Grumpy Outed: ADD and Depression For A Lifetime

ADD, ADHD Stimulant Medication Dosage: The ‘Bottom Bewitching Hours’
November 17, 2008
ADD, ADHD Medications: Immediate Release Stimulants – Cheap and Low Compliance
December 4, 2008

Image by Brain Toad Photography via FlickHoliday Case Report

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 ~ 50 years old.

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.

True History, Actual Case Report

At over 50 years old, this Grumpy is married, 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 be 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 and wears a Grumpy hat everyday, and has between 12 and 15 Grumpy tee shirts, which go with the whole outfit. In my office he presented as short, very robust and muscular in stature, mustache, with 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 grandkids to Disneyland.

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 Sensewith examples and testimonials here.]

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 admission 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 on my website below for more on this common problem.] With a greater sense of futility that last door, that last opportunity at self realization, was swinging shut for the rest of his life.  His 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, will be relieved of obsessional worry, and his depression will dissolve in less than one week.

“Character disorders with depression” result more from biology than is often appreciated – more on Clint Eastwood's ‘Stranger' in High Plains Drifter, and the vet in Gran Torino, and this Grumpy guy – why men and 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.

Best wishes to you here in the States for a ‘Happy' Thanksgiving

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9 Comments

  1. Ginny says:

    Dr, I wanted to guage your thoughts on the following advice provided by my Doctor which he says has worked for his patients who have developed tolerance in the past:

    “Another approach is to alternate between two stimulants. Because methylphenidate is more chemically distinct from the amphetamine preparations than they are from each other, switching between a methylphenidate drug and an amphetamine can maintain the benefits of each with less danger of tolerance. For simplicity, alternating every month or two seems to be a reasonable frequency.”

    I have tried eliminating foods and taken reccommended supplements but I have been left frustrated.

  2. Chanel,
    Thanks for your kind remarks, it’s great fun reporting on these matters, and next year promises to be even more fun for all CorePsychBlog readers – from ADD to SPECT imaging we have several interesting educational programs planned – so please stay tuned.

    The good news for our Tidewater patients, we are redoing that old Parker Schlichter and Assoc site for the new year – might as well join the 21 century!

    And regarding my email, it is linked on this blogs about page, that one I get every day,

    Thanks for your comments!
    cp

  3. Chanel says:

    Hi Dr. Parker,
    I really enjoy your blog, & wish that you could be my doctor! I will definitely be buying your new book. Thanks for another great post. I’m wondering if there’s an email address I can email you at regarding a possible referral? I tried to email you using a couple of different email addys found on your VA Beach Clinic website, but neither one worked. Thanks so much – have a great weekend. 🙂

  4. Tom-
    Excellent comments, from a practitioner who has clearly see a few Grumpys.

    Sounds like you have been reading my new ADD book, as I spend one whole chapter on how to get the meds straight on mixed presentations, and we completely agree on the importance of sequencing with mood disorders.

    This particular Grumpy had already tried antidepressants, and if mood disorder is not on the table I simply go lower than expected and start the meds almost simultaneously, – about 4-6 days apart for the stimulant and AD. Depression appeared to be first on ‘his’ list, and with no likely complications, I started the AD [antidepressant] first, then the Vyvanse.

    I am looking forward to our next visit – he was so classic, and so removed from his own characterization of himself.

    Best Wishes for a Happy Holiday to you and yours down in NC,

    – BTW, please stay tuned as this next year will be doing a series of SPECT training seminars for professionals who want to learn how to use them in the office.
    Warm regards,
    Chuck

  5. R. Thomas Mathew says:

    Loved the vignette ,Chuck. Really useful points. Im wondering though whether the order of the intervention makes a difference in treating the ADD with depression patient. I have had patients who have had similar experience with SSRI’s but have done well with an initial stimulant intervention and then adding on an antidepressant for leftover mood symptoms . On the other hand , the ADD with mood instability and bipolar features seems to require the mood stabilizer be added first and then the stimulant trial. And sometimes the Grumpies can be a bipolar 2 mixed pt. that requires the latter.

  6. Gina,
    Thanks so much – you made my day! I do strongly recommend that all our CorePsych readers review Gina’s outstanding book on Adults with ADD

    – her work covers the Grumpy guy, in a different way, but she know what she is talking about

    – Her book takes you to the details – “Is It You, Me or Adult ADD,” and it’s right over here:

    http://astore.amazon.com/cpbks-20/detail/0981548709

    Thanks G!

  7. Gina Pera says:

    Dr. P — You’ve outdone yourself this time!!

    What a great story. I’m forwarding this to everyone I know.

    We’ve been trained to think that there’s no help for people like this — that it’s their personality or deep childhood psychological wounding. That means many live out their years in grumpiness, making everyone’s lives harder.

    And THANK YOU for mentioning that the SSRIs can make untreated ADHD worse. The public has this weird idea that the SSRIs are safer than stimulants, and that an SSRI is better than nothing at all.

    Love the photo…:-)

    Gina