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Grumpy's Dysphoria – Revisited From Posting in '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 . 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.
Actual Case Report: Grumpy Shows Up In My Va Beach Office
At over 50 years old this other, 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 an unmistakeable 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 indicated that he owns 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 [< see the video at this link] – 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 bitter vet in Gran Torino, and then this sour 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.
On Rejection Sensitivity – Thinking and Feeling:
That “rejection sensitivity” arises from Attention Abundance Disorder, too much thinking – not too little [a Deficit]. Rejection awareness starts as a counterproductive cognitive [dopamine] challenge, based on sorting reality and executive dysfunction – a working memory challenge with the increased complexity of both personal and group relationships [both troubled by real, unpredictable variables].
That original cognitive-dopamine stuckness,, then devolves into an affective-serotonin, self-deprecatory state associated with affective depression and perhaps affective anxiety. No longer just a cognitive problem, now it’s both cognitive and affective.
My main problem with his too-coalescent term: it doesn’t tease out what must be accomplished in treatment, but rather encourages a simple, reductionisitic view that confounds the complexity of these two neurotransmitter systems working in synchrony, together. The unhappy and potentially tragic outcome: dopamine medications don’t treat serotonin problems – but rather aggravate them. More depression is quite likely. To treat this “dysphoria” as an ADHD subset completely misses this important differentiation of neurotransmitter activities.
See the video on this important subject below, and also linked here: http://corepsych.com/balance
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.
Dr Charles Parker
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