as outlined carefully in New ADHD Medication Rules.

Cognitive Depression remains too often overlooked as we think cognitive imbalances are only associated with ADHD. Cognitive depression shows clinically as clinically different from affective depression, but it remains treatable with serotonin products – and, as Dr Dodson quite rightly pointed out, won’t respond well to dopaminergic, stimulant meds – for all the medical seesaw reasons outlined in New Rules.

See what you think –  and please do forward to others for further discussion.

cp

 

 

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17 Comments
  1. I love this article but have never been more confused in my life. I’ve been diagnosed first with depression and gad, then adult adhd, then Bipolar.

    I always experienced the crash and eventually I was told that if the ADHD wasn’t calming me down and I was so depressed at night perhaps I had something else.

    Would you say Effexor is a good medication for a situation like this?

    • Natalia,
      My first choice is Effexor [Pristiq and Venlafaxine are sisters] for the simple reason that in my experience it works best most often in presentations such as you describe about yourself.
      cp

  2. My 12 year old son takes Biphentin 40mg once per day. However, eight hours later he is experiencing an emotional crash, that is perfectly described by the Rejection Sensitivity Dysphoria. He is completely unable to bear failure, rejection or the constructive criticism, helping and direction associated with those situations, making if very hard to teach him in school or deal with his emotional outbursts whether they be rage or tears. I hate the idea of more medications at his age, but am open to any suggestions.
    Thanks
    Tracy

    • Tracy,
      Accolades to Dr Dodson for effectively describing that PM crash so often associated with an associated imbalance on the serotonin side of that equation. You are describing a type of cognitive depression, less affective than vulnerable and sensitive. I can assure you that, in spite of the fact that your pediatrician may hesitate, it would appear likely [from this admittedly distant and marginally informed perch], upon checking w a doc on the scene and “in-the-know” on your child, that two interventions could work either together or at different times: a very low dose SSRI, see the linked video, a measurement and verification of likely impaired serotonin level [with consequent indications for:] a helpful dose of a serotonin precursor.

      See if he/she would accept a very small trial of Zoloft 25 mg 1/2 QAM with Bipherin. Use the Kelsey Scale to assess sensitivity progress.
      cp

  3. So what meds were used to treat him?

    • Stephanie,
      Effexor, low dose, and Vyvanse. As I recall the Effexor XR was about 75mg and the Vyvanse at 40mg had a ~ 12 hr DOE – Duration of Effectiveness.
      cp

      • Do you reliably get a 12hr DOE for vyvanse without split dosing? I’ve tried 30,40, and 50 mg and get a bad crash 6 or 7 hrs later on any of these doses. I’ve tried titrating down below 30mg but lose a lot off the DOE. Thanks

        • JC,
          Metabolism is a very tricky interloper. If you are “crashing” two issues come to mind.

          1. As in this video you might have some depression cooking right alongside of the ADHD. Stimulants aggravate the depressive crash in the afternoon almost every time.
          2. The crash could arise from simply having a metabolic/neurotransmitter deficit… not enough neurotransmitters in the synaptic ranch. Meds only collect neurotransmitters they don’t make them. If you are low for other metabolic reasons the crash is almost always harder even if no associated depression is present.

          Yes, one should shoot for that 12 hr burn rate, that DOE, and if it’s insufficient the dose is too low for a variety of reasons, not just the med but the body the med is passing thru.
          cp

  4. Hi Dr. Parker, sorry if this may be a little off topic. I’m currently trying my second adhd med, vyvanse and have also been taking Viibryd for depression. Are there any interactions between these two? Also, what’s your opinion on Viibryd? I haven’t heard you mention it. To me it seems somewhat of a “dirty” AD but is really popular with the medical community in the area.

    • JC,
      Viibryd has no interactions w stimulants, is clean on 2D6 as a blocker, and is metabolized primarily thru 3A4 and 2D6. The substrate path is of little concern as blocking doesn’t occur. My own experience is that when it works well, it works quite surprisingly well – but in my own offices, discussing it w several other medical staff, it appears less efficacious, less predictable than the Effexor group. The main point: responses to antidepressants vary considerably, are idiosyncratic, and require careful trials.
      cp

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