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From: sbharris@ix.netcom.com (Steven B. Harris )
Subject: Re: Attention Deficit Disorder (ADD)
Date: 08 Sep 1995
Newsgroups: sci.skeptic
In <42o6rr$2jr@newsbf02.news.aol.com> tbrown2873@aol.com (TBrown2873)
writes:
>I have come across a few patients with narcolepsy who claim they have
>adult ADD. They have many of the symptoms, but that's because the are
>sleepy and miss many things and the sleepiness also affects their
>attention. As a psychiatrist I am a little skepitical about this ADD of
>adulthood diagnosis-not so much the disorder of childhood. I have a
>standing joke about adult ADD. I start telling it, then lose my train of
>thought...
Well, speed wakes up patients with narcolepsy, and the only way
they can get it is to claim adult ADD (AADD). So it's not surprising
they do it.
The hypocrisy of this whole undertaking is breathtaking. Our jails
are full of self-medicating AADD people (no, kids don't always outgrow
it). Yes, they are the speed freaks. This situation is now sort of
like us discovering diabetes, and discovering that a lot of borderline
diabetics had been illegally manufacturing and shooting insulin all
these years, while we were too dumb to know what to do to help them.
Except in the case of people helped by amphetamines, no retroactive
apologies are forthcoming. We don't even let the ones in jail, out.
And of course their (untreated) AADD helps keep them in jail longer,
since they can't function very well, and look bad to parole boards.
And they certainly can't be treated with amphetamines in most prisons.
Lovely situation. Our ancestors will probably look at it in somewhat
the same vein as we now view slavery.
Steve Harris, M.D.
From: sbharris@ix.netcom.com (Steven B. Harris )
Subject: Re: Attention Deficit Disorder (ADD)
Date: 09 Sep 1995
Newsgroups: sci.skeptic
In <42qbja$naj@gap.cco.caltech.edu> carl@SOL1.GPS.CALTECH.EDU (Carl J
Lydick) writes:
>In article <42p2fb$j9r@ixnews2.ix.netcom.com>, sbharris@ix.netcom.com
>(Steven B. Harris ) writes:
>
>> The hypocrisy of this whole undertaking is breathtaking. Our jails
>> are full of self-medicating AADD people (no, kids don't always
>> outgrow it). Yes, they are the speed freaks.
>
>Hmm. Your claim that anyone who uses amphetamines suffers from AADD seems
>rather extreme. Perhaps you have some evidence to back it up?
Did I say every one? If you look at the classic defining symptoms of
adult attention deficit disorder, they are nearly classic for the kind
of often illiterate, angry, poorly performing and badly self-controlled
person who fills our prison systems. If there is no large intersection
between this kind of person and the (large) numbers of people who just
happen to be in prison for methamphetamine abuse, it would be the most
incredible coincidence since the timing of those lost 11 minutes on
Nixon's office tapes.
Steve Harris
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: benedryl, sexism, and neurobiochemistry
Date: 2 Oct 1998 04:51:31 GMT
>> Don Royal wrote:
>> >
>> > My next door neighbor who is a pediatric psychiatrist and treats ADD
>> > almost exclusively (and has done so for 40 years although the
>> > condition has had a number of names during that time), states that
>> > his patients cannot tolerate antihistamines even in small doses. Says
>> > it "wreaks havoc on the machinery of those with ADD".
That observation has been made several places. Apparently the
problem is the anticholinergic activity of these OTC antihistamines
(the same thing that makes elderly people with marginal cholinergic
activity wig out when taking them).
The cholinergic system and the dopaminergic system must be in more
or less equal balance. Too much dopamine and you get the figdets
(akathesia). Too much acetylcholine, or not enough dopamine, and you
more or less freeze in place. It's rather easy to see which category
ADHD people most resemble.
If these folks are hypersensitive to anticholinergies, this
suggests that cholinergies might be something to try. That would be
nicotene patches (!). Or, better still, perhaps the new Alzheimer's
anticholinesterase drugs (Aricept, etc) which are quite safe.
Hmmm. I wonder if ADHD people tend to get addicted to nicotene, as
schizophrenics do.
Steve Harris, M.D.
From: Steven B. Harris <sbharris@ix.netcom.com@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Dexedrine and feeling drained
Date: Wed, 11 Apr 2001 12:57:44 GMT
In article <20010406203624.27990.00000396@ng-ft1.aol.com>,
mnsoccerfan6@aol.com (soccerfan) wrote:
>I have a rather strong case of ADD and have to take a lot of dexedrine in
>order to to fufill the demands of my rigorous schedule in grad school.
>The problem is that the next day, for instance, when I go for a run or
>some other kind of workout, my muscular endurance is terrible. It is
>like my muscles are completely of energy at the very onset of exercise.
>I am 30 years old, and in decent enough shape. While I am not on the
>medicine while running, I am absolutely certain that my extensive use of
>it is the cause.
Well, this used to be called a speed-trip followed by a strung-out
let down. Now that we have defined a disease called ADHD which lets
students take a lot of speed to study in school (illegal as hell
years ago, and illegal as hell now if you do it illicitly) I suppose
we'll just have to find another more polite and politically correct
term for being drug dependent, strung-out, and in withdrawal, when
you don't take all the uppers.
But I can't think of one.
Why don't you use your down days to practice the following nasal
whine: "My DOOOctor says I NEEEEEED it!! It's a prescrIIIIption!
I'm not the same as a druuuuuugie! How DAAAAARE you??" This will
stand you in good stead with those who take a more cynical view of
what you and your beloved medical profession is doing, in kahoots.
All this, while this country has more people in jail per capita than
any other in the world. Over half of them there because they felt
that drugs gave them a boost and performance edge. Why, the cheaters.
Throw away the key.
Can you do that with a really self-righteous whine? "Throooow away
the KEEEEY!" Practice.
Steve Harris, M.D.
And you can quote me.
From: Steven B. Harris <sbharris@ix.netcom.com@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Dexedrine and feeling drained
Date: Wed, 11 Apr 2001 21:00:29 GMT
In article <20010411144034.12585.00001341@ng-fv1.aol.com>,
mnsoccerfan6@aol.com (soccerfan) wrote:
>A little quick to judge, perhaps, Doctor Harris?
Nope. Show me a student who needs dexedrine to study, and I'll show
you a student who needs dexedrine to study. The legalities make no
difference whatsoever. None. Zip.
From: Steven B. Harris <sbharris@ix.netcom.com@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Dexedrine and feeling drained
Date: Thu, 12 Apr 2001 03:35:50 GMT
In article <20010411201431.00489.00000198@ng-ct1.aol.com>,
montyfuller675@aol.com (MontyFuller675) wrote:
>>Nope. Show me a student who needs dexedrine to study, and I'll show
>>you a student who needs dexedrine to study.
>
>Explain, please.
There is no difference between a student who "needs" dexedrine to
study, and an athelete who "needs" EPO to run a marathon or "needs"
testosterone to run the 100 meter dash. Amphetamines are performance
enhancers for everyone, don't you know. The Germans came out on
dexedrine in the Battle of the Bulge, and the Allies throught they
were fighting madmen. Perhaps the Allied invasion forces actually had
"battle-fatigue deficit disorder," and didn't know it; what do you
think? Anyway, after a few days, the weather got better and the
Germans collapsed. That's the way the stuff works. The student who
complains he feels fatigued on the days he doesn't get his speed is
no different than the heroin user who is strung out and hurts all
over. So? What do you want me to tell you?
From: Steven B. Harris <sbharris@ix.netcom.com@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Dexedrine and feeling drained
Date: Thu, 12 Apr 2001 04:00:23 GMT
In article <3ad50090$1_3@corp.newsfeeds.com>,
"Angel" <anonymous@none.net> wrote:
>soccerfan <mnsoccerfan6@aol.com> wrote in message
>news:20010411144034.12585.00001341@ng-fv1.aol.com...
>> A little quick to judge, perhaps, Doctor Harris?
>
> It's rather human to judge. There is nothing wrong with judging others.
>Actually, it's even sanctioned in the bible, if you read the New
>Testatment accurately.
> What's wrong is taking drugs to function.
There's nothing wrong with taking drugs to function, so long as it's
on the up-and-up, and everybody gets the same chance to see what
makes them run best. What I cannot stand is the hypocrisy of doing
some of this, in this of all puritanical societies when it comes to
the "war on drugs" (a.k.a. the war on the underclass).
The underlying problem is that we've set up a society where we
handicap people as though the average person was competing in the
Special Olympics. Now, in this olympics, we don't know what to do
with performance-enhancing drugs, and performance-robbing diseases.
We've got drugs to fix your shyness, drugs to focus your mind, drugs
to make your kids study better and grow to be taller. But what if you
don't show up for work in the morning? Perhaps you're sleeping off a
bender. Perhaps you're coming down from 3 days of Ritalin or cocaine
(does it make a difference which?). Perhaps you're suffering from
post traumatic stress syndrome and took too much alprazolam to drag
your butt out of bed. How do we tell all that from you just being a
lazy louse? Well, we haven't a prayer without knowing all about your
medical history, do we? So the intimate details of THAT, are now
everybody's business, aren't they? No, you don't like that? Sorry.
Welcome to the modern world.
I don't like it. I suggest instead that if you're going to have an
"olympics of life," where you give out prizes and medals and money
and recognition for performance, you've either got to have an
entirely drug-free olympics (no exceptions, period), or else you've
got to have a "no drug rules at all" olympics. Anything in between is
inherantly unfair, because it simply favors the biggest whiners
who've managed to make themselves out to be the sickest, so they can
get the best performance-enhancing drugs and treatments as "fixes"
for supposedly being "ill." And no, before you ask, there is no
objective test for AHDD, nor any evidence that there's any difference
between AHDD kids and anyone else of their own sex. And we have 20
times the incidence of it in the US that they do in the UK. That
sounds like a social disease to me. And I don't mean V.D.
I further suggest that when the kind of Whiner's Olympics I describe,
and the one which we now play, is backed with police and guns and
prisons for those who haven't played the whining game properly, the
whole thing really starts to stink like no social ill this side of
slavery.
Does that clarify my point of view any?
SBH
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Dexedrine and feeling drained
Date: Thu, 12 Apr 2001 22:57:29 -0600
CBI wrote in message <9b5hec$bu3$1@slb6.atl.mindspring.net>...
>In other words - you don't believe in ADD?
>
>--
>CBI, MD
I "believe" in it the same way I "believe" in "obesity." Is "obesity"
an objectively "real" pathology? If you push it far enough, I suppose.
The question of what objectively "is" or "isn't" a "disease" is often
akin to arguing about angels and pinheads. In any case, there is,
in cases such as these, no bright dividing line between "illness" and
"health."
Now, even if there was, that wouldn't necessarily mean the wise
treatment for "obesity" was Dexatrim.
And (even for the sake of argument) even if Dexatrim did
indeed work for some "obese" people, I would still
be the last to suggest that people holding an M.D. might have
such Godlike powers of discernment as to to be able to tell,
apriori and ex cathedra, just who those people would be,
and should be.
Or that society should have the arrogance to imprison those who
wanted to make that decision for themselves, or experiment to find
out for themselves what category they (by the grace of genetics and
chance) happened to fit into.
SBH
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Dexedrine and feeling drained
Date: Thu, 12 Apr 2001 19:08:42 -0600
CBI wrote in message <9b5hhb$cq5$1@slb2.atl.mindspring.net>...
>I would suggest that you stick to whatever part of medicine it is that you
>do understand.
>
>--
>CBI, MD
Comment:
Alas, I understand this part where the doctors are expected to play the part
of legalized pushers, all too well. But you're quite welcome to explain how
and where you think I'm wrong. You can start with the biological basis for
"attention defficit disorder." Is it a disease? What makes you think so?
What is your evidence? Why do we have 20 times more of it than in (say)
England? Do you think they have worse doctors there,and are missing 19 out
of 20 cases? Golly.
If you think you know more medicine than I do, bub, here's your golden
chance to teach me. Don't forget the literature cites.
I think this will be a lot of fun. But I think on this one you'll wimp out
long before I have the pleasure of rubbing your nose in this properly.
Steve Harris, MD
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Do doctors work too much?
Date: Thu, 12 Apr 2001 22:35:49 -0600
Angel wrote in message <3ad67985_2@corp.newsfeeds.com>...
>CBI <replytothegroup@spamblock.nospam> wrote in message
>news:9b5iba$24a$1@slb6.atl.mindspring.net...
>> I'm sure this happens all the time.
>> CBI, MD
>
> thank you for your honesty. I truly hope you are a doctor. I meet so
>few who are willing to admit that fatigue can affect their ability to work
>effectively.
ROFL. Doctors have been complaining that fatigue affects their ability to
work effectively as long as there has have been residencies. But after
doctors get into private practice they in many cases feed off the proximity
of the resident who is almost a "resident" in the hospital, or
(in some cases) more or less "interned" there. So there is little reason
for the system to change. Everybody agrees that it's bad, but nobody
really has much incentive to do anything about it. So change has been
seen, but it's been very slow.
Certainly nobody with the power to change it has themselves been in the
nasty position of hospital medical training for at least several decades,
and in fact, is probably managing to avoid a few trips from home to
hospital in the middle of the night because of it. So there you are. It's
sort of like Thomas Jefferson complaining (in a very intellectual way)
about slavery. In the case of doctors it's not slavery, but simply a
nasty old-time apprenticeship. With all of the trimmings. Apprentices
complain; masters yawn.
SBH
From: "Steve Harris" <SBHarris123@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Dexedrine and feeling drained
Date: Fri, 13 Apr 2001 21:25:51 -0600
"CBI" <replytothegroup@spamblock.nospam> wrote in message
news:9b88ga$9$1@slb7.atl.mindspring.net...
> This is not the same as saying that psychiatric diagnoses (ADD included) do
> not represent real pathology. This is doubly so in the case of ADD since
> there are measurable differences in brain structure,
No, there aren't. Try again. A hugely publicized study finding PET
differences in dopaminergic receptors between ADD kids and controls, forgot
to control for sex. It was actually seeing the difference between the brains
of little boys and little girls. Snaps and snails and puppy dog tails. If
you can find me any good studies showing differences between ADD brains and
those of same-sex non-ADD controls, I'll give you $5.
> reaction to medications,
Bullshit! That's the polite term for this piece of urban mythology which
seems to be believed even by physicians! Let us start here begin to stamp it
out.
Hyperactive kids don't react "oppositely" to amphetamines. They only react
oppositely to the way everybody very naively expected them to react. What
they do is the same thing that the average child (and adult) does when
given an appriate dose of a sympathomimetic. They become hyperalert and
focused. Surprise.
Now use your brain. If you could help diagnose ADD by performing an
"amphetamine reaction test" to see which kids reacted "wrong," you would
certainly do that, and at least have something objectively, like a glucose
tolerance test, to tell you who has a problem and who doesn't. Strange to
tell, no such controlled test is done, or can be done (sure, it's done often
in ;a nonblinded way, but we all know how valuable that is).
This should tell you something. Amphetamines focus attention in EVERYONE.
There is nothing that makes people come quiveringly alert like adrenaline,
which is what amphetamines mimic. You may be silly and bouncy, but you still
darn well pay attention to the shark and the snarling dog, when you run
across them. And to the teacher about to hit you with a switch, which is how
"ADD" kids (90% of whom are boys, strange to tell) used to be handled,
before all that became polically less correct than drugging them. What a
tale.
> and heritability between patients and normal
> people.
Which does not make it a disease any more than having freckles. Every human
behavioral trait is going to have some heritability. How could you expect
otherwise? Nervous little dogs are born to nervous little dogs, and nasty
big dogs are born to nasty big dogs. They may have tought you this in
medical school. If we find the same kind of thing happening in human beings,
it shouldn't be tomorrow's newsflash. Just as with a labrador retreiver,
your temperment is partly in your genes. But so what?
> One could
> argue that if you give Valium to any person they
> will become more calm, even
> if not diagnosed with an anxiety disorder
You certainly could.
>(I wouldn't - there are differences)
No, there aren't.
>but the same argument does not hold for >medications and ADD.
Actually, it holds quite well.
> Similarly, it would be silly to label hypertension as not a real
> disease by claiming that hypertensives are merely at one end of a
> normal spectrum.
No, but you can't make the opposite argument, either, and claim that
because we have some diseases that are merely quantitative, we must have
diseases for every quantitative spectrum. Hypertension wouldn't BE a disease
if at some point having higher blood pressure didn't start affecting your
chance of *dying*. Last I looked, however, nobody claimed this for ADD. For
ADD, if you want a better analogy, you should look at "height deficit
disorder," aka being pathologically short. Is it a disease? People who say
no tend to be looked down on ;-). Are they right? How about nose
hyperelongation? Blonde hair deficit disorder? I prescribe peroxide myself.
--
Steve Harris
From: "Steve Harris" <SBHarris123@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Dexedrine and feeling drained
Date: Fri, 13 Apr 2001 23:07:40 -0600
> 3) You neglected to provide your references. I'm sure it was an error
>of omission that will not be repeated.
Okay, here's one for you to chew on:
Science 1978 Feb 3;199(4328):560-3
Dextroamphetamine: cognitive and behavioral effects in normal
prepubertal boys.
Rapoport JL, Buchsbaum MS, Zahn TP, Weingartner H, Ludlow C, Mikkelsen EJ.
The behavioral, cognitive, and electrophysiological effect of a
single dose of dextroamphetamine (0.5 milligram per kilogram of body weight)
or placebo was examined in 14 normal prepubertal boys (mean age, 10 years
11 months) in a double-blind study. When amphetamine was given, the group
showed a marked decrease in motor activity and reaction time and improved
performance on cognitive tests. The similarity of the response observed in
normal children to that reported in children with "hyperactivity" or minimal
brain dysfunction casts doubt on pathophysiological models of minimal brain
dysfunction which assume that children with this syndrome have a clinically
specific or "paradoxical" response to stimulants.
Publication Types:
Clinical trial
Controlled clinical trial
PMID: 341313 [PubMed - indexed for MEDLINE]
From: "Steve Harris" <SBHarris123@ix.netcom.com>
Newsgroups: soc.culture.indian,alt.fan.jai-maharaj,soc.culture.usa,sci.med,
misc.health.alternative,alt.drugs
Subject: Re: 40 PERCENT OF MENTALLY ILL USE CANNABIS
Date: Fri, 13 Apr 2001 22:31:44 -0600
"Lucich" <oxbow_lebach@msn.com> wrote in message
news:9b886r$82lan$1@ID-30297.news.dfncis.de...
> <address.below.or@web.site www.mantra.com/jyotish (Dr. Jai Maharaj)> wrote
> in message news:health-0512.20010404@news.mantra.com...
> > 40 per cent of mentally ill use cannabis
> > Forty per cent of young people with mental
> > disturbances are cannabis users at the time of their
> > first psychotic attack, a study has found. And 18 per
> > cent of young people with psychosis had used the drug in
> > the month before seeking treatment, it found. . . .
> > Read the news story here:
> > http://www.theage.com.au/breaking/0104/04/A34119-2001Apr4.shtml
> >
> And 100% of dead people drank milk....
>
> The statement "Project coordinator Kathryn Elkins said... those that
> continued to use cannabis were more likely to experience relapses and
> hospitalisation than patients who did not use the drug." seems to imply a
> link, if not an actual cause and effect relationship, but I couldn't help
> but smile when I read "users were often... suspicious..." I bet they were
> hungry too.
>
> I presume a significant number of mental patients take prescription
> drugs intended to treat their condition, but it may not be correct to
> suggest that those drugs are responsible for their disorders.
>
> In regards to "we need to await the results of a post six-month
> follow-up before we can start saying with any confidence that this
> specific intervention is useful in treating cannabis in patients with
> psychosis," I wonder, what is an appropriate treatment for cannabis? An
> herbicide? If so, Monsanto's Roundup may prove to be a panacea against
> all kinds of mental illness.
>
> Then again, I may be wrong about all this.
>
> Kirby Lucich
COMMENT
There may be an association, but when A is associated with B, to the extent
that it's not chance, it's either because because A causes B or B causes A,
or A and B are caused by C. Which comes first, mental disease or drug use?
Perhaps they are both caused by some third factor, such as damage to
dopaminergic brain systems. How much of drug "abuse" is attempt at
self-medication? If even any of it is, how do we justify putting such people
in jail?
Apropos of our previous discussions, if you read the papers below you get
the clear idea that perhaps a large chunk of cocaine abusers have attention
deficit disorder, and some people in the medical profession have seriously
considered whether we might get them off cocaine and on to speed. No, I am
not joking about this. I'm almost afraid to do the search to see how many
people who are "meth" abusers are diagnosable with ADHD.
1: J Clin Psychiatry 2000 Apr;61(4):244-51
Prevalence of attention-deficit/hyperactivity disorder and
conduct disorder among substance abusers.
Schubiner H, Tzelepis A, Milberger S, Lockhart N, Kruger M,
Kelley BJ, Schoener EP
Department of Internal Medicine, Wayne State University School of
Medicine, Detroit, Mich. 48207, USA.
BACKGROUND: This cross-sectional study sought to determine the
prevalence of attention-deficit/hyperactivity disorder (ADHD) and
conduct disorder among adults admitted to 2 chemical dependency
treatment centers. It was hypothesized that ADHD alone or in
combination with conduct disorder would be overrepresented
in a population of patients with psychoactive substance use
disorders. METHOD: Two hundred one participants were selected
randomly from 2 chemical dependency treatment centers. Standardi-
zed clinical interviews were conducted using the Structured
Clinical Interview for DSM-IV, the Addiction Severity Index, and
DSM-IV criteria for ADHD. Reliabilities for the diagnostic
categories were established using the Cohen kappa, and the
subgroups of individuals with and without ADHD and conduct
disorder were compared. RESULTS: Forty-eight (24%) of
the participants were found to meet DSM-IV criteria for ADHD. The
prevalence of ADHD was 28% in men (30/106) and 19% in women
(18/95; NS). Seventy-nine participants (39%) met criteria for
conduct disorder, and 34 of these individuals also had ADHD.
Overall, individuals with ADHD (compared with those
without ADHD) were more likely to have had more motor vehicle
accidents. Women with ADHD (in comparison with women without
ADHD) had a higher number of treatments for alcohol abuse.
Individuals with conduct disorder (in comparison with those
without conduct disorder) were younger, had a greater number of
jobs as adults, and were more likely to repeat a grade in school,
have a learning disability, be suspended or expelled from school,
have an earlier age at onset of alcohol dependence, and have had
a greater number of treatments for drug abuse. They were more
likely to have a lifetime history of abuse of and/or dependence
on cocaine, stimulants, hallucinogens, and/or cannabis.
CONCLUSION: A significant overrepresentation of ADHD exists among
inpatients with psychoactive substance use disorders. Over two
thirds of those with ADHD in this sample also met criteria for
conduct disorder. Our sample had a very large overlap between
ADHD and conduct disorder, and the major comorbidities identified
here were attributable largely to the presence of conduct
disorder. Individuals who manifest conduct disorder and/or ADHD
represent a significant proportion of those seeking treatment for
psychoactive substance use disorders. They appear to have greater
comorbidity and may benefit from a treatment approach that
addresses these comorbidities specifically through medical and
behavioral therapies.
PMID: 10830144
2: Am J Drug Alcohol Abuse 1999 Aug;25(3):441-8
Attention-deficit/hyperactivity disorder and substance use:
symptom pattern and drug choice.
Clure C, Brady KT, Saladin ME, Johnson D, Waid R, Rittenbury M
Medical University of South Carolina, Department of Psychiatry,
Charleston 29425, USA.
While there has been much recent interest in the relationship
between attention-deficit/hyperactivity disorder (ADHD) and
substance use disorders (SUDs), little has been reported about
ADHD diagnostic subtypes, persistence of symptoms from childhood
into adulthood, and substance of choice in individuals with
substance use disorders (SUD+) and comorbid ADHD. To examine the
prevalence and subtypes of ADHD in a group of SUD+ individuals,
136 inpatients with an SUD diagnosis (cocaine vs. alcohol vs.
cocaine/alcohol) were administered a structured interview for
ADHD. Of the SUD+ individuals, 32% met criteria for
ADHD, and 35% of those with a childhood diagnosis of ADHD
continued to have clinically significant symptoms into adulthood.
There were no significant differences in the percentage of ADHD
between the SUD+ groups divided by drug choice. Of ADHD subtypes,
subjects with combined and inattentive types were significantly
more likely to have symptoms continue into adulthood (p < or =
..05) than the hyperactive/impulsive subtype. Patients with
cocaine use were more likely to have ADHD in childhood only when
compared to the alcohol or cocaine-alcohol groups. The findings
of this study indicate that ADHD is prevalent in treatment-seek-
ing substance users without difference in prevalence or subtype
by drug choice.
Publication Types:
Multicenter study
PMID: 10473007
3: J Am Pharm Assoc (Wash) 1999 Jul-Aug;39(4):526-30
Methylphenidate: increased abuse or appropriate use?
Llana ME, Crismon ML
Department of Psychiatry, Scott & White Hospital and Clinics,
Temple, Tex., USA.
OBJECTIVE: To address the question of the significant increase in
methylphenidate (MPD) prescriptions being written and to make
recommendations for health care providers involved in providing
care for patients with attention deficit hyperactivity disorder
(ADHD) and their families. DATA SOURCES: Medline search 1966-1998
for professional articles using the following search terms--me-
thylphenidate, children, adolescents, abuse; Internet search
using MPD, Ritalin, and ADHD; and Paper Chase search using
methylphenidate. DATA EXTRACTION: The available literature
regarding potential abuse or diversion of MPD consists of case
reports, review articles, newspaper articles, and a Drug
Enforcement Administration (DEA) publication. All available
literature sources were used. DATA SYNTHESIS: Although the media
and DEA report significant abuse and diversion of prescribed MPD,
a review of the available literature did not reveal data to
substantiate these claims. Nonetheless, there are reasons to
suspect that abuse and diversion occur. A potential contributing
factor to abuse is the reported similarities in pharmacodynamics
and pharmacokinetics between MPD and cocaine. Recommendations are
made to decrease the possibility of abuse and diversion of
prescribed MPD. CONCLUSION: A balanced middle ground must be
found regarding the benefits of MPD and its abuse potential.
Education of clinicians, patients, and family members is key in
ensuring that MPD is used appropriately.
PMID: 10467818
4: Drug Alcohol Depend 1998 Sep 1;52(1):15-25
Prevalence of adult attention-deficit hyperactivity disorder
among cocaine abusers seeking treatment.
Levin FR, Evans SM, Kleber HD
Division on Substance Abuse, New York State Psychiatric Institu-
te, NY 10032, USA.
In this study, 281 cocaine abusers seeking treatment were
assessed for adult attention-deficit hyperactivity disorder
(ADHD). Structured assessments included the SCID for DSM-IV, a
SCID-like module for ADHD, and a pattern of drug use questionnai-
re. The sample consisted of 82% men, 67% African-Americans, 19%
Hispanics, and 14% Caucasians identified at several treatment
sites. Average age was 33.7 +/- .4 years. Twelve percent (n = 34)
of the sample met DSM-IV criteria for childhood ADHD. Of the
entire sample, 10% (n = 27), or 79% of the patients
diagnosed with childhood ADHD, had adult ADHD. A history of
conduct disorder and antisocial personality disorder were preval-
ent among those with adult ADHD (63% and 52%, respectively). This
subpopulation of cocaine abusers may be one of themost difficult-
-to-treat cocaine-abusing groups, particularly if the ADHD
remains undetected. To provide effective treatment for cocaine
abusers, clinicians may need to identify subpopulations of
patients, such as those with ADHD, and target both pharmacologic
and nonpharmacologic interventions for these groups.
PMID: 9788002
5: J Clin Psychiatry 1998 Jun;59(6):300-5
Methylphenidate treatment for cocaine abusers with adult
attention-deficit/hyperactivity disorder: a pilot study.
Levin FR, Evans SM, McDowell DM, Kleber HD
Department of Psychiatry, Columbia University/New York State
Psychiatric Institute, New York 10032, USA.
BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is
common among cocaine abusers seeking treatment. This open trial
was carried out to assess the efficacy of sustained-release
methylphenidate for the treatment of cocaine abuseamong individu-
als with ADHD. METHOD: Twelve patients who met DSM-IV diagnostic
criteria for adult ADHD and cocaine dependence were entered into
a 12-week trial of divided daily doses of sustained-release
methylphenidate ranging from 40 to 80 mg. In addition to the
pharmacotherapy, patients also received individual weekly relapse
prevention therapy. Individuals were assessed weekly for ADHD
symptoms; vital signs and urine toxicologies were obtained 3
times a week. RESULTS: Of the 12 patients entered, 10 completed
at least 8 weeks of the study and 8 completed the entire study.
Using both a semistructured clinical interview and a self-report
assessment, patients reported reductions in attention difficulti-
es, hyperactivity, and impulsivity. Self-reported cocaine use and
craving decreased significantly. More importantly, cocaine use,
confirmed by urine toxicologies, also decreased significantly.
CONCLUSION: These preliminary data suggest that under close
supervision, the combined intervention of sustained-release
methylphenidate and relapse prevention therapy may be
effective in treating individuals with both adult ADHD and
cocaine dependence.
PMID: 9671342
6: Harv Rev Psychiatry 1995 Jan-Feb;2(5):246-58
Attention-deficit hyperactivity disorder and substance abuse:
relationships and implications for treatment.
Levin FR, Kleber HD
Department of Psychiatry, Columbia University, New York, N.Y.,
USA.
Attention-deficit hyperactivity disorder (ADHD) and substance-use
disorders are related to each other in a variety of ways.
Although within the child-psychiatry literature earlier invest-
igations were inconsistent regarding such a link, recent prosp-
ective studies that followed hyperactive children and normal
controls into adulthood have found that hyperactive adults with a
history of ADHD are more likely than controls to have substance--
use disorders. The substance-abuse literature is less consistent
regarding the potential association between ADHD and substance
abuse. However, recent studies suggest that persons with a
substance-use disorder, and particularly those with a
cocaine-use disorder, may be more likely than the general
population to have a childhood history of ADHD. Some of the
inconsistency regarding this association is due to differences in
diagnostic criteria, type of assessments used, and reliability of
information obtained. Each of the potential relationships that
may exist between ADHD and substance abuse has treatment implica-
tions for the clinician. Pharmacological as well as nonpharmacol-
ogical approaches deserve further investigation. Because pharm-
acotherapy is a central component in the treatment of childhood
ADHD, clinicians designing a strategy to treat both a substance--
use disorder and ADHD need to consider pharmacological intervent-
ions. At present, the literature on pharmacological treatment for
childhood ADHD is extensive and that for adult ADHD is growing;
information regarding the treatment of cocaine abuse and conco-
mitant ADHD symptoms remains limited.
Publication Types:
Review
Review, tutorial
PMID: 9384909
7: Compr Psychiatry 1993 Mar-Apr;34(2):75-82
History and significance of childhood attention deficit disorder
in treatment-seeking cocaine abusers.
Carroll KM, Rounsaville BJ
Department of Psychiatry, Yale University, New Haven, CT.
Thirty-five percent of 298 treatment-seeking cocaine abusers met
DSM-III-R criteria for childhood attention deficit hyperactivity
disorder (ADHD). Subjects with childhood ADHD were likely to be
male (78%), meet Research Diagnostic Criteria (RDC) for conduct
disorder (93%) and antisocial personality disorder (47%), and
report a history of conduct disorder in first-degree relatives.
With respect to those without the disorder and regardless of
co-occurrence with sociopathy, cocaine abusers with childhood
ADHD were younger at presentation for treatment and reported more
severe substance use, earlier onset of cocaine abuse, more
frequent and intense cocaine use, intranasal rather than freebase
or intravenous use of cocaine, higher rates of alcoholism, and
more previous treatment. This pattern of cocaine use is consist-
ent with clinical descriptions of self-medication of residual
symptoms of ADHD in cocaine abusers. Data from this study suggest
that there may be more cocaine abusers with a history of ADHD
than previously recognized in clinical samples of cocaine users,
and that these individuals may differ in clinically meaningful
ways from those without childhood ADHD. Moreover, the poorer
outcome of subjects with ADHD in this sample underlines the
importance of identifying and treating residual symptoms
of ADHD in cocaine abusers.
PMID: 8485984
--
Steve Harris
From: "Steve Harris" <SBHarris123@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Dexedrine and feeling drained
Date: Sat, 14 Apr 2001 06:06:20 -0600
Happy Dog says:
>Well, there is evidence that giving speed to some people makes
>them feel like they can accomplish things that require
>concentration that they previously found near impossible. Does
>this not make it a treatable mental disorder?
Answer: Sure, Charley. If there's an Algernon Pill that makes you twice as
smart as you ARE, then when it wears off you'll definitely feel as though
you have a *disease* when you go back to being as dumb as you WERE. Nicht
wahr? Probably if Murry Gell-Mann got some brain disease that made him
think all the time only as well as I do, he'd complain like hell about it.
To his doctors. To everyone. These things are relative.
It's not that I'm completely against amphetamines. I'm not completely
against any drug. It's only hypocrisy that I cannot abide.
We've had some people show up here and say, basically, "Well, Dr. H, if you
don't believe in ADD, then you must not believe in schizophrenia or
depression either, since they are only diagnosed subjectively as mental
syndromes. Why, the very idea...
My answer is that I certainly believe in syndromes, so long as one remembers
that they are syndromes. Schizophrenia and depression and paleness and
jaundice are syndromes. They are perceptual precursors of diseases, inasmuch
as you can tell there's something funny going on, and even that there's
probably something bad going on (at least if they get too severe). But you
must not fool yourself into thinking that you know more than that. The guy
whose eyes are turning yellow after a day of hard work in Army Basic
Training may be perfectly healthy (with Gilbert's syndrome, not Gilbert's
"disease") or he may be headed for death by some fulminant and fatal
hepatitis. Without lab tests, you don't know. You may say "Prithee, Sirrah,
I perceive that you be far gone with cholera morbius and it be imperative
that you be well-bled." You can quote chapter and verse from your great
scriptural Holy Book of Symptoms, version IV. But you're STILL looking at an
ignorant wastebasket-y kind of thing if you don't know the pathology, and if
all you DO have is some the not-very-severe set of symptoms of
system-failure.
Likewise, the pale person may benefit from drinking wine mixed with rust, as
they sometimes did in the middle ages. Or, they may not. That's all anyone
can say, without more knowledge. Even anemia is a syndrome; it's certainly
not always caused by iron deficiency.
What bothers me about ADD is precisely that it's so clearly a general
failure syndrome for the brain, not unlike (say) shortness-of-breath as a
symptom of problems with the lungs. The mental co-morbidity rates that show
up in the ADD studies are spectacular. Children with ADHD often either
oppositional defiant disorder or conduct disorder, and in one study 20% had
coexistent mood disorder, 25% coexistent anxiety disorder, and 20% specific
developmental disorders such as dyslexia or dyspraxia.* With all those
problems, it would be incredible if their brains *didn't* differ on some
imaging test from normal ones; remember, these are brain metabolic scans
sensitive enough to tell if you have an itch and want to scratch. How could
they not show the secondary effects of major mental health problems?
However, you'd expect them to differ in different ways for every study,
because you're looking at a very mixed group of people. And indeed, that is
just what they DO do.
Look, think about it: We're talking about an "attention" deficit. Since
paying strict attention is the highest level intellectual function a working
brain can bring to muster, it should be obvious that the first thing that
happens when anything goes wrong with any brain -- anything at all-- is that
THAT person has more trouble with his attention. When this happens acutely
(medical-ese for suddenly) we call attention-deficits "deliriums". As in
"Doctor, what is the differential diagnosis for "delirium"? Well, it's
pretty long. In fact, it includes most of medicine, when you get to
geriatrics. And that's for a reason. Delirium is not a disease. Not if it
lasts a short time, and not if it lasts a long time. Delirium is a syndrome;
a complex response of a complex system.
The people with the purely "hyperactive" part of ADHD (these always seem to
be children -- adults grow out of THAT part) may have a purer and simpler
syndrome, and (as a group) I can guess may come closer to having what we
ordinarily think of as having a "disease" (there's some literature support
of that also). Or, they may just need a lot more exercise. The other folks
with the ADD, however, despite all doctors can do to rule out more obvious
causes of permanent cognitive/brain dysfunction, are going to be a huge
grab-bag. They can be thought of as having a "semi-permanent delirium"
(oxymoronic as that may be), which isn't quite severe enough to be called a
dementia, but at the same time isn't really just lack of some chemical that
you're likely to fix with a pep pill, either. Or, if you do fix some of the
symptoms, you may run the same kind of risk as injecting nitromethane or
nitrous oxide into a jalopy when it sputters and won't climb the hill. It
may work for a bit, but you may also pay the price. Which is fine also, but
again, let us cut out the hypocrisy and quit fooling ourselves as to what
we're doing. When certain doctors talk about "attention deficit disorder" as
a "real disease" and pound their DSM scriptures to "prove" it, it makes me
want to take them by the nose and shove some Ritalin down THEM to see if the
stuff might "cure" them of their damn-fool view of reality.
Probably it wouldn't, though. The chemical fix is never that simple. It
isn't for stupidity, and it isn't for ADD either.
SBH
P.S. While we're on the subject of focus, I highly recommend Vinge's novel
_A Deepness in the Sky_. Besides fun sci-fi things like cultures of
intelligent spiders, it features FOCUS-- a virus that can focus a human's
attention for all the hours he or she is awake. It's used by slavers to make
people into intelligent monomaniac thought-slaves. Like grad students, but
more-so. As an old programmer, I'm sure Vinge knows what he's talking about.
It's a great read.
* Jensen PS, Martin BA, Cantwell DP. Comorbidity in ADHD: implications for
research, practice, and DSM-IV. J Am Acad Child Adolesc Psychiatry
1997;36:1065-1079
--
Steve Harris
From: "Steve Harris" <SBHarris123@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Review of Imaging in ADHD (Re: Dexedrine and feeling drained)
Date: Sat, 14 Apr 2001 03:26:42 -0600
"CBI" <replytothegroup@spamblock.nospam> wrote in message
news:9b8is2$q5v$1@nntp9.atl.mindspring.net...
> There is evidence of physical differences in the brains of people with
>ADD prior to the use of medications. [Zametkin NEJM
>1990;323:1361-66, Rapoport, Am J Psych 1994;151:1791-96]
COMMENT:
Well, here we go. There is nothing to do at this point but a review. You
wanted the cites, so have at it.
The question is not whether somebody or other has reported some difference
or other between their small group of ADHD brains and normals, but whether
or not any such differences are seen repeatedly in other studies and by
other groups, and are robust enough to be seen by most groups. In short, are
real. The answer, so far as I can tell, is that there are no such
differences known yet.
Here is the abstract from the 1994 paper you quote from the NIMH group
(Rapoport is last author, not first):
This study finds that the normally larger R > L caudate nucleus volume seen
in normal boys is not present in ADHD boys.
Caudate volume decreases with age in normals, but not in the ADHD. Brain
volume is also 5% smaller in ADHD boys.
Am J Psychiatry 1994 Dec;151(12):1791-6
Quantitative morphology of the caudate nucleus in attention deficit
hyperactivity disorder.
Castellanos FX, Giedd JN, Eckburg P, Marsh WL, Vaituzis AC, Kaysen D,
Hamburger SD, Rapoport JL
Child Psychiatry Branch, NIMH, Bethesda, MD 20892.
OBJECTIVE: Because the caudate nuclei receive inputs from cortical
regions implicated in executive functioning and attentional tasks,
caudate and total brain volumes were examined in boys with attention
deficit hyperactivity disorder (ADHD) and normal comparison subjects.
To gain developmental perspective, a wide age range was sampled for
both groups. METHOD: The brains of 50 male ADHD patients (aged 6-19)
and 48 matched comparison subjects were scanned by magnetic resonance
imaging (MRI). Volumetric measures of the head and body of the
caudate nucleus were obtained from T1-weighted coronal images.
Interrater reliabilities (intraclass correlations) were 0.89 or
greater. RESULTS: The normal pattern of slight but significantly
greater right caudate volume across all ages was not seen in ADHD.
Mean right caudate volume was slightly but significantly smaller in
the ADHD patients than in the comparison subjects, while there was no
significant difference for the left. Together these facts accounted
for the highly significant lack of normal asymmetry in caudate volume
in the ADHD boys. Total brain volume was 5% smaller in the ADHD boys,
and this was not accounted for by age, height, weight, or IQ. Smaller
brain volume in ADHD did not account for the caudate volume or
symmetry differences. For the normal boys, caudate volume decreased
substantially (13%) and significantly with age, while in ADHD there
was no age-related change. CONCLUSIONS: Along with previous MRI
findings of low volumes in corpus callosum regions, these results
support developmental abnormalities of frontal-striatal circuits in
ADHD. PMID: 7977887
COMMENT:
Now, a previous study by the same group: again similar findings but also a
smaller RIGHT globus pallidus (note this, since the opposite will be found
at Johns Hopkins).
Arch Gen Psychiatry 1996 Jul;53(7):607-16
Quantitative brain magnetic resonance imaging in attention-deficit
hyperactivity disorder.
Castellanos FX, Giedd JN, Marsh WL, Hamburger SD, Vaituzis AC, Dickstein DP,
Sarfatti SE, Vauss YC, Snell JW, Lange N, Kaysen D, Krain AL, Ritchie GF,
Rajapakse JC, Rapoport JL
Child Psychiatry Branch, National Institute of Mental Health, Bethesda, Md,
USA.
BACKGROUND: Anatomic magnetic resonance imaging (MRI) studies of
attention-deficit hyperactivity disorder (ADHD) have been limited by
small samples or measurement of single brain regions. Since the
neuropsychological deficits in ADHD implicate a network linking basal
ganglia and frontal regions, 12 subcortical and cortical regions and
their symmetries were measured to determine if these structures best
distinguished ADHD. METHODS: Anatomic brain MRIs for 57 boys with ADHD
and 55 healthy matched controls, aged 5 to 18 years, were obtained
using a 1.5-T scanner with contiguous 2-mm sections. Volumetric
measures of the cerebrum, caudate nucleus, putamen, globus pallidus,
amygdala, hippocampus, temporal lobe, cerebellum; a measure of
prefrontal cortex; and related right-left asymmetries were examined
along with midsagittal area measures of the cerebellum and corpus
callosum. Interrater reliabilities were .82 or greater for all MRI
measures. RESULTS: Subjects with ADHD had a 4.7% smaller total
cerebral volume (P = .02). Analysis of covariance for total cerebral
volume demonstrated a significant loss of normal right > left
asymmetry in the caudate (P = .006), smaller right globus pallidus
(P=.005), smaller right anterior frontal region (P = .02), smaller
cerebellum (P = .05), and reversal of normal lateral ventricular
asymmetry (P = .03) in the ADHD group. The normal age-related
decrease in caudate volume was not seen, and increases in lateral
ventricular volumes were significantly diminished in ADHD. CONCLUSION:
This first comprehensive morphometric analysis is consistent with
hypothesized dysfunction of right-sided prefrontal-striatal systems in
ADHD. PMID: 8660127
COMMENT:
Now we ask: are these findings repeatable by other groups? Is the difference
"real"?
The Spanish also find reversed caudal asymmetry, which is due to an
abnormally enlarged RIGHT caudate in AHDH boys. So far so good. (There is
also a Spanish version of this article in Rev Neurol 2000 May
16-31;30(10):920-5, using data from the same 11 patients).
Arch Neurol 1997 Aug;54(8):963-8
Magnetic resonance imaging measurement of the caudate nucleus in adolescents
with attention-deficit hyperactivity disorder and its relationship with
neuropsychological and behavioral measures.
Mataro M, Garcia-Sanchez C, Junque C, Estevez-Gonzalez A, Pujol J
Department of Psychiatry and Clinical Psychobiology, University of
Barcelona, Spain.
OBJECTIVE: To investigate structural basal ganglia abnormalities in
attention-deficit hyperactivity disorder (ADHD) and their relationship
with the neuropsychological deficits and behavioral problems found in
ADHD. DESIGN: Case-control study. SETTING: Adolescents were recruited
from a local polytechnic institute of secondary education. SUBJECTS:
Eleven adolescents with ADHD and 19 healthy control subjects. Subjects
with ADHD were diagnosed by the school psychologist from a total
population of 450 students according to the Diagnostic and Statistical
Manual of Mental Disorders, Third Edition, Revised. Diagnosis was
confirmed by the Conners Teachers Rating Scale and a structured family
interview. MAIN OUTCOME MEASURES: Magnetic resonance imaging
single-slice transversal measurements of the head of the caudate
nucleus and a comprehensive neuropsychological evaluation, which was
specially designed to assess frontal-striatal functioning. RESULTS:
The ADHD group had a larger right caudate nucleus area than the
control group. In control adolescents, larger caudate nucleus areas
were associated with poorer performance on tests of attention and
higher ratings on the Conners Teachers Rating Scale. CONCLUSIONS:
These findings provide further evidence of the involvement of the
caudate nucleus in the neuropsychological deficits and behavioral
problems found in ADHD. The larger caudate nucleus found in the ADHD
group could be related to a failure of the maturational processes that
normally result in volume reduction. PMID: 9267970
COMMENT:
The Greeks, alas, see LEFT > RIGHT pattern in normals, the reverse of what
the above groups see (very confusing -- what IS normal?), and think that
AHDH kids have a smaller LEFT caudate than is normal, not a larger RIGHT
one. Hmmm.
BTW, L > R size for motor nuclei is what one would expect to happen a little
more often in R handedness, which is (of course) what one should see most
often. But these studies do not control for handedness. One suspects that we
are seeing noise:
J Child Neurol 1993 Oct;8(4):339-47
Attention deficit-hyperactivity disorder and asymmetry of the caudate
nucleus.
Hynd GW, Hern KL, Novey ES, Eliopulos D, Marshall R, Gonzalez JJ, Voeller KK
Department of Special Education, University of Georgia, Athens 30602.
The neurologic basis of attention deficit-hyperactivity disorder
(ADHD) is poorly understood. Based on previous studies that have
implicated metabolic deficiencies in the caudate-striatal region in
ADHD, we employed magnetic resonance imaging to investigate patterns
of morphology of the head of the caudate nucleus in normal and ADHD
children. In normal children, 72.7% evidenced a left-larger-than-right
(L > R) pattern of asymmetry, whereas 63.6% of the ADHD children had
the reverse (L < R) pattern of asymmetry of the head of the caudate
nucleus. This reversal of normal asymmetry in ADHD children was due to
a significantly smaller left caudate nucleus. The reversal in
asymmetry of the head of the caudate was most notable in ADHD males.
These results suggest that normal (L > R) morphologic asymmetry in the
region of the caudate nucleus may be related to asymmetries observed
in neurotransmitter systems implicated in ADHD. The behavioral
symptoms of ADHD may reflect disinhibition from normal levels of
dominant hemispheric control, possibly correlated with deviations in
asymmetric caudate-striatal morphology and deficiencies in associated
neurotransmitter systems.PMID: 8228029
COMMENT:
Okay, very well, what do we see when we DO control for handedness? Here is a
study from Johns Hopkins. They find small LEFT globus pallidus volume in
AHDH, in contrast to the NIMH study above which finds smaller RIGHT globus
palidus volumes in AHDH. Wups. Also, at Johns Hopkins they see NO difference
in the caudates in these boys, contradicting everybody else. Wups again.
J Child Neurol 1996 Mar;11(2):112-5
Basal ganglia volumes in children with attention-deficit hyperactivity
disorder.
Aylward EH, Reiss AL, Reader MJ, Singer HS, Brown JE, Denckla MB
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University,
Baltimore, MD 21205, USA.
Previous research has demonstrated volume reduction of the left globus
pallidus in children with the codiagnoses of Tourette syndrome and
attention-deficit hyperactivity disorder (ADHD), in comparison with
children who have Tourette syndrome alone and with normal controls.
The purpose of this study was to determine whether children with ADHD
alone also had volume reduction of the globus pallidus or other basal
ganglia structures. Subjects were 10 boys with ADHD, 16 boys with
Tourette syndrome and ADHD, and 11 normal control boys. Groups were
matched for age. Boys with ADHD were individually matched for age,
handedness, and IQ to 10 of the 16 boys with Tourette syndrome and
ADHD. Volumes of caudate, putamen, and globus pallidus were measured
and corrected for brain volume. The boys with ADHD had significantly
smaller left globus pallidus volume and total globus pallidus volume
(corrected for brain volume) than the normal controls. The Tourette
syndrome plus ADHD group did not differ from the ADHD group on any of
the measures. We conclude that small globus pallidus volume,
particularly on the left side, is associated with ADHD.PMID: 8881987
COMMENT:
But wait. It's not the basal ganglia which are different in ADHD.
It's the cerebellum. The cerebellar posterior/inferior vermis is smaller in
ADHD boys. Johns Hopkins again:
J Child Neurol 1998 Sep;13(9):434-9
Evaluation of cerebellar size in attention-deficit hyperactivity disorder.
Mostofsky SH, Reiss AL, Lockhart P, Denckla MB
Kennedy Krieger Institute, Department of Neurology, Johns Hopkins University
School of Medicine, Baltimore, MD 21205, USA.
Evidence from animal and human research suggests that the cerebellum
may play a role in cognition. This includes domains of executive
function that are normally attributed to the prefrontal cortex and are
typically deficient in individuals with attention-deficit
hyperactivity disorder (ADHD). To investigate cerebellar structure in
ADHD, magnetic resonance imaging morphometry was used to measure the
area of the cerebellar vermis in 12 males with ADHD and 23 male
controls matched for age and Wechsler Full-Scale IQ. Analyses were
conducted to evaluate group differences, as well as differences
between matched pairs of subjects with ADHD and those without ADHD.
All measurements were corrected for overall brain size. Both analyses
revealed that the size of the posterior vermis was significantly
decreased in males with ADHD (P < .05 in both analyses), and that
within the posterior vermis, the inferior posterior lobe (lobules
VIII-X) was involved in this reduction (P < .05 for group analysis, P
< .005 for matched pair analysis), while the superior posterior lobe
(lobules VI/VII) was not involved in the reduction. The finding of
abnormal inferior posterior vermal size suggests that dysfunction
within this region of the cerebellum may underlie clinical deficits
seen in individuals with ADHD.PMID: 9733289
COMMENT:
And now, for the French opinion: they agree with the Hopkins people. It's
the cerebellum posterior/inferior vermis. This is Rapoport again, however,
so it's not a totally independent report from the NIMH study.
Neurology 1998 Apr;50(4):1087-93
Cerebellum in attention-deficit hyperactivity disorder: a morphometric MRI
study.
Berquin PC, Giedd JN, Jacobsen LK, Hamburger SD, Krain AL, Rapoport JL,
Castellanos FX
Service de Pediatrie 1, CHU Hopital Nord, Amiens, France.
Clinical, neuroanatomic, neurobehavioral, and functional brain-imaging
studies suggest a role for the cerebellum in cognitive functions,
including attention. However, the cerebellum has not been
systematically studied in attention-deficit hyperactivity disorder
(ADHD). We quantified the cerebellar and vermal volumes, and the
midsagittal areas of three vermal regions, from MRIs of 46
right-handed boys with ADHD and 47 matched healthy controls. Vermal
volume was significantly less in the boys with ADHD. This reduction
involved mainly the posterior inferior lobe (lobules VIII to X) but
not the posterior superior lobe (lobules VI to VII). These results
remained significant even after adjustment for brain volume and IQ. A
cerebello-thalamo-prefrontal circuit dysfunction may subserve the
motor control, inhibition, and executive function deficits encountered
in ADHD.PMID: 9566399
COMMENT:
No, wait. It's actually the posterior corpus callosum which is different. So
say the folks in Seattle:
J Am Acad Child Adolesc Psychiatry 1994 Jul-Aug;33(6):875-81
Attention-deficit hyperactivity disorder: magnetic resonance imaging
morphometric analysis of the corpus callosum.
Semrud-Clikeman M, Filipek PA, Biederman J, Steingard R, Kennedy D, Renshaw
P, Bekken K
University of Washington, Seattle 98195.
OBJECTIVE: The following study seeks to document possible differences
in corpus callosal area and shape between children with
attention-deficit hyperactivity disorder (ADHD) and controls. METHODS:
Fifteen carefully diagnosed right-handed male subjects with ADHD with
overactivity symptomatology were compared to 15 right-handed male
control subjects. The corpus callosum was divided into seven areas on
the midsagittal slice of a magnetic resonance image with shape
analysis also conducted. RESULTS: An exploratory shape analysis showed
no significant differences in shape between the groups. No group
differences were found in the area, length, or anterior regions of the
corpus callosum. The ADHD subjects were found to have significantly
smaller posterior corpus callosum regions than the control group, with
the splenium accounting for most of the variance between the groups.
CONCLUSIONS: The splenial area of the corpus callosum is smaller in
children with ADHD than in a sample of normally developing children.
These smaller areas may relate to commonly seen sustained attention
deficits which in turn negatively impact on the development of more
advanced levels of attention such as self-regulation. Further study of
the regions surrounding the splenial area is suggested to determine
whether they are correlated in size to the smaller corpus callosum.
PMID: 8083145
COMMENT:
And finally, just to confuse the issue a bit, the NIMH people find that
girls with ADHD have the same cerebellar volume reduction as boys with the
same (supposed) disease and also slightly smaller brains (p = .05). BUT
their caudal nuclei are perfectly normal. And are not asymmetric, even in
controls.
Arch Gen Psychiatry 2001 Mar;58(3):289-95
Quantitative brain magnetic resonance imaging in girls with
attention-deficit/hyperactivity disorder.
Castellanos FX, Giedd JN, Berquin PC, Walter JM, Sharp W, Tran T, Vaituzis
AC, Blumenthal JD, Nelson J, Bastain TM, Zijdenbos A, Evans AC, Rapoport JL
Child Psychiatry Branch, National Institute of Mental Health, Bldg 10, Room
3N-202, 10 Center Dr-MSC 1600, Bethesda, MD 20892-1600, USA.
BACKGROUND: Anatomic studies of boys with
attention-deficit/hyperactivity disorder (ADHD) have detected
decreased volumes in total and frontal brain, basal ganglia, and
cerebellar vermis. We tested these findings in a sample of girls with
ADHD. METHODS: Anatomic brain magnetic resonance images from 50 girls
with ADHD, of severity comparable with that in previously studied
boys, and 50 healthy female control subjects, aged 5 to 15 years, were
obtained with a 1.5-T scanner with contiguous 2-mm coronal slices and
1.5-mm axial slices. We measured volumes of total cerebrum, frontal
lobes, caudate nucleus, globus pallidus, cerebellum, and cerebellar
vermis. Behavioral measures included structured psychiatric
interviews, parent and teacher ratings, and the Wechsler vocabulary
and block design subtests. RESULTS: Total brain volume was smaller in
girls with ADHD than in control subjects (effect size, 0.40; P =.05).
As in our previous study in boys with ADHD, girls with ADHD had
significantly smaller volumes in the posterior-inferior cerebellar
vermis (lobules VIII-X; effect size, 0.54; P =.04), even when adjusted
for total cerebral volume and vocabulary score. Patients and controls
did not differ in asymmetry in any region. Morphometric differences
correlated significantly with several ratings of ADHD severity and
were not predicted by past or present stimulant drug exposure.
CONCLUSIONS: These results confirm previous findings for boys in the
posterior-inferior lobules of the cerebellar vermis. The influence of
the cerebellar vermis on prefrontal and striatal circuitry should be
explored.PMID: 11231836
========================================
So which parts are real and which are artifacts of small samples
and measurements of small differences?
THE NUCLEAR IMAGING STUDIES:
Here is the OTHER study you quote, another NIHM study:
N Engl J Med 1990 Nov 15;323(20):1361-6
Cerebral glucose metabolism in adults with hyperactivity of childhood onset.
Zametkin AJ, Nordahl TE, Gross M, King AC, Semple WE, Rumsey J, Hamburger S,
Cohen RM
Section on Clinical Brain Imaging, National Institute of Mental Health, NIH,
Bethesda, MD 20892.
BACKGROUND AND METHODS. The cause of childhood hyperactivity
(attention deficit-hyperactivity disorder) is unknown. We investigated
the hypothesis that cerebral glucose metabolism might differ between
normal adults (controls) and adults with histories of hyperactivity in
childhood who continued to have symptoms. Each patient was also the
biologic parent of a hyperactive child. None of the adults had ever
been treated with stimulant medication. To measure cerebral glucose
metabolism, we administered 148 to 185 MBq (4 to 5 mCi) of
[18F]fluoro-2-deoxy-D-glucose intravenously to 50 normal adults and 25
hyperactive adults while they performed an auditory-attention task.
Images were obtained for 30 minutes with a Scanditronix
positron-emission tomograph with a resolution of 5 to 6 mm.
Whole-brain and regional rates of glucose metabolism were measured
with computer assistance by two trained research assistants, working
independently, who were blinded to the subjects' status (control or
hyperactive). RESULTS. Global cerebral glucose metabolism was 8.1
percent lower in the adults with hyperactivity than in the normal
controls (mean +/- SD, 9.05 +/- 1.20 mg per minute per 100 g vs. 9.85
+/- 1.68 mg per minute per 100 g; P = 0.034). In the adults with
hyperactivity, glucose metabolism was significantly reduced, as
compared with the values for the controls, in 30 of 60 specific
regions of the brain (P less than 0.05). Among the regions of the
brain with the greatest reductions in glucose metabolism were the
premotor cortex and the superior prefrontal cortex. When the seven
women with hyperactivity or the six patients with learning
disabilities were omitted from the analysis, the results were similar.
CONCLUSIONS. Glucose metabolism, both global and regional, was reduced
in adults who had been hyperactive since childhood. The largest
reductions were in the premotor cortex and the superior prefrontal
cortex-areas earlier shown to be involved in the control of attention
and motor activity.
Comment in:
N Engl J Med. 1990 Nov 15;323(20):1413-5
N Engl J Med. 1991 Apr 25;324(17):1216-7
PMID: 2233902
MY COMMENT:
The areas where the largest deficits in uptake occurred were the prefrontal
and premotor cortices.
Alas, what you don't add to your reference is that the same group (with two
of the same authors) writing 8 years later cannot find any real metabolic
differences between ADHD and normals. Naturally, they downplay this. If
you've been published in the NEJM, what are you going to do-- say you can't
see the effect anymore?
J Neuropsychiatry Clin Neurosci 1998 Spring;10(2):168-77
Age-related changes in brain glucose metabolism in adults with
attention-deficit/hyperactivity disorder and control subjects.
Ernst M, Zametkin AJ, Phillips RL, Cohen RM
Laboratory of Cerebral Metabolism, National Institute of Mental Health,
Rockville, Maryland, USA.
Using positron emission tomography and
[18F]-2-fluoro-2-deoxy-D-glucose, the authors determined cerebral
metabolic rates for glucose (CMRglc) in 39 adults (18-51 years old)
with attention-deficit/hyperactivity disorder (ADHD) and 56 healthy
control adults (19-56 years old) during the performance of a
continuous attention task. Increased age was associated with reduced
global CMRglc in ADHD women, but not in ADHD men, control men, or
control women. Better performance on the attention task was
significantly associated with increased age only in the ADHD female
group. Determining the role of behavioral, hormonal, and genetic
factors is a challenge for future research. PMID: 9608405
COMMENT:
Golly, it's "challenging" when you can't find your own jazzy effect, all
right....
Below we find Zemetkin trying again, with teenaged girls. His results are
not significant, but he reports the % decreases anyway. That takes guts, but
we're not fooled.
Arch Gen Psychiatry 1993 May;50(5):333-40
Brain metabolism in teenagers with attention-deficit hyperactivity disorder.
Zametkin AJ, Liebenauer LL, Fitzgerald GA, King AC, Minkunas DV, Herscovitch
P, Yamada EM, Cohen RM
Section on Clinical Brain Imaging, National Institute of Mental Health,
Bethesda, Md.
OBJECTIVES: We sought to obtain and compare values of cerebral glucose
metabolism in normal minors and minors with Attention Deficit
Hyperactivity Disorder (ADHD). We also sought to confirm our earlier
findings of reduced brain metabolism in adults with ADHD, and to
examine whether these results might be diagnostically useful. DESIGN:
Case-control study. SETTING: Adolescents were recruited to National
Institutes of Health Clinical Center/Research Facility through
advertisement at local high schools and ADHD organizations. PATIENTS:
Subjects were 10 normal adolescents and 10 adolescents with ADHD
diagnosed with structured interviews using DSM-III-R criteria. MAIN
OUTCOME MEASURES: Positron emission tomography and fludeoxyglucose
F18 were used to study cerebral glucose metabolism in minors while
they performed an auditory-attention task. RESULTS: Global or absolute
measures of metabolism did not statistically differ between groups,
although hyperactive girls had a 17.6% lower absolute brain metabolism
than normal girls. As compared with the values for the controls,
normalized glucose metabolism was significantly reduced in six of 60
specific regions of the brain, including an area of the left anterior
frontal lobe (P < .05). Lower metabolism in that specific region of
the left anterior frontal lobe was significantly inversely correlated
with measures of symptom severity (P < .001-.009, r = -.56 to -.67).
CONCLUSIONS: Global or absolute measures of metabolism using positron
emission tomography and fludeoxyglucose F18 did not statistically
differentiate between normal adolescents with ADHD. Positron emission
tomography scans can be performed and are well tolerated by normal
teenagers and teenagers with ADHD. The feasibility of normal minors
participating in research involving radiation was established.
Comment in:
Arch Gen Psychiatry. 1996 Nov;53(11):1059-61
PMID: 8489322
COMMENT:
Here is another earlier one failing to find any glucose metabolism
differences in ADHD girls. Subregional differences are seen on multiple
after-the-fact comparisons, but if you do enough fishing expedition
comparisons, you're of course bound to see some differences somewhere in
something, just by the luck of the draw. (There's a rock song about that:
"I've got a girl named Boniferroni...")
J Am Acad Child Adolesc Psychiatry 1997 Oct;36(10):1399-406
Cerebral glucose metabolism in adolescent girls with
attention-deficit/hyperactivity disorder.
Ernst M, Cohen RM, Liebenauer LL, Jons PH, Zametkin AJ
Laboratory of Cerebral Metabolism, National Institute of Mental Health,
Bethesda, MD, USA.
OBJECTIVE: Low cerebral metabolic rates for glucose (CMRglc) have been
reported in a small sample of girls with
attention-deficit/hyperactivity disorder (ADHD). This study was an
effort to replicate this finding in a larger independent sample.
METHOD: Using positron emission tomography and
[18F]fluorodeoxyglucose, CMRglc were compared between 10 girls with
ADHD (14.10 +/- 1.91 years) and 11 normal girls (14.3 +/- 1.70 years).
RESULTS: Global CMRglc was similar between ADHD and control girls.
Lateralization of normalized CMRglc differed significantly between
ADHD and control girls in parietal and subcortical regions, with
rCMRglc lower on the left than on the right side in girls with ADHD,
and conversely in control girls. The sylvian area of the parietal
region and the anterior putamen of the subcortical region were the
main contributors to this effect. Normalized rCMRglc of the
hippocampus was higher in ADHD than in control girls. Sexual
maturation was the only clinical characteristic that differed between
present and previous samples, and it correlated with global CMRglc.
CONCLUSIONS: Although failing to confirm abnormally low CMRglc in
girls with ADHD, this study suggested that (1) functional interactions
between sex and brain development may contribute to ADHD
pathophysiology, and (2) sexual maturation should be controlled in
future CMRglc studies of adolescent girls.
PMID: 9334553
COMMENT:
In the above study, they found that what they thought was an ADHD effect in
girls was just the female brain turning off at puberty <allow myself a grin
here; feminists deserve it for their comments about the same process in
boys>. Anyway, the NIMH people above were trying to replicate the study
below, in which they thought they had found glucose uptake differences
between ADHD and normal girls, but did NOT see it in boys. And as we've
seen, the latter study could not confirm the girl data, either, so
basically, they are back to square-one by the above 1997 study. I don't
think the New England Journal of Medicine made them retract the 1990
article, however. This is, after all, the National Institute of Mental
Health.
J Am Acad Child Adolesc Psychiatry 1994 Jul-Aug;33(6):858-68
Reduced brain metabolism in hyperactive girls.
Ernst M, Liebenauer LL, King AC, Fitzgerald GA, Cohen RM, Zametkin AJ
Section on Clinical Brain Imaging, National Institute of Mental Health, NIH,
Bethesda, MD 20892.
OBJECTIVE: This study assesses the effect of attention-deficit
hyperactivity disorder (ADHD) and gender on cerebral glucose
metabolism (CMRglu), using positron emission tomography and
18F-fluorodeoxyglucose. METHOD: Nineteen normal (6 females; 14.3 +/-
1.3 years old) and 20 ADHD adolescents (5 females; 14.7 +/- 1.6 years
old) participated in the study. An auditory continuous performance
task was used during the 30-minute uptake of 18F-fluorodeoxyglucose.
RESULTS: There were no statistically significant differences in global
or regional CMRglu between ADHD (N = 20) and normal (N = 19)
adolescents. However, the global CMRglu in ADHD girls (N = 5) was
15.0% lower than in normal girls (N = 6) (p = .04), while global
CMRglu in ADHD boys was not different than in normal boys.
Furthermore, global CMRglu in ADHD girls was 19.6% lower than in ADHD
boys (p =.02) and was not different between normal girls and normal
boys. Clinical rating scales did not differentiate ADHD girls from
ADHD boys, nor normal girls from normal boys. CONCLUSIONS: The greater
brain metabolism abnormalities in females than males strongly stress
that more attention be given to the study of girls with ADHD.PMID:
8083143
COMMENT:
Ah, but not to be outdone. If glucose doesn't work, there's always dopamine
metabolism! And after the 1997 final glucose fiasco, that's what we see NIMH
focus on.
Am J Psychiatry 1999 Aug;156(8):1209-15
High midbrain [18F]DOPA accumulation in children with attention deficit
hyperactivity disorder.
Ernst M, Zametkin AJ, Matochik JA, Pascualvaca D, Jons PH, Cohen RM
Laboratory of Cerebral Metabolism, NIMH, Bethesda, Md., USA.
mernst@intra.nida.nih.gov
OBJECTIVE: Attention deficit hyperactivity disorder (ADHD) is a highly
prevalent childhood psychiatric disorder characterized by impaired
attention, excessive motor activity, and impulsivity. Despite
extensive investigation of the neuropathophysiology of ADHD by a wide
array of methodologies, the neurobiochemical substrate of this
disorder is still unknown. Converging evidence, however, suggests a
primary role of the dopaminergic system. METHOD: This study examined
the integrity of presynaptic dopaminergic function in children with
ADHD through use of positron emission tomography and the tracer
[18F]fluorodopa ([18F]DOPA). Accumulation of [18F]DOPA in synaptic
terminals, a measure of dopa decarboxylase activity, was quantified in
regions rich in dopaminergic innervation, including caudate nucleus,
putamen, frontal cortex, and midbrain (i.e., substantia nigra and
ventral tegmentum). RESULTS: Accumulation of [18F]DOPA in the right
midbrain was higher by 48% in 10 children with ADHD than in 10 normal
children. Despite its magnitude, this difference would not have
reached statistical significance if corrected by the Bonferroni test
for multiple comparisons. However, [18F]DOPA in the right midbrain was
correlated with symptom severity. No other dopamine-rich regions
significantly differed between groups. CONCLUSIONS: These findings are
suggestive of dopaminergic dysfunction at the level of the
dopaminergic nuclei in children with ADHD. Abnormality in dopa
decarboxylase activity may be primary or secondary to deficits in
other functional units of the dopamine pathway (e.g., receptor, uptake
transporter, vesicular transporter, degradation enzymes). Efforts
toward defining the origin of this abnormality should help delineate
mechanisms of midbrain control of attention and motor behavior
important for the understanding of the causes and treatment of ADHD.
PMID: 10450262
COMMENT:
Again we're reporting non-statistically significant fishing expedition data.
Same-old, same-old. The midbrain, eh? But no, earlier, it had actually been
reprorted to be........the prefrontal cortex:
J Neurosci 1998 Aug 1;18(15):5901-7
DOPA decarboxylase activity in attention deficit hyperactivity disorder
adults. A [fluorine-18]fluorodopa positron emission tomographic study.
Ernst M, Zametkin AJ, Matochik JA, Jons PH, Cohen RM
Laboratory of Cerebral Metabolism, National Institute of Mental Health,
Bethesda, Maryland 20892, USA.
Converging evidence implicates the dopaminergic system and the
prefrontal and nigrostriatal regions in the pathophysiology of
attention deficit hyperactivity disorder (ADHD). Using positron
emission tomography (PET) with [fluorine-18]fluorodopa (F18-DOPA), we
compared the integrity of the presynaptic dopaminergic function
between 17 ADHD adults and 23 healthy controls. The ratio of the
isotope concentration of specific regions to that of nonspecific
regions reflects DOPA decarboxylase activity and dopamine storage
processes. Of three composite regions (prefrontal cortex, striatum,
and midbrain), only the prefrontal cortex showed significantly
different F18-DOPA ratios in ADHD as compared with control adults (p <
0.01). The medial and left prefrontal areas were the most altered
(lower F18-DOPA ratios by 52 and 51% in ADHD as compared with
controls). Similarly, the interaction [sex x diagnosis] was
significant only in the prefrontal cortex (p < 0.02): lower ratios in
men than in women in ADHD and vice versa in controls. These findings
suggest that a prefrontal dopaminergic dysfunction mediates ADHD
symptoms in adults and that gender influences this abnormality. On the
basis of previous neuroimaging findings in ADHD showing discrepant
findings in adults and adolescents and on evidence for midbrain
dopaminergic defect in adolescents, we hypothesize that the prefrontal
dopaminergic abnormality in ADHD adults is secondary and results from
an interaction of the primary subcortical dopaminergic deficit with
processes of neural maturation and neural adaptation.PMID: 9671677
COMMENT:
You'll notice they don't dare publish this stuff in the same journal the
next time they find some OTHER brain area lighting up. A little
gamesmanship, there.
======================================================
EXECUTIVE SUMMARY:
The MRI data for AHDH are completely screwed up, and nobody can agree with
anybody else on what's different, if anything. Rapoport, working with the
French, and also at the NIHM, seems to think that the cerebellar vermis is
smaller, and at Hopkins they actually agree with this. Abstracting from
everything I've read, I judge that this one difference has the largest
chance of being a real, objective, repeatable finding. However, the
available MRI data are overall in such a state that at this point the jury
is still out. No candy bar for you.
The nuclear imaging (PET) data are (if anything) in even worse shape. Some
early data reports lower glucose uptake, later data basically contradicts
that thorougly. The hot areas in dopaminergic uptake (a better bet for a
finding, probably) are found variously in various places, and none of them
are at this time statistically significant if you Bonferroni-correct for the
large number of inter-area comparisons done. So again, no candy bar. The
NIHM in general seem to have made it their mission to find some kind of
imaging difference between ADHD people and normals. Rapoport in particular
travels around the world rustling up such differences. That's nice, but
we'll need to see some more of that popping up in the same places in the
brain, when Rapoport is not around. That's what's required in science.
Final conclusion: no cigar.
--
Steve Harris
From: "Steve Harris" <SBHarris123@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Review of Imaging in ADHD (Re: Dexedrine and feeling drained)
Date: Sat, 14 Apr 2001 13:32:58 -0600
> Furthermore, there is no reason to expect that all publications by
> an author will appear in the same journal.
Straw man. Never suggested they should. It's nice if you get a different
result or modified result using the exact same technique on more or less the
same group, to publish this in the journal in which the first article
appeared. Not doing this is fishy.
>It is more commonly the contrary.
So?
>To suggest that this reflects "gamesmanship" would indicate either
>ignorance or dishonesty.
Dishonesty? Jump in the lake. Ignorance of the "publishing process" ? I've
published in many journals, but only because I've been writing about
different topics. You must have a long CV if you think you're going to teach
me about the gamesmanship of publishing what where.
Gosh, am I writing to a famous professor? Do tell.
SBH
From: "Steve Harris" <SBHarris123@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Review of Imaging in ADHD (Re: Dexedrine and feeling drained)
Date: Sat, 14 Apr 2001 21:08:58 -0600
> "Steve Harris" <SBHarris123@ix.netcom.com> wrote in message
> news:9ba8n0$v1n$1@slb7.atl.mindspring.net...
> > > Furthermore, there is no reason to expect that all publications by
> > > an author will appear in the same journal.
> >
> > Straw man. Never suggested they should.
>
> "Steve Harris" wrote in message news:9b956k$oi8$1@slb0.atl.mindspring.net:
> "You'll notice they don't dare publish this stuff in the same journal the
> next time they find some OTHER brain area lighting up. A little
> gamesmanship, there."
>
> You stated that to not do so constituted "gamesmanship" and implied that it
> was motivated by a desire to conceal conflicting results.
>
>
> > It's nice if you get a different result or modified result using the
> > exact same technique on more or less the same group, to publish this
> > in the journal in which the first article appeared. Not doing this is
> > fishy.
Yes, all that is what I said. Now, once again, if it's not too much for you,
where did I suggest that all publications by an author should appear in the
same journal?
> My experience is that publishing all of a series of studies in the same
> journal is the exception and not the norm. I could bore you with
> examples if you choose to suffer the embarrasment.
There's no embarrasment, since I never claimed otherwise.
It may well be the norm. I shouldn't be, and we can both (I hope) think of
good reasons why not (though I admit that in the era of med-line the whole
issue is becoming more and more moot). However, readers of an initial study
who read the study because they actually subscribed to the journal (assuming
the journal has properly published an article to the tastes of the audience
it is trying to serve) will also want to see the followups. If the followups
contradict the intitial conclusions, the readers will particularly want to
see *them.* Alas, if an author finds things which contradict an initial
study (the glucose brain metabolism- ADD connection being a prime example)
will certainly not want to submit that to the same journal the first article
went to. And if he or she did, the journal might well not want to publish
it, for obvious reasons. So it rarely happens. I hope I do not shock you by
suggesting that the NEJM does not like to publish articles showing that
articles published earlier by it contain results that are not repeatable. So
where to publish conflicting data is a game played by both authors and
journals, and "gamesmanship" is quite an appropriate word for it.
> > >It is more commonly the contrary.
> >
> > So?
> So? I do not believe that the majority of journal choices are not made
>out of gamesmanship. I find it disturbing that you would question the
>relevance of calling a normal pattern of publishing dishonest.
Well, you can be disturbed all you like. I hope it doesn't keep you up at
night. If you don't like that, you've certainly not going to like the
statistics of how often studies funded by drug companies find results
favorable to the drug company.
For the record, I never called any of this "dishonest," for that would be
overblown. I said "fishy" and that carries as close the shade of meaning as
I can get. If there's an article which claims a brain scanning difference
between ADD and normals, that's medical news and it goes in the most
prestigious journal, the NEJM. If later studies find no such thing, how come
that's NOT news? We get cynical about that kind of thing in our tabloids,
but should not our best medical journals be different? Is there an issue of
responsiblity here, particularly for the journals which published the
positive result initially? These are the issues I raise. You can choose to
pretend they don't exist, and normal publishing patterns are completely
random insofar as whether or not the conclusions of the papers fit with
those which the journals in question have previously published. Be my guest.
> Is it really your opinion that most reasearchers are choosing their
>journal submissions in order to obscure their previous publishing
>records?
That overstates it. What I mean is what I wrote above.
>To suggest that this reflects "gamesmanship" would indicate
>either ignorance or dishonesty.
Apparently you and I have a different understanding of the word
"gamesmanship".
> I am published but hardly a distinguished, nevermind famous,
>professor. If you are truly knowledgeable about the publication
>process then you know that several factors contribute to the choice of
>which journals to submit papers to including likelihood of acceptance
>(it is a lot of work even after the draft is written) and prestgiousness of
>the journal. I have never known an author (I have known several
>including Harvard professors and a Nobel Laureate) to consider in
>which journals he had previously published other
>than when considering likelihood of acceptance.
Oh, boy. All I can say is that you need to get out more.
> I stand by my statement that to offer publications in differing journals
>as evidence of "gamesmanship" either represents ignorance or
>dishonesty.
You can stand by it all you like. You can stand on one foot if that will
help.
> You are free to claim whichever applies.
I'm free to claim whatever I please.
>One perfectly common and innocent
> possibility is that one or the other journal was not the first choice. I
> presume you are so expediant in the publication process that this
>represents a revelation.
Yes, it's a revelation that the NEJM might not have have wanted to publish
the negative glucose uptake brains studies, after publishing the initial
positive one. That could all be perfectly innocent. As innocent as what your
local newspaper finds to be "news."
However, I think you live in a more innocent world than I do.
> --
> CBI, MD
>
> P.S. A review of Pub Med shows that you have probably forgotten more about
> rodent diabetes than I should ever care to know (or are you the hand
> surgeon?). I will be careful never to challenge you on this subject. I do
> note a variety of journals even when discussing apparently similar subjects.
> I also note a paucity of publications in any mental health field.
PS. You have the advantage of me in being anonymous, oh professorial
claimant. We can continue the academic pissing match when you reveal your
name and thus your own CV. Otherwise, don't bother.
From: "Steve Harris" <SBHarris123@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Dexedrine and feeling drained
Date: Sun, 15 Apr 2001 01:56:47 -0600
"Paul" <paul@xhawaii.rr.com> wrote in message
news:q6qhdtor1ilpot35gb80u2ag99a9j0o5nk@4ax.com...
>>It's not that I'm completely against amphetamines. I'm not
>>completely against any drug. It's only hypocrisy that I cannot
>>abide.
>But you are also saying (or at least strongly suggesting) that
>you don't think that it is appropriate for physician's to use
>their clinical judgment and decide to use amphetamines to treat
>ADHD suggesting that to do so is akin to playing God.
COMMENT:
Not quite. For physicians to decide that an entire psychotropic drug class
is appropriate for a particular class of children, which one must formally
label as having a "disease" before they are allowed to try the drug, is
what's akin to playing God. And of course, it's not only physicians, but
also their societies who practice this bit of nonsense. The body is so
complex that there's generally no way to tell whether or not a given drug
will be "good" for a given person, except to experiment with it. You know
that.
"Doctor, will it help me unwind after work at home if I have a glass of
wine?"
"Hell, how do I know? Maybe. Try it and see."
"But doctor, what if I become an alcoholic?"
"Well, what if you do? You pay your money and you take your chances. It's up
to you, Joe"
That's honest. Whole-scale prohibition because of what MIGHT happen is
dishonest. The doctor pretending to know who's going to be come
alcohol-dependent, is dishonest. As would be doctors writing prescriptions
for wine with the presumption that by this means we could keep people from
ever becoming winos (doubtless we'd only dispense to people who had
post-work or cocktail-party unwinding disorder). But no, we have had the
wisdom (circa 1930) to see that it doesn't work that way. Can't. Doesn't.
Shouldn't. The situation with other drugs is something we haven't come to
grips with. But must.
There are a number of separate issues, here, of course. One is: what risks
should a society allow adults to take? Can you hang-glide without a license?
Well then, why can't you smoke dope? The second issue is what risks we allow
children to take, with and without consent of parents and the State. The
final issue is what role doctors should play in the LEGAL aspects of all of
this. My own feeling is almost none when it comes to adults, and very little
even when it comes to children, unless somebody notices something badly
wrong. We doctors are not really supposed to be judges, cops, and
child-welfare social-workers. Those jobs are taken by the appropriate people
who want to do them and do them well. Doctors ought to be coaches and
advice-givers, which you as an adult consult when things get rough, rather
as you do your money manager when you play with the stock market, or your
skydiving instructor when you decide you want to learn to rig your own
chute. For children, when it comes to drug use, the state might want to make
social-workers somewhat in loco parentis to keep track of the occasional
nutty parent who wants their kid to do something really dangerous, or
doesn't mind it. But even here, we should be wary. And here we've certainly
already gone far too far when it comes to drugs.
If you'd like a metaphor for the correct approach, I give you Scuba Rangers.
That's the local program here in SoCal under which kids learn scuba. I've
seen 12-year olds drop off a dive boat into the Pacific with a parent, and
the program allows this even at age 10. If you haven't seen a ten-year-old
in a wetsuit with a weenie 40 cf airtank, I suppose you need to be there to
appreciate how surreal it is. My jaw certainly dropped the first time I saw
it at the local pool.
Now, if little Susie, age 10, and her dad want to drop down to 70 feet of
depth in the ocean and breathe 40% oxygen 60% nitrogen at more than 3 atm of
pressure while learning not to pet sea urchins, it turns out that I as a
doctor have nothing to say about any of it. Legally, it's all between little
Susie, her Daddy, her dive instructor, and the State of California. As for
the FDA, they, in their bureaucratic un-wisdom, don't officially yet know
about nitrox even for adults, let alone children, so they're not in the
picture (when the FDA thinks about scuba they think about adults breathing
compressed air; ie, they are still in the Dark Ages).
All this is probably as it should be. The poor kids were not required to
come to me The Doctor and have their parents make an argument that they have
"ocean biology appreciation deficit disorder," (that's coming in DSM-V) and
therefore had need to risk drowning, nitrogen narcosis, oxygen toxicity,
pulmonary gas embolism, and the bends, all of it in order to treat this
severe learning deficiency. I don't have to prescribe nitrox to help prevent
bends and extend no-deco bottom time. Instead, the kids just started to dive
and enjoy it. With good instruction they set their dive computers for nitrox
and off they go, as in some kind of playstation game. That's my metaphor.
Ethics progresses by letting people try stuff to see what happens, not by
consulting committees and Mrs. Grundy. And ethics is not by prescription,
because I the doctor am no more ethical than you are. CBI might think he is,
but that's his problem. I promise you that he isn't, either.
Now, if we asked the FDA formally about all this kid scuba stuff, and forced
them to notice it, they'd freak. (We won't even talk about kids on
rebreathers and helium, which is all coming...) And if, 15 years ago, I'd
gone to a Human Subjects Committee and proposed to send a bunch of kids to
the ocean floor on compressed high oxygen mixtures, just to see how they
tolerated it, I would no doubt have been compared to Dr. Mengele (Godwin's
Law of Controversial Research Proposals).
But here we are. As it happened, no Ethics Committee was ever consulted
about children's scuba or nitrox for children. Thus, no professional
ethicists ever got to do the only thing which professional ethicists ever
do, which is wring their hands and express anxiety that people might do
things that they don't know the full consequences of. And therefore should
be prevented from doing, Until We Know Much More.
But, interestingly, it all turned out okay in scuba. One wonders how the
world survives without ethicists making laws, but it does. Turns out that
scuba is like skateboarding, and the kids do it better than the adults do.
Surprise. Little Johnny is still in way more danger of getting his skull
flattened by some adult in a car when he rides his bike out into traffic,
than he'll ever been of drowning if he does scuba. The risk is there, but
it's smaller than you'd think.
Now that you sat through all that, here's the message.
My fundamental contention in all of this, is that life is full of risks and
dangers, and that you grow only by learning how to face and manage
increasingly tricky situations. Society's legitimate interests in all of
this are only that you be coached until you show competence, at which point
you ought to be free to do-it-yourself. As an adult you might want to know
how to handle a piton, a corrosive chemical, an airplane, a tank of
compressed oxygen, a high voltage line, a high-powered rifle, a radioactive
isotope. And you should be able to learn at your own pace. And you should be
able to try any drug you want to try, so long as you demonstrate some basic
knowledge about it first. Society's interest is only that you don't harm
somebody else (and perhaps yourself) while you're learning; after that, you
should be on your own. UNTIL you screw up. That's the way we handle
airplanes, and that's the way we should handle drugs. Not just alcohol, but
all psychotropic drugs.
We have pilot's licenses, scuba licenses, driver licenses, and architect's
licenses. What we need are drinking licenses and psychotropic drug-use
licenses. The first does not exist, the second really doesn't either. Even
my medical license doesn't let me take controlled substances by myself. Nor
even under supervision unless I can convince somebody I have a disease or a
recognized pathology (forget endorphin deficiency disorder). And even my
medical license is both ridiculous over-and underkill for use of
pharmaceuticals. It does NOT take 5 years of higher education to teach you
how to use any one drug or class of drugs. What, do you want a collage
degree in how to drink scotch-and-soda? But 5 years is not really enough to
teach you how to use all drugs. Even on yourself, must less on other people.
So we have a bad system that needs fixing.
As for children, there must be some subset of all of these risk-taking and
learning opportunities. You cannot simply tell children that they cannot
take any risks until they become adults. For one thing, children are at high
risk in most of the things they do NOW, so that would be silly. For another,
we don't really want the kind of adults we'd get if we over-mothered our
children that badly. Yes, I'm sure there are some mothers who'd chase out
after dive boats if they knew about them, and outlaw the whole business,
just to be on the safe side (most divers are out there on the ocean trying
to get away from such people, who thankfully do not follow). How do you know
that micro-bubbles from decompression won't harm little Johnny's
development, like Ritalin may (indeed, as Ritalin probably will, to some
small extent)? Well, we don't. Life is risk. Do you really want to LIVE at
all? That is the question.
So what if Johnny wants to ski through the trees, dive to the bottom of the
sea, self-inject testosterone, take a belt of whisky or a hit of Ritalin? Or
have sex? I see all mothers wringing their hands now! But it all comes down
to the truth that one can only judge these things on a case-by-case basis.
How old is he? Is he mature enough to handle his part? Does he know and
appreciate the risks? Who is monitoring his progress? Does Johnny need a
disease before we let him take risks? I say no - not so long as the results
look good. If he does fine, then fine. The average competent adult doesn't
need a disease to take alcohol or breathe high pressure nitrogen, so why
does he need one to take methylphenidate? If his life starts getting messed
up from some activity, then you make him wait until he turns 18 or 19 or 21
or whatever it is you decide is the age of majority. And if he screws up
after that, you can take away his freedoms in accordance. Keep tabs however
you like, but let outcomes in individual cases be your guide.
So that's tonight's essay. Back to your objections.
>>And apparently you believe in semantic arguments. Whether you call them
syndromes or diseases, the issue is whether it is within the purview of
physicians to diagnose and prescribe various medications for various
conditions including but not limited to ADHD, depression, schizophrenia.<<<
And the answer is: what do you mean by "purview"? Legal purview, moral
purview, scientific purview--- what?
I'm afraid I've been misunderstood here, somewhat. There are no objective
tests for ADD. I suspect but cannot prove that it is a
pseudo-disease, invented more or less subconsciously by people who don't
like how their kids behave, and who have no other way of thinking about it
if they are to get hold of the chemicals that may (or may not, depending on
the kid) modify that unwanted behavior. Behavior modification in humans is a
necessary thing, but not everybody who needs behavior mod needs to be
labeled as having a "disease." Do they? (what disease for your
mother-in-law?) My argument is that, in the absence of objective
pathological tests, the "disease" model is as poor a way to handle kids who
won't sit still in class, as it is of handling kids who want to scuba dive
in the ocean at night, or ski though the trees. As an adult, I did not need
to convince some doctor that I had a disease in order to get permission to
go down to 130 ft depth and look at fish while trying to see if I'm feeling
the edge of nitrogen narcosis. I did have to satisfy my dive instructor
regarding compressed gas use, but he did not need to go to medical school
for that. Nor does my bartender need an advanced degree to serve me alcohol,
thank you very much. So why the funny business when it comes to other
psychotropic drugs? I don't know. It makes no sense to me.
Here's what I think happened historically. We got suckered by some new stuff
and we didn't really know what to do about it, so we fudged. We needed
somebody to monitor drug use, and physicians were the obvious choice. And
physicians look at the world in terms of disease, and so we made up a couple
for the people who wanted to try the new sympathomimetic drugs to see if
they helped with the problems of life. And here we are. Ciba-Geigy gave
$800,000 to CHADD to sell them on the idea that there was this horrid
disease called ADD in the US, and Ritalin was one of the answers.
Prescriptions thereafter exploded as people found out that Ritalin is a
powerful and not too dangerous stimulant (not unlike caffeine but more-so
and with fewer jitters), so that now at least one boy in 20 out there is on
the drug. And all that middle-class influence bought enough politicians that
now Novartis is the biggest meth lab in the country, and it's completely
legal. Amazing! Just like Children's Scuba. Suggest any such thing, though,
and doctors who prescribe Ritalin will be outraged that they might be taking
part it what is basically a recreational industry. Naturally. If
prostitution is illegal, nobody really likes being called a prostitute, do
they?
If you push this metaphor, I'm merely suggesting that prostitution be fully
legalized. Let us NOT, however, call it "sex therapy" and require doctor's
prescriptions for it. That's the Wrong Model. Let us, instead, be more
honest and call a call girl a call girl, so to speak. Some things are not
medical. Even drugs (gasp) are not inherently medical. It's only the use of
drugs to treat DISEASE that is inherently medical. The wine you drink at
dinner is not medicinal. Some drugs might be used under other circumstances
by completely healthy people. The supervisors for learning in this process
might be doctors, or they might not. It doesn't matter, so long as they have
enough experience to be guides. So as it is in scuba and flying, so should
it be in all of life.
>Do you think it ever appropriate for a physician to prescribe
>stimulants for ADHD??
Sure. Call it what you like so long as you don't fool yourself that you know
more about it than you do.
>If so, how do you determine appropriateness of such action.
By outcome, of course.
>It matters little whether you call it disease or
>syndrome.
Not if you're interested in humanism or happiness, which means often
symptomatic or palliative treatment (see sex therapy ;)). However, it is
necessary to differentiate disease from syndrome if you want to do any
science. They are different THINGS, and the words were invented because we
needed them to describe two different things. So don't mess with them.
>What is important is the appropriate treatment
>to maximize benefit and minimize suffering.
Absolutely. So let us get on with doing THAT. Divorce it from doctoring,
please. There's an overlap, but happiness is not mere freedom from disease.
Nor does suffering all derive from "disease", as the Buddha could have told
you. So don't try to shoehorn the Problem of Life into medicine.
Psychotropics like alcohol and all the rest are historically just one small
part of the many ways in which people have sought to deal with the problems
of life. Let them get on with it, and get out of their way. License whatever
part of it you must to keep people from dying in large numbers on the
sidewalks and in the gutters, but you do not necessarily need to license it
to doctors of medicine. For my part, I only ask that they all stay off the
freeways.
SBH
--
Steve Harris
From: "Steve Harris" <SBHarris123@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Dexedrine and feeling drained
Date: Sun, 15 Apr 2001 16:57:38 -0600
"CBI" <replytothegroup@spamblock.nospam> wrote in message
news:9bcdrr$3b0$1@slb5.atl.mindspring.net...
> There you go mixing your arguments again. You move freely
> (schizophrenically?) between saying ADD does not exist and that we
>should do away with prescriptions. If you wish to push the matter of the
>former I suggest you come up with new rhetoric and provide
>documentation (which has again become lacking BTW).
Come now. Onus of proving a thing exists is on the positive claimant.
>If you wish to discuss the latter I suggest you start a new thread
>and, again, try to find some documentation to support your thought
>that society would be better off with drugs unregulated. In the mean
>time do us all a favor. Try to decide for yourself just what your
>point is before posting again.
Comment:
The message you're replying to wasn't posted to you, but rather in response
to comments of Paul. The fact that it happens to have been posted in a
thread you contribute to, does not mean that it necessarily must live up to
whatever standards you think arguments must live up to.
Since one man's synthetic reasoning seems to be another man's
"schizophrenic" reasoning, I'll keep this message to one narrow point for
you. I can see you're not exactly a broad-picture kind of a guy. That's
fine; it takes all kinds.
You claim that ADD is not just the tail of a normal bell-distribution curve
in behavior. Okay, show me that curve with the bump in the tail, then. I'm a
reasonable man. Where is it? Who's published this notable drawing? And I
further want evidence that the area under this abnormal bump-the one I'd
notice and draw a line around if you showed me the graph naively-- is
approximately the incidence of the disease that we now use to justify the
present prescribing practices of Ritalin.
Now, before you go off, I have a couple of further requests to make. First,
as we all know, there's no well-accepted objective test for either attention
deficit or hyperactivity. Proposed tests come and they go, and historically
none have been very repeatable, so far as I can tell, which is one reason
why there isn't a quantitative test in the DSM. But I haven't gone through
the entire literature-all I know is what the reviews tell me on that point,
and that's what the reviews say. You come up with a good candidate. I'll
take any test in which 3 independent groups have found more or less the same
results. This is not a high standard- I can get you a dozen such references
for (say) the Hamilton Depression Scale, so you should have no trouble in
coming up with just 3, if you're talking about a truly repeatable finding.
Second, I'd like the bump in the bell curve to be found in the same series
that finds the bell curve. That is, I'd like to see a nice random sample of
kids tested, and see the abnormals emerge clearly from it. Finally, I'd like
to see that happen naturally and objectively, not because some rater who
believes a priori he or she is going to find 5% abnormals, tests some group
and (Lo!) finds that 5 of 100 are abnormal. If this is a real thing,. we
ought to be able to have some fairly blinded and mechanical assessment of
activity or attention which is done by somebody who isn't interested in the
results, and THEN show that that the group of abnormals is STILL apparent
and obvious only afterwards, when the raw data is reduced to that
all-important bell curve graph.
Now this, too, is not an unreasonable request for the kind of thing you've
claimed ADD is. Blinded assessment is the essence of science, and if you don
't have it, you have Feynman's Cargo Cult Science. It's pretty much possible
to do the kind of thing I'm talking about with a great many undoubted
pathologies in medicine. If I make a graph of the FEV spirometry data from
of 1000 randomly selected people, for example, then Hilda the cleaning lady
can point to the funny asymmetrical bump at one end, where the people with
active asthma and COPD pile up. There is no corresponding bump at the other
end of the curve, for extra good lungs. If I do the same for the Hamilton or
Beck depression assessment on a normal population, and have the test
administered by anybody at all (even self-administered), then again I can
graph the results and Whiled the cleaning lady can show me that at one end
there are clearly an extra bunch of people reporting quite a lot of
distress. THAT end of the curve doesn't look at all like the other end,
where the happy-happy well-satisfied people reside, but not in a pile.
Okay, so let's see this for ADD or ADHD. You come up with it, and I'll be
impressed. Fair enough? Otherwise, when you tell me that ADD is NOT just the
end of the bell curve, I'll continue to say: `Oh yeah? How would the world
be different if it were?' I assume if it were, we'd have something rather
as we do with `obesity,' where there is a bell curve and there are people
running around trying to label one chunky end of it as a `disease' anyway,
and people at that end who are being labeled are either happy or unhappy
about being given a `disease.' But who, in any case, have a good argument to
make that this is `glass is half-full vs. half-empty' situation, and that it
's not exactly a clear thing right now how much weight is too much.
Finally, let me add a comment. I'm asking for this ADD bump data only since
you seem to think it exists, and have claimed it. I'm not asking for it
because I necessarily feel that ALL pathological conditions must have a bump
in the bell curve tail. Sometimes we do see lots of pathology in populations
where the entire curve is shifted over (cholesterol and blood pressure and
fasting blood sugar come to mind), and the damage done by the conditions
happen well within `normal' limits for the `abnormal' population (ie,
Finland where the average cholesterol level is 250) . It's not a sine qua
non for a disease to show that bump. However, when it doesn't, the standards
for what we define medically as a `disease' necessarily become quite a lot
higher. In the US, for example, supposedly more people are obese than not,
so it's normal to be diseased if you want this to be a disease. Hmmm. Maybe,
maybe not. The problem with you being modestly `overweight' but otherwise
completely healthy, however, is that I the doctor can't point to any
randomized studies, which prove that if you lose the extra weight, you'll
live longer. Let alone be happier. There's the rub.
To put it shortly, if you want to define a disease out in a normal-looking
bell curve tail, you have to show BOTH that it's associated with some
clearly nasty outcome AND ALSO that changing the variable changes the
associated bad outcome. You may know the history of the great medical
debates over whether or not a systolic pressure of 150 Torr or an LDL of 170
mg/dL or a fasting glucose of 135 mg/dL are themselves intrinsically bad for
the average person, and should therefore be called `diseases.' Rather than
mere risk factors (a halfway term for an epidemiological association which
persists dispute all attempts to control for other things and make it go
away), or lowly risk markers (a skeptical term for a possible but not proven
causal variable, for which the statistical controls have not yet been so
thorough). There have been historical knock-down, drag-out fights in
medicine on all these issues, with well-respected researchers fighting to
the bitter end against the concept that mildly elevated cholesterol, sugar,
and blood pressure are intrinsic pathologies and not just non-causal
markers. These folks lost the argument clearly and finally, only when the
very clear randomized INTERVENTION data came in. If they hadn't, these
conditions would STILL not be diseases, even yet.
Since none of this exists for ADD (I think you hinted at it, but you'll
never find that data), the point above is moot. One doesn't absolutely
require a bell-curve bump for a condition to be a recognized pathology.
However, if you don't have such data, then you're in a very intellectually
slippery place where you MUST have other randomized intervention outcome
data to buttress your argument. Otherwise you may end up treating PVDs for
the sake of treating PVDs, and killing people with anti-arrhythmic drugs (a
well-known black eye for medicine, which dates from an era when fewer people
paid attention to the sort of arguments I'm making here). This very kind of
randomized treatment outcome data that in ADD we don't have. So you're out
of luck there, also. In other words, I want to make it clear that I'm not
arguing with the standard way in which medicine conservatively defines
`diseases' which are to be treated with powerful drugs. Which definition
requires that the term have something useful to imply about either prognosis
or treatability (if there is a bell curve bump), or BOTH (in the case there
ISN'T a bump).
I simply don't think ADD has met those standards. Many mental diseases
(depression, schizophrenia) have. A lot of the stuff in the DSM
unfortunately has not, and that's why the APA keeps getting embarrassed
about having once tried to define things like `self-defeating personality
disorder' and `homosexual orientation disorder.' Medicine has a long and
ridiculous history of doing that kind of thing. People once went to prison
for homosexual acts and were forced to be treated medically with sex
hormones (mathematician Alan Turing, for example). That's pathological
medicine (Turing killed himself). And (to use another infamous example) did
you know that not that long ago, doctors actually once thought masturbation
was unhealthy and led to pathologies? It wasn't a joke-most respected
doctors actually thought this. People died of masturbation, inasmuch as
doctors wrote it on death certificates as the underlying cause of disease,
rather as we do with smoking today. All that was happening about the turn of
the century, at just about the time you say what we now called ADD was first
noticed. Well, just `noticing' doesn't count much by itself, is my point.
We notice things for years that then go away, or become something we don't
any longer try to change, like being left-handed. We `see' what we (think)
we know, and we need to be skeptical about what it is that we think we know.
Now over to you, to present your best papers. I've I'm going to have to go
to the library and pull them, keep it down to a couple, please.
SBH
From: "Steve Harris" <SBHarris123@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Dexedrine and feeling drained
Date: Sun, 15 Apr 2001 18:38:00 -0600
"Steve Harris" <SBHarris123@ix.netcom.com> wrote in message
news:9bd92e$p27$1@slb1.atl.mindspring.net...
[Yada snip]
And by the way CBI, please make sure that your studies of nonhyperactive ADD
as opposed to the hyperactive ADHD control for comorbidities that are
already known to affect concentration ability. We all know that depressed
kids don't pay attention. Heck, kids with pneumonia don't pay
attention--that does not mean that antibiotics are a specific treatment for
AHDH. I have the same comment regarding tricyclics.
If you're not going to talk about hyperactivity per se, there are a lot of
things to control for. Why is this kid not paying attention? Depression?
Lack of intelligence? A learning disorder? Hormone rage? Plain old
adolescent rage rage?
And finally, dispite my protest that the burden of proof about existence of
a "bell-curve blip" disease being upon you, I cannot resist posting the
following negative report. Funny that Down Under they don't see things the
same way you do. Could it be due to being upside down all the time? What do
you think, Mr. Science?
J Am Acad Child Adolesc Psychiatry 1997 Jun;36(6):737-44
Attention-deficit hyperactivity disorder: a category or a continuum? Genetic
analysis of a large-scale twin study.
Levy F, Hay DA, McStephen M, Wood C, Waldman I
Department of Psychiatry, University of New South Wales, Australia.
f-levy@unsw.edu.au
OBJECTIVE: To investigate heritability and continuum versus categorical
approaches to attention-deficit hyperactivity disorder (ADHD), using a
large-scale twin sample. METHOD: A cohort of 1,938 families with twins and
siblings aged 4 to 12 years, recruited from the Australian National Health
and Medical Research Council Twin Registry, was assessed for ADHD using a
DSM-III-R-based maternal rating scale. Probandwise concordance rates and
correlations in monozygotic and dizygotic twins and siblings were
calculated, and heritability was examined using the De Fries and Fulker
regression technique. RESULTS: There was a narrow (additive) heritability of
0.75 to 0.91 which was robust across familial relationships (twin, sibling,
and twin-sibling) and across definitions of ADHD as part of a continuum or
as a disorder with various symptom cutoffs. There was no evidence for
nonadditive genetic variation or for shared family environmental effects.
CONCLUSIONS: These findings suggest
that ADHD is best viewed as the extreme of a behavior that varies
genetically throughout the entire population rather than as a disorder with
discrete determinants. This has implications for the classification of ADHD
and for the identification of genes for this behavior, as well as
implications for diagnosis
and treatment.
Publication Types:
Twin study
PMID: 9183127
From: "Steve Harris" <SBHarris123@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Dexedrine and feeling drained
Date: Sun, 15 Apr 2001 14:12:46 -0600
"Happy Dog" <happydog@sympatico.ca> wrote in message
news:KrlC6.579740$Pm2.9437320@news20.bellglobal.com...
> "Steve Harris" <SBHarris123@ix.netcom.com>
> > >Well, there is evidence that giving speed to some people makes >them
> > >feel like they can accomplish things that require >concentration that
> > >they previously found near impossible. Does >this not make it a
> > >treatable mental disorder?
>
> > Answer: Sure, Charley.
>
> That's "Charly".
Wups duh. Of course, dr nemur. that was stoopid since speling it charly is
the point huh.
> > If there's an Algernon Pill that makes you twice as
> > smart as you ARE, then when it wears off you'll definitely feel as though
> > you have a *disease* when you go back to being as dumb as you WERE.
>
> No such drug currently exists. And we weren't discussing intellectual HP.
> But, when one is created, stupidity will be called a disease, I guess.
Actually, caffeine, nicotine, sympathomimetics, ginkgo, vinpocitine,
piracetam, and a whole raft of related "smart pills" can be fairly said to
increase your mental horsepower, unless you happen to be endowed by nature
with an very unusual amount of energy, memory, and ability to focus and
concentrate on a problem at will (as of course a few people are-- that is
part of what makes for "genius"-- see Edison, Einstein, etc). You can take
some of these things and think for 12 hours as clearly and effectively as
you ever have in your life.
Alas, they wear off, and after that you feel like crap. And if you take any
of them every day or even every other day, your brain adapts (in some people
faster than in others). So it's not at all clear if any of them make you
smarter over time, integrated over weeks or months or years. Some of them
are quite useful if you suddenly have to be smart and alert NOW, however.
The way brain norepinephrine acetylcholine work for you normally, but with a
vengeance. Military pilots have long carried dexedrine for emergencies and
combat, and that's probably a good use for the stuff. And of course, you
can see why stage performers, who have to be at their best on a set
schedule, get sucked into cocaine use. We hear about the ones who go on to
use this stuff all the time and get habituated and dependent, but there are
many others who don't, I'm sure. And there are (particularly among the
latter) people known as "chippers" who seem to have quite a resistance to
having their brains adapt to the effects of opiates, stimulants, and
anxiolytics. If we knew what made these people different, we might be able
to re-do it artificially, and that would make use of all psychomimetics much
less problematic.
Steve Harris
From: "Steve Harris" <SBHarris123@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Review of Imaging in ADHD (Re: Dexedrine and feeling drained)
Date: Sun, 15 Apr 2001 19:07:53 -0600
"CBI" <replytothegroup@spamblock.nospam> wrote in message
news:9bcfmd$7tk$1@slb7.atl.mindspring.net...
>
>
> "Steve Harris" <SBHarris123@ix.netcom.com> wrote in message
> news:9bb4f0$j3e$1@slb3.atl.mindspring.net...
> > If the followups
> > contradict the intitial conclusions, the readers will particularly
> > want to see *them.* Alas, if an author finds things which contradict
> > an initial study (the glucose brain metabolism- ADD connection being a
> > prime example) will certainly not want to submit that to the same
> > journal the first article went to. And if he or she did, the journal
> > might well not want to publish it, for obvious reasons. So it rarely
> > happens. I hope I do not shock you by suggesting that the NEJM does
> > not like to publish articles showing that articles published earlier
> > by it contain results that are not repeatable. So where to publish
> > conflicting data is a game played by both authors and journals, and
> > "gamesmanship" is quite an appropriate word for it.
> That having been said, how do you know the authors didn't submit the
> followup to the same journal? If you do not, would you admit that
> accusing them of gamesmanship was unfounded?
Sure. You want me to call them and see? You want to make a bet before I do?
You know you'll almost certainly lose. "Dr. Zametkin, did you submit your
later papers finding no glucose uptake differences in AHDH to the NEJM? No?
Why not?" Ability to make predictions is how we tell if our theories are any
good. Do you predict Zametkin submitted the the NEJM when he couldn't repeat
his results printed there in 1990? What say you?
> To say that publishing in a different journal is gamesmanship implies
>that something irregular has been done and further implies duplicitous
>motives.
You need to get out your dictionary.
> The logical extension is that followups should be printed in the same
> journal as the original. All of this is hogwash.
No, that's not hogwash. There are good reasons why followups should be
submitted to the same journal, especially if they end up modifying or
contradicting previous results. Yes, I think that's hardly ever done. Yes, I
think that this is partly due to embarassment. I don't think it's really
duplicitous, since it's all on medline. But even so, we don't like to rub
our own noses in our own dyscordant data too often, do we?
>Basically, you have only weak arguments so you bolster your claims with
>insubstantiated accusations. Now when challenged you are trying to back
>down.
I'm not backing down. I told you my guess what what Zametkin did and why. If
you want to push this, we can call Zametkin and ASK him what he did and why.
I think it would be interesting if you'd make your predictions and place
your bet beforehand, since you seem to be so outraged at my guesses at acts
and motives.
Do you think he submitted the later papers to NEJM? If not, why you you
think he didn't? If he didn't think they'd be published, why do you think he
would think so? Isn't it just as important a piece of news if the brains are
the same on scan when we thought they weren't, as the news that they weren't
in the first place? Particularly if the latter is more *correct*? Please
consider that last word.
>>If there's an article which claims a brain scanning difference between
>>ADD and normals, that's medical news and it goes in the most
>>prestigious journal, the NEJM. If later studies find no such thing,
>>how come that's NOT news?
> Ask the journals and the news agencies. I think it has to do with public
> interest.
Aha. So you are saying that the scientific journals serve their readers
interests, rather than the interests of truth. If a correction isn't
interesting, don't print it? This does begin to seem more of a game, don't
you think? It's called "the advertising game."
> > We get cynical about that kind of thing in our tabloids,
> > but should not our best medical journals be different?
>
> Space is limited. They are trying to present articles that reflect the
> interests of the readership. I'm sure the potential for publicity also
>plays a role (that's why they hold press conferences). It would be nice
>if things would be more objective but this does not reflect poorly on
>the authors.
Only the editors, eh? It's a non-objective publicity game, but your claim is
that it's played honestly on one side? One side only? Now why do you think
your claim is better than mine? I think you're arguing that editors are
human and authors aren't. How's that, again?
> notice that you have again (see the other post) tried to shift your
>stance away from the original accusation (in this case whether the
>authors were trying to conceal results by publishing them - previous
>on whether ADD is a legitimate diagnosis) into some broad social
>commentary. Let's try to maintain focus.
I'm focused. If you think that my idea that human nature doesn't differ much
between the people who edit science journals and the people who publish in
them, is "broad social comentary", then you have a pretty broad view of what
things are broad. Gosh, I hope I didn't shock you.
> ????? - You said that the authors were publishing in a different journal to
> obscure conflicting results and called it gamesmanship.
I never said it was to "obscure" conflicting results. However, publishing
somewhere else does tend to draw less attention to them. Is that the same
thing?
> I questioned whether
> this could be taken as showing dishonest intent on the part of the
>authors (which hiding results would be).
Nothing which is published is hidden. But it may be harder to find.
>You now are trying to simultaneously blame
> it on society, medicine, and the journals while also denying what you
>said in the first place,
Find where I used the word "obscure" If you're going to accuse me of denying
saying what I said, then you'd darn well better get it right.
As for simultaneously blaming society, medicine and the journals, I do. I
think your answer was that it's entirely the problem of society and
journals, and only the part of medicine which doesn't have to do with
authors. Right? Everybody BUT the authors?
> saying that you were not wrong when you said it, and
> concluding that I am at fault for putting forth the very notion that you
>now argue. Are you nuts?
No. Are you?
SBH
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Dexedrine and feeling drained
Date: Mon, 16 Apr 2001 16:53:11 -0700
CBI wrote in message <9bab0p$jin$1@slb5.atl.mindspring.net>...
>When did knowledge of the pathology become prerequisite to terming something
>a disease? Malaria was certainly a disease even when presumed to be the
>result of bad air (mal -air).
Was it? Or was it a number of diseases all lumped into the same
syndrome, like infectious hepatitis?
Was typhus a disease? Was typhoid? Were they one disease
or two diseases?
> Psychosis, migraines, asthma/allergy/atopy,
>most back pain, and complex regional pain syndromes (formerly RSD) are all
>examples of things generally considered to be true entities worthy of
>treatment in search of a causitory explanation.
They're as worthy of treatment as any complaint; causation is
a separate but connected issue to treatment. I never said that
knowledge of pathology is necesssary for treatment, but it modifies the
treatment advice you give greatly. The guy with low back pain gets
treated differently if it's from a prostate met vs Pott's disease
vs. the guy with the bulging disc and nerve damage vs
the guy in whom you can't find a cause. But the pain and even
the entire syndrome may be just the same in all these guys.
Still, they won't take any but the first guy into hospice,
and you the doctor are going to have various legal
problems of various degrees using morphine or other
narcotics on all those guys that they don't. It's
hard enough to treat any kind of chronic pain
without having the state looking over your shoulder.
However, application of such knowledge of mechanisms
as you have must be key to how you approach medical problems
(at least in the long term). If you dont' know the mechanism, that
needs to go into your thinking also. Back pain is not a disease.
>I believe that your distinction between a disease and a
>syndrome is largely
>semantic and of only slight practical importance.
Well, you believe wrong. These are central and pivotal concepts in
the practice of medicine.
>Certainly, the clinician
>in the presence of a child who is failing in school cares little for the
>term you apply, only what help can be afforded.
Then why bother to make up a new term? If Billy cannot pay
attention to his teachers or his homework, but pays
great attention to his Nintendo, why not just say: "How
about if we see if this pill or this set of exercises will help
Billy pay attention to stuff you want him to? If he can't
pay attention to anything, then we have
a good word for this already: "delirium." "Billy is delirious, and
let us see if we can find out what is wrong with him." "Billy
is delerious but we can't figure out why. We'd like to
treat him symptomatically."
>If you wish to label ADD a
>syndrome rather than a disease I should think it matters not, as long as
>you would recognize the validity of the diagnosis and the appropriateness
>of treatment, pharmacologic and otherwise.
In absense of knowledge of pathology, the "validity" of the diagnosis
only applies to its special utility in prognosis or treatment. Wastebasket
diagnoses are not very useful, as a rule. "Well, granny is delerious at
least and may be getting demented, and there's not much we can
do. Maybe this here Ritalin will help." I've actually seen that done.
But a new disease for Granny so we can get past the scrutiny
of the DEA? That's silly.
>I do not find your "Olympic allusions" to be apt as life is not designed as
>a competition to be played on a level field, as even sport only pretends to
>be.
Er, dont' look now, but I think you're about to argue exactly that.
>If a subset of demonstrably abnormal people function significantly
>better while responsibly consuming a stimulant I fail to see the virtue in
>withholding it.
I fail to see the virtue in withholding it from anybody. The only
folks who want to withhold this stuff from "normals" (use your pet
definition) are people who really DO want to level the playing field
of life. Ala Harrison Bergeron, if you know that Vonnegut story.
>Your concept of intellectual Darwinism could be applied to
>almost all of medicine (not to mention coffee).
Now, you're getting it. Though it tickles me to hear somebody
who allegedly carries the title of professor use the
term "intellectual Darwinism" as though it was a dirty one.
Methinks you need to be displaced from your job position
by somebody who has been intellectually marginalized due
to being, well, intellectually marginal. That is, if that's not how
you got the position already. Which I'm still striving to decide.
>You reject it when applied
>to the rest of your "cures" (rarely truly cures but rather temporization
>measures) because we have long ago recognized that civilized societies do
>not marginalize the disadvantaged even if it would result in the breeding of
>a stronger species.
Whenever I hear the terms marginalize and disadvantaged in the same
sentence, I want to reach for the Liberal Bug Spray. Though I confess
I cannot for the life of me figure out what you meant in the above
sentence. No doubt the sentiment was politically correct-- I can tell
that from the music. Want to try again? I'm for letting anybody try
whatever they want, so long as it's not so dangerous that it leaves
bodies in the streets. Or, at least, more bodies than alcohol does.
>Comorbidity does not offer proof that a diagnosis is not a valid entity as
>is illustrated by the associations between asthma, aspirin sensitivity, and
>nasal polyps; syndrome X; and differing autoimmune diseases.
It's when the comorbility begins to statistically explain the entire thing
that I worry.
>I suspect that you are correct that ADD likely represents a variety of
>related pathologies, a point I raised when discussing the discordant
>imaging data. For the record, I have never cited the DSM as proof of
>anything (nor have I thumped it).
Well, you did bring up the authority of the APA. Doesn't that count? The
only reason I'm sure you're a real doctor is that you didn't mention the
authority of the AMA. Or did you? Hmmm.
>I have never held that medication is the cure or the only worthwhile
>therapy. To the contrary, a combined approach is usually best although some
>benefit primarily or fully from one or the other. Your reference to "paying
>the price" is unfounded as there is no evidence of later difficulty as a
>result of consuming stimulants in appropriate doses.
There isn't? Why then, would you like to write me a prescription? I'll keep
to well below the median dose of (what is it?) 30 mg a day or so
of Ritalin. Promise. If there's no evidence of later difficulty in my
life as the result of using speed, then I think I'd like to. Objections?
>The opposite is true.
>There is evidence that medication reduces the incidence of later drug
>abuse.*
Not to mention paraphilia. Like I said, Ritalin appears to be the best
thing since sliced bread. What do you say? I'll write you a triplicate if
you write me one.
SBH
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Dexedrine and feeling drained
Date: Tue, 17 Apr 2001 17:42:22 -0700
CBI wrote in message <9bieq1$ifn$1@slb3.atl.mindspring.net>...
>I never claimed to be a professor.
>
>--
>CBI, MD
>I am published but hardly a distinguished, nevermind famous, professor.
Well, I can't be blamed for misinterpreting that sentence. Okay, what are
you?
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Dexedrine and feeling drained
Date: Mon, 16 Apr 2001 12:40:29 -0700
CBI wrote in message <9bdh75$ou7$1@slb2.atl.mindspring.net>...
>"Steve Harris" <SBHarris123@ix.netcom.com> wrote in message
>> Come now. Onus of proving a thing exists is on the positive claimant.
>>
>If one suggests something novel then the onus is on that person to
>demonstrate its validity. If one questions accepted practice then the onus
>is on that person to demonstrate the common error.
Oh, not really. Or rather, it depends on the circumstances. If I were
writing in a journal there would be different standards for how many
references I'd have to have. And I'm sure that in this climate, I'd have
a hard time getting published anywhere with a paper that said that
basically "attention deficit" is just another word for "delerium" and that
making up a "delerium disorder" for pediatrics is hardly any more
useful than it is in geriatrics.
I think I've more than done my duty to counter such claims here.
I've given you my reasons why I don't think "attension deficit" is
a useful idea when it comes to a "disease" or anything like
a disease or disorder. You don't get to think muzzily in medicine
just by calling something a disorder. A shortness-of-breath disorder
would be stupid and nonuseful. Likewise a weak-and-dizzy disorder
or a chronic stress disorder. It's a waste of language which is
meant to be more powerful and precise and to imply more in
medicine. I fine it inaesthetic. I can find no scientific reason
to employ it.
I'll be glad to address any positive evidence you have. I've actually
posted one study suggesting that ADHD using many proposed
definitions all comes out looking like merely a spectrum of many
genetic tendencies, like tallness. So my contention is that
short stature disorder, long nose, and various other things of
this type are debasing to the normal medical language,
and they pollute it.
It isn't as though I haven't read the reviews. I have. I'm
not impressed.
>"Steve Harris" <sbharris@ix.netcom.com> wrote in message
>news:9b5jls$d13$2@slb0.atl.mindspring.net...
>>
>> If you think you know more medicine than I do, bub, here's your golden
>> chance to teach me. Don't forget the literature cites.
>>
>> I think this will be a lot of fun. But I think on this one you'll wimp
>> out long before I have the pleasure of rubbing your nose in this
>> properly.
>>
>
>And you have been forgetting them ever since.
I've posted more references that you have in this debate.
I suggest you get cracking. You're looking worse than
you think you are.
>Go ahead and prove that the rest of us (AMA, NIH, AAP, APA, etc.) are
>mistaken.
A poor Argument from Authority. They've all been wrong before, and they
all will be wrong again. Evidence is all that matters in science.
> I would request that if you impose a standard such as requirements
>for a bell curve, demonstration of pathology, magnitude of the adversity of
>outcome, or treatment response you have the double burden of showing it
>is a valid prerequisite for disease status and that ADD does not satisfy
>it.
What does or does not constitute a disease is something of an
aesthetic and semantic debate. It's not something you can fix by
running to the library. I can, however, point out the problems in
calling ADD a "disease" and have been doing so.
>Now go ahead and run to the library.
>CBI, MD
You first.
SBH
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Dexedrine and feeling drained
Date: Mon, 16 Apr 2001 13:53:43 -0700
CBI wrote in message <9bcdrr$3b0$1@slb5.atl.mindspring.net>...
>"Steve Harris" <SBHarris123@ix.netcom.com> wrote in message
>news:9bbk9r$jgr$1@slb1.atl.mindspring.net...
>> "Paul" <paul@xhawaii.rr.com> wrote in message
>> news:q6qhdtor1ilpot35gb80u2ag99a9j0o5nk@4ax.com...
>>
>>
>> >>It's not that I'm completely against amphetamines. I'm not >>completely
>> against any drug. It's only hypocrisy that I cannot
>> >>abide.
>>
>> >But you are also saying (or at least strongly suggesting) that
>> >you don't think that it is appropriate for physician's to use
>> >their clinical judgment and decide to use amphetamines to treat >ADHD
>> suggesting that to do so is akin to playing God.
>>
>>
>> COMMENT:
>> Not quite. For physicians to decide that an entire psychotropic drug
>> class is appropriate for a particular class of children, which one must
>> formally label as having a "disease" before they are allowed to try the
>> drug, is what's akin to playing God.
>
>See Steve, this is what I mean when I say you don't understand.
>
>Who does the above? Nobody has said that stimulants are beneficial for all
>kids with ADD and nobody has said that ADD is the only indication for
>stimulants. This assumption of yours that a diagnosis of ADD mandates any
>particular therapy (only about 75% of ADD kids respond to stimulants, less
>with adults) and that you must have ADD to be given stimulants (they are
>used for other diagnoses in both adults and kids) is just plain wrong and
>seems to form the basis for you flawed point of view.
Again, you're not reading what I'm writing. You must label children as
having a disease before you give them C-II sympathomimetics (the
drug class I meant.) No, the disease doesn't necessarily have to be
ADHD; never said so. The point is, you have to label them as having some
disease.
I'm certainly aware that shrinks use Ritalin for all kinds of things.
I know of a pilot study when Ritalin and SSRIs were used on people
with paraphilia. It keeps them from masturbating while looking a
pictures of child porn. Who'd a thunk it. Ritalin is almost the
greatest thing to hit psychiatry since SSRIs and benzodiazepines. It
works on practically everything they don't work on, and some that they
do. And if not, it gives you nasty side effects that you can look good
for stopping when you stop it. What a deal. I've gotten many a patient
of mine back from the psych guy on speed and had to deal with all
kinds of problems. And I've had a few adults who did spectacularly
better on it. It's certainly not a placebo and it's certainly
powerful medicine. A great drug if you want to make money, that's for
sure.
>Stimulants and ADD are not the only place where we "play God." It is what
>doctors do all day.
Not unless we want the cops and prisons to back us up. Otherwise, the
patients get to chose, and that's not playing god.
>We evaluate the symptoms and decide if prescribing
>certain drug are appropriate as well as maing other recommendations. It is
>not playing God, it is practicing medicine.
Yep. Until the use of force is involved. And when people break the law
unless YOU give them permission, and become subject to getting
their lives ruined by the legal system, that its something else entirely.
I don't know what it is, but it's not really medicine.
>> And of course, it's not only physicians, but
>> also their societies who practice this bit of nonsense. The body is so
>> complex that there's generally no way to tell whether or not a given drug
>> will be "good" for a given person, except to experiment with it. You know
>> that.
>>
>
>Of course this is true. Tell me who you think is doing otherwise.
Everyone who requires that somebody have a diagnosis of a disease
before they can try a drug. Of course.
>> That's honest. Whole-scale prohibition because of what MIGHT happen is
>> dishonest. The doctor pretending to know who's going to be come
>> alcohol-dependent, is dishonest. As would be doctors writing
>> prescriptions for wine with the presumption that by this means we could
>> keep people from ever becoming winos (doubtless we'd only dispense to
>> people who had post-work or cocktail-party unwinding disorder). But no,
>> we have had the wisdom (circa 1930) to see that it doesn't work that
>> way. Can't. Doesn't. Shouldn't. The situation with other drugs is
>> something we haven't come to grips with. But must.
>>
>
>Are you suggesting that amphetamines should be over the counter?
Perhaps sold in state stores, as is liquor in Utah, in order to keep
it out of the hands of minors without their parents involvement.
Selling alcohol in separate carefully controlled private stores of
sections of stores (which must have a different entrance) is done in
many states. Alaska, for example. I probably would like to see
powerful drugs kept slightly better track of then they do alcohol in
(say) California. Cigarettes may be a better model.
>> There are a number of separate issues, here, ....<rest snipped>
>
>You seem to be saying that all drugs should be over the counter and doctors
>have no place in regulating use. I disagree. We tries that a one time. It
>was a social experiment that lead to immediate high level antibiotic
>resistance
Antibiotics are a separate issue, rather like pollution. They are a public
health hazard in a far more direct way than most psychotropics. You can
get drunk in your living room and it doesn't affect me as much as if you
breed rats in your back yard, or breed antibiotic-resistant bugs in your
kids and send them to school with mine.
In my ideal world, we'd actually regulate antibiotics as we do
psychotropics, and regulate psychotropics as we do cigarettes.
> wide spread opium abuse, and huxterism run wild. The FDA and
>presciption regulations were created in response to this problem, not
>because of some theoretical fear of it.
The FDA was created for many reasons, most of them having to do
with food, not drug problems (The Upton Sinclair book, etc). The FDA
narcotic crackdown didn't happen all at once, and has parallelled the
spread of IV drug abuse, which in turn happened mostly as an
inner city problem. Had it been a while middle class problem at that
time, we'd never have seen it. Also, please remember that the FDA was
created at roughly the same time we were trying to eliminate all
psychotropic drug use. But alcohol prohibition didn't work. The FDA
prohibition for other drugs stayed because it couldn't get majority
support for repealing other drug laws at the time prohibition ended
for alchohol. But that's simply a matter of bigotry. Different cultures
like different drugs. The majority likes to legalize its pleasures, and
outlaw those of minorities cultures. In the old west, opium smoking
was illegal because the Chinese did it, but laudanum drinking wasn't
because the whites did it. It's a defect of democracy, don't you know.
We've only partly compensated with the idea of privacy rights, but
somehow have failed to figure out that what drug you take is just
as personal a decission as who you sleep with and whether or not
you can buy a condom to do it with.
>In any event we digress. The point I had originally objected to was your
>rejection of ADD as a diagnosis, apparently due to lack of an objective
>test.
Yep. And for other reasons, already stated.
>> I'm afraid I've been misunderstood here, somewhat. There are no
>> objective tests for ADD. I suspect but cannot prove that it is a
>> pseudo-disease, invented more or less subconsciously by people who
>> don't like how their kids behave, and who have no other way of thinking
>> about it if they are to get hold of the chemicals that may (or may not,
>> depending on the kid) modify that unwanted behavior.
>
>Ah back the original contention. You are wrong. Still first described what
>we now call ADD in the Lancet in 1902.
Oh, come now. That was in the days of masturbation disease. I'm sure
doctors noticed a lot of things we still want to give names to today, but
none of that means much. It's like saying that somebody or other first
noticed homosexuality and left handedness long ago, so it must be
a disease.
The condition that we're all druging our kids for, is not necessarily
the rare whatever that somebody described in 1902. In 1902, the
hysteria was lacking.
>At that time stimulants were freely
>available.
But not used on this! And amphetamines were not invented.
Don't be disingenuous.
>> Behavior modification in humans is a
>> necessary thing, but not everybody who needs behavior mod needs to be
>> labeled as having a "disease." Do they?
>
>Of course not. Some people just have maladaptive behaviours. In the case of
>ADD it is not just a case of bad behavior, a notion rejected in the 1960's
>(as reflected in - note: not proven by - the DSM II in 1968). I can see
>mistaking hyperactive behavior as merely a behavioral problem as, indeed,
>it usually is. The diagnosis of ADD requires much more than this and is
>reflected in other spheres of functioning. Sure, we all have trouble
>paying attention to some things that we fnd boring but to not be able to
>focus even on the things we do have an interest in is just abnormal (and
>not by itself sufficient for the diagnsosis).
But ADHD kids (as somebody pointed out) are supposed to be able
to concentrate in the things that interest them. That's one of debates.
What, you want it both ways?
>When you test kids with scales such as Connor's and others it can be seen
>that there is a "blip" at the extreme and and not just the continuation
>of a smooth normal curve. These kids are different and not just
>behaviorally challenged.
You're supposed to be gathering this reference for me. I say baloney.
>>(what disease for your mother-in-law?) My argument is that, in the
>>absence of objective pathological tests, the "disease" model is as poor
>>a way to handle kids who won't sit still in class, as it is of handling
>>kids who want to scuba dive in the ocean at night, or ski though the
>>trees.
>
>We have been through this. You will be throwing out a lot more than
>psychiatric diagnoses if you insist on an understanding of pathology.
Yes, we would! And we'd be creating a lot more if we insisted that
the operational definition of a "disease" is something not operating
well in his society. That would give every person in prison a
psychiatric disease, just for starters. Now, you may agree that
every (guilty) person in prison DOES have a mental disease. But
considering that these people need primarily medical help would
certain turn your society upside down, would it not?
I'm merely asking you to apply the same standards in several spheres
and stop the cognative dysnonance. I'm sure it's hard for you.
But USENET helps people open their minds, does it not?
> I would say you might have to discard all of medicine if you hold a
>sufficiently high standard for this understanding as there is know disease
>known completely.
But I didn't demand complete understanding, did I? Just something
a little better than a distressing syndrome which looks like the tail of
a bell curve. Like having too long a nose.
>I don't see why all areas should be regulated in an identicle manner.
Fairness and intellectual honesty?
> Laws
>are usually passed to address a newly noted concerns. Yes, this leads to a
>somewhat happenstance patchwork of regulations that are not consistent and
>sometimes conflicting. Come up with a better system and you will have my
>vote.
I did and you haven't been very enthusiastic.
>We did try to outlaw alcohol as it has no specific medical use.
Yep.
>The social experiment failed.
And what did you learn from that?
>The reason that SCUBA is not regulated is because
>the lack of regulations has not been seen as a cause for concern by the
>public and lawmakers, partially because they do pretty well policing
>themselves.
And what do you learn from that?
>Why do you make it sound like psychotropic drugs are the only ones
>regulated?
They aren't off course, but they are the ones with the harshest penalties.
>If you wish to argue that we should do away witht he FDA and make
>all drugs OTC then start a new thread and do so.
I prefer not to, since these issues are bound together in a way
which may not be obvious to you, but I think will be to most
people reading this thread.
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Dexedrine and feeling drained
Date: Mon, 16 Apr 2001 15:21:27 -0700
CBI wrote in message <9bcdrr$3b0$1@slb5.atl.mindspring.net>...
>> Here's what I think happened historically. We got suckered by some new
>> stuff and we didn't really know what to do about it, so we fudged. We
>> needed somebody to monitor drug use, and physicians were the obvious
>> choice.
>
>Naturally.
>
>
>> And physicians look at the world in terms of disease, and so we made up
>> a couple for the people who wanted to try the new sympathomimetic drugs
>> to see if they helped with the problems of life.
>
>Huh? I don't suppose you have a cite for this.
Oh, it's a little difficult to provide citations one's opinions about other
people's political motives, don't you know. However, we all have them.
You too.
>> And here we are. Ciba-Geigy gave
>> $800,000 to CHADD to sell them on the idea that there was this horrid
>> disease called ADD in the US, and Ritalin was one of the answers.
>
>Um, CHADD was organised by people who had children with ADD already. If
>Ciba had to concince them that there was a disease called ADD what do you
>think the ADD in CHADD stands for?
Sorry, that was badly written. No, of course the money went to promote
and popularize the disease, not invent it. Effect was the same.
>> Prescriptions thereafter exploded as people found out that Ritalin is a
>> powerful and not too dangerous stimulant (not unlike caffeine but
>> more-so and with fewer jitters), so that now at least one boy in 20 out
>> there is on the drug.
>
>The presciptions are soaring for many reasons. Since it has become
>increasingly clear that ADD continues to affect people into older age
>groups they are being kept on it longer. As they grow larger they require
>increased doses.
They require increased doses just from tolerance. The mean time to dose
increase in the blinded studies is a few months, and it keeps going up
the longer they measure it. This is not just growth. Happens too fast.
>Ritalin is also being used for other purposes than kids with ADD.
That's for sure. <g>. "I was booorn a NAMBLA man..."
>In addition, more girls are being treated (the ratio of boys to girls
>dropped from 8:1 to 5:1 during the period 1971-1987). Most of the rise in
>Ritalin is not due to increased new prescriptions (although some
>certainly is).
Your source on that?
>The rate of diagnosis of ADD has doubled every 4-7 years since 1971.
But most of the rise in Ritalin is NOT due to new prescriptions? Think, man.
How likely do you think it is that you can reconcile those two statements?
>Since
>population surveys have cnsistently found that the prevalence has been
>consistent over decades and locations this probably represents improved
>diagnosis and not overdiagnosis.
Population surveys by the same people, you mean. If you're going to argue
that prevalence is consistent between locations you've got reading to do.
Improved diagnosis, my foot. The diagnosis of mental problems comes
and goes in fads like hoola hoops and pet rocks. PTSD went from being
something that a few vets had, to being number two or three most
common mental diagnosis in the country, representing pretty much
anybody who ever had anything bad happen to them and still thinks
about it (or doesn't), but isn't happy now. It's time a few people said that
the emporer has no clothes.
>At least part of this is due to the
>recognition of other symptoms than hyperactivity as being part of the
>disease (especially for girls)
"Recognition?" This is a disease whose prevalence doesn't chance
longitudinally, you said. How are we going to recognize new prevalence
of that which we've long known about? We never knew you could have
just attention deficit without hyperactivity? Oh, I think we knew about it
when we were calling it minimal brain dysfunction. But minimal
brain disfunction doesn't sound nearly as much like a disease.
>and to increased awareness on the part of
>both the public, educators, and doctors. It probably
>needs to double again
>and probably will within the next decade.
I've no doubt of it. We may yet figure out how to get more
people on Ritalin than not. And all paying to see their
doctors once a month to get that piece of paper.
>It is hard to determine if your statement that Ritalin is being prescribed
>for recreational use is more ignorant or insulting. Fortunately it is not
>short in either.
>Glad you enjoyed it.
>Apples and oranges. Your argument becomes more ludicrous by the minute. We
>shouldn't have to have a prescription for Ritalin because we can't get one
>for a prostitute? Drugs shouldn't be regulated becuase SCUBA diving isn't?
>Why should government regulation be all or nothing? Maybe the appropriate
>scheme is one with moderation and carefully targeted subjects.
Sure. I haven't notice any moderation in the war on drugs. Have you?
>You are the one who imagines that ADD is a diagnosis cooked up to justify
>the use of a party drug and calls it knowledge.
Yep. It might be more knowledge than you have.
>The distinction [between syndrome and disease] has some relevance
>for some things and I would not advocate
>dispensing with either term. For the practicing clinician or one discussing
>whether the entity exists at all there is no difference.
ROFL. Remind me not to let you treat my jaundice, anemia, or chest
pain.
The clinician needs to be aware of the spectrum from syndrome to
disease all the time, and at least have some idea of whether or not the
goal of a treatment is merely paliative or actually interventive in
the pathophysiology. This allows you better guesses at what risks
are worth taking, and what advice to give. Perhaps this is a new
thought for you (I think it may be for the local psych guys who
pass out Cytomel to my own unsuspecting patients). But give it a
try, and see what you think of this novel idea.
SBH
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Dexedrine and feeling drained
Date: Tue, 17 Apr 2001 13:54:07 -0700
>SumBuny4Me wrote in message ...
>>
>>
>>"Steve Harris" <sbharris@ix.netcom.com> wrote in message
>>news:9bfrb2$otk$1@slb4.atl.mindspring.net...
>>> >
>>> >Um, CHADD was organised by people who had children with ADD already.
>>> >If Ciba had to concince them that there was a disease called ADD what
>>> >do you think the ADD in CHADD stands for?
>>>
>>> Sorry, that was badly written. No, of course the money went to promote
>>> and popularize the disease, not invent it. Effect was the same.
>>
>>By this logic, then any donations by medical companies to other support
>>groups such as the American Cancer Foundation, the American Heart
>>Association, the American Diabetic Foundation are solely to "promote and
>>popularize the disease" that each of these supports?!?!?!
It's certainly suspect. Example: I got a whole big fancy kit in the
mail not long ago which encouraged me to carefully screen all my
patients to see if they had age-associated forgetfullness. Hmmm,
another disease. Another company doing a public service. Well, no.
They're a company all set let to release an oral acetylcholinesterase
inhibitor, which I take it is not going to be targetted only at the
demented. You wouldn't know that from the literature. Heck, I've only
started to see adds saying the stuff is coming in the NEJM recently.
At the time the marketing campaign was out you had to do a web search
to see what the company was up to. I'm sure that very shortly there
will be a great explosion of people who have this disease.
The complicated screening tool would have taken me about half
an hour per patient. ROFL. Now, what did I do with it...?
Quick, I need a nerve-gas knockoff pill, and then perhaps it will
come to me.
>>> They require increased doses just from tolerance. The mean time to dose
>>> increase in the blinded studies is a few months, and it keeps going up
>>> the longer they measure it. This is not just growth. Happens too fast.
>>> >Ritalin is also being used for other purposes than kids with ADD.
>>>
>>>
>>> That's for sure. <g>. "I was booorn a NAMBLA man..."
>>
>>So narcolepsy is not a valid condition(in *your* opinion) to use ritalin
>>for? And dexedrine was(is?) used as a dieting aide for those who are
>>overweight....
In 1946 some doctor listed 39 conditions it could be used for, from hiccups
to asthma to schizophrenia.
I already said I'm willing to admit that speed can be used on any condition.
At worst it's a good diagnostic, since if you use it wrong, the condition
gets worse. "Golly, I suppose that depression had more
features of aggitation and paranoia than I thought it did. Wow, that ADD
sure was the anxious and obscessive sort.
>> But most of the rise in Ritalin is NOT due to new prescriptions? Think,
>> man. How likely do you think it is that you can reconcile those two
>> statements?
>
>How amny children with ADHD are now adults with ADHD? How many of thes
>adults need higher doses of ritalin than they did as children? How many
>adults with ADHD were undiagnosed as children and are only now receiving
>treatment?
Lots and lots and lots. And lots. And those that doesn't (over 50% of us)
could lose a little weight and god knows we need more pep.
>I don't suppose that *this* could count for the "rise" in ritalin?
Undoubtedly.
>>> Improved diagnosis, my foot. The diagnosis of mental problems comes
>>> and goes in fads like hoola hoops and pet rocks. PTSD went from being
>>> something that a few vets had, to being number two or three most
>>> common mental diagnosis in the country, representing pretty much
>>> anybody who ever had anything bad happen to them and still thinks
>>> about it (or doesn't), but isn't happy now. It's time a few people
>>> said that the emporer has no clothes.
>>
>>By this same logic, the increase in cancer diagnoses is also a "fad".....
In part. Some of those new diagnoses are elderly people who would have
died of something else and never been bothered by their noninfiltrating
intraductal tumor first. So yes, it's a little like the increase in
diagnoses of prostate cancer. Every so often in medicine you run
across stuff you wish you hadn't known about (on autopsies you run
across stuff you're sorry you didn't know about, but also stuff you're glad
you _didn't_ know about.) Same in lots of areas of medicine.
Don't listen to a carotid in a routine physical if you don't want to
hear a bruit (a murmur from a partial blockage).
Of course, there a limit to how hard you can push this analogy. The
increase in breast cancer (some of which I'm sure is real) is still
relatively small when expressed as a % increase over the
previous incidence. Not so for the "mental diseases" we're talking about.
SBH
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Dexedrine and feeling drained
Date: Mon, 16 Apr 2001 11:32:41 -0700
Happy Dog wrote in message ...
>"Steve Harris" <SBHarris123@ix.netcom.com>
>> Actually, caffeine, nicotine, sympathomimetics, ginkgo, vinpocitine,
>> piracetam, and a whole raft of related "smart pills" can be fairly said
>> to increase your mental horsepower
>
>Are some better than others or is the an optimal effect peculiar to each
>person?
It's extremely person-specific.
>> And if you take any of them every day or even every other day, your
>> brain adapts (in some people faster than in others).
>
>Adapts to Ginko?
Can't prove it from a study, but in my own experience, yep.
So take that one anecdotally.
There a lot of nootropic studies out there, BTW, but very
very few showing long term improvements for many of
the drugs which have been seen to cause short term
ones. Is absense of evidence, evidence of absense?
Mildly, in science. Especially when you have a
mechanistic reason to suspect an effect already.
SBH
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Dexedrine and feeling drained
Date: Tue, 17 Apr 2001 12:17:38 -0700
Happy Dog wrote in message ...
>"Steve Harris" <sbharris@ix.netcom.com
>> >> Actually, caffeine, nicotine, sympathomimetics, ginkgo, vinpocitine,
>> >> piracetam, and a whole raft of related "smart pills" can be fairly
>> >> said to increase your mental horsepower
>> >
>> >Are some better than others or is the an optimal effect peculiar to each
>> >person?
>>
>> It's extremely person-specific.
>
>IOW, experiment with drugs. Hard to find an MD that will help you do this
>though.
>arf
Sure. But that's only partly philsophical. Doctors have their professional
licenses on the line, and can't do whatever they like.
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Dexedrine and feeling drained
Date: Tue, 17 Apr 2001 13:45:13 -0700
Happy Dog wrote in message
<0A1D6.684649$JT5.18194640@news20.bellglobal.com>...
>"Steve Harris" <sbharris@ix.netcom.com>
>
>> >IOW, experiment with drugs. Hard to find an MD that will help you do
>> >this though.
>> >
>> > Sure. But that's only partly philsophical. Doctors have their
>> > professional licenses on the line, and can't do whatever they like.
>
>Understood. But we are talking about drugs where subjectivity is
>everything. If one needs a psychoactive drug, wouldn't a "sampler pack",
>within reason, be a good approach?
>erf
I'm trying to think of a good reason why not. Nope, can't think of one.
Wait a sec. Does this mean you don't have to come see me and pay me for
the office time to convince me you have a problem and get me to
write you a prescription? Well, then, I'm against it. ;-9
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Dexedrine and feeling drained
Date: Wed, 18 Apr 2001 12:12:45 -0700
Patrick Riley wrote in message
<83tpdto8gv6s8241hamgfm6gomatg9ndpv@4ax.com>...
>This time I said I was feeling depressed. "How depressed?" he says.
>Well, I actually said I feel depressed when I think of Bill Gates'
>money, so he prescribed Prozac. (The guy will prescribe anything in
>small doses but drew the line when I suggested Ritilan.)
I think Bill Gates Lifestyle Contemplation Dysphoria Disorder will
be coming along in DSM IV. If you've used the software much
you get one of the major disorder components. Melinda's
apparently quite a fine woman, and that only contributes, since
Gates really actually deserves Madonna or Anna
Nichole or something. Put this down as one of the minor
envy/outrage criteria.
>Well, how Prozac got such a great name is beyond me. At 10mg (1st two
>weeks) it does nothing. Zilch. Zero. At 20mg it's like adding a pack a
>day of cigarettes. Fuzzy feeling. Lack of concentration. Constant
>shifting of attention from one subject to another. Teeth grinding.
>Only the latter seems to have any relationship to its supposed illegal
>analog, Extasy. After a week at 20 mg, I'm going to stop. It might be
>useful for someone who wants to give up smoking though, except for the
>lack of concentration which might not occur if I wasn't OD'ing on
>nicotine as well as whatever Prozac contains.
Give it 3-4 months at 10 mg. You might not notice the difference at all, but
perhaps the people you live with will... <g>.
I have often seen what I call the SSRI head shake. It's a side effect
of the drug. The person says "Doc, I don't think this [names SSRI] is
doing a thing for me. Do you think I should quit it? The spouse,
sitting next to them in the office, starts silently shaking head back
and forth like a mule who just ran into a fence post. Of course, these
are marriages where both people are fairly on-spec. In one of those
dysfunctional codependent jobs where handwasher is married to
hand-wringer, nobody likes the SSRIs.
>BTW, when I last had root canal, the dentist prescribed some Emprin
>with Codeine and then, because it didn't alleviate the pain, another
>higher level codeine-containing substance which didn't work either.
>Aspirin and alcohol and sleep were far more effective. Maybe I just
>don't respond well to these drugs.
>
>So I'm about to use up some more of my MD's time and
>prescription-writing hand to see what else is in his pharmaceutical
>box-of-wonders. So far I'm not impressed. Any suggestions?
Try neurontin. Not a controlled substance but has a fairly short
half-life, few interactions, and is a decent sleeping pill for
some people. Get the 300's as you'll never be able to afford
it otherwise. Probably better for you than alcohol or valium.
Ditto for hydoxyzine, though you might get some dry mouth
with that one.
>It might be helpful to describe what I want to achieve
>(realistically--or at least semi-realistically). Note also that this
>is an area where you don't need to see the patient and where there are
>no objective tests.
>
>I'm a worrier, anal-retentive, anxious, lack concentration anyway it's
>just worse with Prozac, lazy, introverted, ... Fix those up without
>killing or injuring me. Maybe a combination of an amphetamine to
>improve concentration and Valium to get me to sleep on time?
>
>
>--
>Patrick Riley
That's surely been tried! I would suggest you see what dilantin and
neurontin do for you first before you get to the habit forming stuff.
Dilantin in particular might mellow you out a bit. The muscle relaxant
drugs are also pretty good sleepers, without being too addictive.
SBH
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Dexedrine and feeling drained
Date: Mon, 16 Apr 2001 11:45:32 -0700
J. Clarke wrote in message ...
>In article <9ba74g$o58$7@slb4.atl.mindspring.net>,
SBHarris123>@ix.netcom.com says...
>> What bothers me about ADD is precisely that it's so clearly a general
>> failure syndrome for the brain, not unlike (say) shortness-of-breath as a
>> symptom of problems with the lungs. The mental co-morbidity rates that
>> show up in the ADD studies are spectacular. Children with ADHD often
>> either oppositional defiant disorder or conduct disorder, and in one
>> study 20% had coexistent mood disorder, 25% coexistent anxiety
>> disorder, and 20% specific developmental disorders such as dyslexia or
>> dyspraxia.* With all those problems, it would be incredible if their
>> brains *didn't* differ on some imaging test from normal ones; remember,
>> these are brain metabolic scans sensitive enough to tell if you have an
>> itch and want to scratch. How could they not show the secondary effects
>> of major mental health problems? However, you'd expect them to differ
>> in different ways for every study, because you're looking at a very
>> mixed group of people. And indeed, that is just what they DO do.
>>
>> Look, think about it: We're talking about an "attention" deficit. Since
>> paying strict attention is the highest level intellectual function a
>> working brain can bring to muster, it should be obvious that the first
>> thing that happens when anything goes wrong with any brain -- anything
>> at all-- is that THAT person has more trouble with his attention. When
>> this happens acutely (medical-ese for suddenly) we call
>> attention-deficits "deliriums". As in "Doctor, what is the differential
>> diagnosis for "delirium"? Well, it's pretty long. In fact, it includes
>> most of medicine, when you get to geriatrics. And that's for a reason.
>> Delirium is not a disease. Not if it lasts a short time, and not if it
>> lasts a long time. Delirium is a syndrome; a complex response of a
>> complex system.
Clarke:
>A point that you miss here is that persons with ADHD are quite capable
>of paying very close attention. The difficulty is that they can't turn
>it on or off at will or consistently control where it will be directed.
COMMENT:
Sure, but as you may know or realize with a little reminding, the same
is true for mild aggitated deleriums. You can't focus well if you have
any chronic pain, or even the flu. Or if your wife just left you or you just
got fired. If you find out that your kid has just been killed in a traffic
accident, you may be able (or may not) to focus for breif periods
in the next few days for some things (cop quesions, funeral
stuff), but insofar as studying for your mid-terms, forget it. We can't
even give you any psych diagnosis for that, but you're certainly
psychologically impared.
I'm telling you that delerium aka attention deficit is a very
general brain response to insult of any kind. Again, if the
pediatricians had done more geriatrics they'd have a better
appreciation of the silliness of callling all of this a disorder.
Calling it a disease about as useful as calling
"shortness of breath" a disease. Or weakness. Howabout
lethargic disorder? No, don't get me going on chronic
fatigue syndrome. At least it's not chronic fatigue disorder.
>> The people with the purely "hyperactive" part of ADHD (these always
>> seem to be children -- adults grow out of THAT part)
>
>ROF,L. A very good friend of mine is an adult diagnosed with
>hyperactive ADHD. If you spend an evening with her off meds, you will
>no longer believe that adults outgrow hyperactivity.
Okay, never say "never" in biology. But hyperactive adults
are far less common than hyperactive children. Hyperactive
cats are far less common than hyperactive kittens. This is not
rocket science.
>> may have a purer and simpler syndrome, and (as a group) I can guess may
>> come closer to having what we ordinarily think of as having a "disease"
>> (there's some literature support of that also). Or, they may just need
>> a lot more exercise. The other folks with the ADD, however, despite all
>> doctors can do to rule out more obvious causes of permanent
>> cognitive/brain dysfunction, are going to be a huge grab-bag. They can
>> be thought of as having a "semi-permanent delirium" (oxymoronic as that
>> may be), which isn't quite severe enough to be called a dementia, but
>> at the same time isn't really just lack of some chemical that you're
>> likely to fix with a pep pill, either. Or, if you do fix some of the
>> symptoms, you may run the same kind of risk as injecting nitromethane
>> or nitrous oxide into a jalopy when it sputters and won't climb the
>> hill. It may work for a bit, but you may also pay the price. Which is
>> fine also, but again, let us cut out the hypocrisy and quit fooling
>> ourselves as to what we're doing. When certain doctors talk about
>> "attention deficit disorder" as a "real disease" and pound their DSM
>> scriptures to "prove" it, it makes me want to take them by the nose and
>> shove some Ritalin down THEM to see if the stuff might "cure" them of
>> their damn-fool view of reality.
>
>So what action do you propose?
Oh, I have no problem with trying various symptomatic treatments,
rather as you would with somebody who has back pain. Just remember
that you're treating back pain. It's a syndrome, not a disease.
Narcotics work, but they have their own problems. Putting "low back
pain" in with "pernicious anemia" in your internal medicine textbook,
and doing it on the same footing, is likely to make you make errors in
good overall judgement.
SBH
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Review of Imaging in ADHD (Re: Dexedrine and feeling drained)
Date: Wed, 18 Apr 2001 11:21:50 -0700
CBI wrote in message <9bj1vp$3tl$1@slb4.atl.mindspring.net>...
>>
>He also questions whether we should be treating it. Seems he thinks that
>people with ADD who are receiving stimulants are getting an unfair
>advantage. You know, like those guys who do marathons in wheelchairs.
>
>"If they can't run let them crawl."
>
>--
>CBI, MD
Hey, another Rosie Ruiz fan! I think probably she had ADD and just
got distracted and didn't realize she hadn't passed all those
checkpoints....
I think we should put the disabled on armpowered bicycles. And
if that fails, just give up and have them "run" them on marathons in
electric wheelchairs. Hell, let them do it in SUVs if it makes them
feel better about themselves.
Let us explore this philosophy of yours.
You know, some women naturally have a lot more testosterone
than others, and some a lot less. It's a bell curve. The ones who
have more get a terrrific advantage in strength and endurance
sports. What do you think the proper replacement dose for
hypoadrenalism or whatever should be. Bring all women up the
FloJo standard, or whoever it is we find out there who
naturally has the most? Or only bring all them only up to the mean of the
population in general, which of course will not be
the mean of the winning women's track team? How far are you
willing to go on this?
Kids. Hmmm. Can we dope track kids in highschool
until they get to the highest hematocrit seen *naturally* in the
kids they are running against? Why not? We wouldn't
want to marginalize them because of a genetic disadvantage
would we? Dyoptimal hemoglobin stress production
syndrome-- what do you think?
Feeling Mellow This AM,
SBH, MD
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Review of Imaging in ADHD (Re: Dexedrine and feeling drained)
Date: Wed, 18 Apr 2001 13:50:24 -0700
P. Wooken wrote in message <9bko5c$9pn3j$1@ID-76840.news.dfncis.de>...
>Look, here is a personal story. From before first grade until the end of
>first grade, my daughter could not sit still anywhere, let alone in
>class. When she was two, three and four, all of this was cute. But then
>we started noticing that she couldn't even draw simple pictures, or write
>simple letters. We couldn't take her anywhere because within minutes
>there would be utter chaos -- broken bottles and toys, spilled milk,
>adults and children avoiding her, and so on. She flunked first grade!
>She was being constantly yelled at by other adults and children, when
>they coudn't avoid her. Even I and my wife couldn't help losing our
>tempers -- we would often hold her down with both hands, and say, "What
>is wrong with you?" In spite of our best efforts it was not hard to get
>angry with her.
>
>At that time, I hadn't heard of ADHD or Ritalin.
>
>After taking her to a physician, and getting a prescription for Ritalin,
>this is what happened. Within about fifteen minutes, she was sitting and
>carefully drawing and writing. She sat in one place. She listened to the
>instructions. She was proud of herself when she finished the work. I was
>there watching this, and tears came out of my eyes. I will not forget that
>moment.
>
>You know, I really don't care about her winning prizes for academic work.
>I don't care if she goes to Harvard or to Podunk U. She is sixteen now,
>and doing OK in school. I don't care if ADHD is simply one end of a bell
>curve, or it is really associated with a second bump. I am certain that
>without the miracle of that medication, she would not read or write
>today, have any friends.
>
>I am the first to admit that Ritalin hasn't solved all her problems, or
>that it hasn't had side effects. I woudn't give her the meidcation for a
>supposed competitive advantage -- not because of moral objections, but
>because if at all possible, I would like her not to experience the side
>effects, such as difficulty falling asleep, and a rather unhealthy eating
>cycle in which she eats a lot after the medicine wears off, but hardly
>eats anything during the day. I would rather she doesn't think of
>herself as ADHD and needing the medication.
>
>There is nothing in what you have written on this thread that remotely
>indicates any understanding of cases like my daughter's. I really have
>no objection to your analysis of the weaknesses of the disease model for
>ADHD, or your analysis of the weaknesses of the current evidence for
>identifiable brain abnormalities. Those are scientific questions and
>need to be approached with the usual skepticism, and I don't fault you
>for that. But I do fault you for then taking off on this ideological
>path that you have taken, a path in which your questioning attitude about
>the data is not leavened with an understanding of real situations and
>real needs. As a cynic, you are only able to conjure up dark hypotheses
>about unfair advantages. Life is not always a race between individuals.
>It is also often just something that one does for oneself, such as being
>able to acquire knowledge, read and write and build uplife skills. I am
>a highly educated scientist myself, so I am fully aware of the problems
>in coming up reliable science about complex phenomena such as ADHD. But,
>even with great intellectual sympathies for your skepticism, I am
>troubled by your arrogance and sarcasm towards real suffering.
>
>P.
Simply because I've pointed out that Ritalin gives advantages to
(some) normal and near normal kids, you seem to think that I don't
think there are cases where it is spectacularly successful for some
kid with a significant problem of some kind. I'm sure it is. My
problem is not generally with parents or kids who find such a drug and
rejoice. My problem is only with hypocrisy: parents who find such a
drug and then say "screw you, I've got mine" to other parents and
other troubled kids looking for them own chemical fix. Some of whom
are destined to find one and some not. And a large fraction of who may
find themselves in prison for 20 to life, for their efforts.
Suppose this had all happened to you 20 years ago. You missed the
doctor. Your daughter grew up wild and destructive and finally found
meth or cocaine, and actually felt normal for the first time in her
life. But then, alas, got arrested and sent away forever. Longer than
Bill Clinton's Brother. And you don't have pardon powers.
Now, so long as we're talking about arrogance, can you summon the
imagination to consider that large fractions of the illegal drugs in
this country are being taken by people looking for some kind of answer
to the pain they are in? And that this kind of thing is so ill defined
that it's in the same class as your daughter's. You say you don't care
what it's called. Is that really true? I take it you've voted to
decriminalize psychoactive drug use? You're out promoting this
agenda, just as I am?
Welcome to the Libertarian fold, then.
But if you're one of those guys whose personally philosophy is 10
degrees right of center when it comes to other people, and 10 degrees
left when it comes to your own family, then so far as I'm concerned,
you can jump in the lake. Your suffering has taught you nothing,
except that when it happens to you and yours, it hurts.
SBH
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Review of Imaging in ADHD (Re: Dexedrine and feeling drained)
Date: Thu, 19 Apr 2001 15:39:20 -0700
CBI wrote in message <9blg9i$b84$1@slb6.atl.mindspring.net>...
>"Steve Harris" <sbharris@ix.netcom.com> wrote in message
>news:9bkuo7$ht4$1@slb1.atl.mindspring.net...
>> Simply because I've pointed out that Ritalin gives advantages to (some)
>> normal and near normal kids,
>
>Reference please.
>
>--
>CBI, MD
I already gave you a reference that Ritalin has the same effect in
normal kids as it does in ADHD kids, and you said you'd never implied
otherwise. Below is another.
Are you going to really going to argue that improvement in focus and
attention is not an advantage when it comes to mental tasks? Where
are you going with THAT?
Behav Brain Res 1998 Jul;94(1):127-52
Neuropsychopharmacological mechanisms of stimulant drug action in
attention-deficit hyperactivity disorder: a review and integration.
Solanto MV
Division of Child and Adolescent Psychiatry, Schneider Children's
Hospital, Long Island Jewish Medical Center, New Hyde Park, NY 11042,
USA.
The psychostimulants, D-amphetamine (D-AMP) and methylphenidate (MPH),
are widely used to treat attention-deficit hyperactivity disorder
(ADHD) in both children and adults. The purpose of this paper is to
integrate results of basic and clinical research with stimulants in
order to enhance understanding of the neuropharmacological mechanisms
of therapeutic action of these drugs. Neurochemical,
neurophysiological and neuroimaging studies in animals reveal that the
facilitative effects of stimulants on locomotor activity,
reinforcement processes, and rate-dependency are mediated by
dopaminergic effects at the nucleus accumbens, whereas effects on
delayed responding and working memory are mediated by noradrenergic
afferents from the locus coeruleus (LC) to prefrontal cortex (PFC).
Enhancing effects of the stimulants on attention and stimulus control
of behavior are mediated by both dopaminergic and noradrenergic
systems. In humans, stimulants appear to exert rate-dependent effects
on activity levels, and primarily enhance the motor output, rather
than stimulus evaluation stages of information-processing. Similarity
of response of individuals with and without ADHD suggests that the
stimulants do not target a specific neurobiological deficit in ADHD,
but rather exert compensatory effects. Integration of evidence from
pre-clinical and clinical research suggests that these effects may
involve stimulation of pre-synaptic inhibitory autoreceptors,
resulting in reduced activity in dopaminergic and noradrenergic
pathways. The implications of these and other hypotheses for further
pre-clinical and clinical research are discussed.
Publication Types:
Review
Review, tutorial
PMID: 9708845
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Review of Imaging in ADHD (Re: Dexedrine and feeling drained)
Date: Thu, 19 Apr 2001 13:32:13 -0700
Norma wrote in message ...
>On Thu, 19 Apr 2001 10:35:10 -0600, mbjq@earthlink.net (Emma Anne)
>
>I'm definitely not a fan on the war on drugs. I think better education
>and accepting that people are different (instead of all being the same
>and needing the same things) is more helpful. The only exception rule
>that I would have to getting rid of the war on drugs, is that for
>minors there should be restrictions (just like we now have on
>alcohol).I do think it's strange that at 18 one is no longer a minor
>but then still have to wait till 21 to drink alchol. I would want that
>to be lowered to 18, or raise the age of everything (including
>fighting in battle) to 21. I think it's plain dumb that you are an
>"adult" in everything except for drinking at 18.
That's a set of frozen historical accidents, mostly. Age of
majority was typically 21, except that they wanted to send 19 year
olds to Vietnam and have them shoot people. At the time, they
weren't even eligible to vote, due, supposedly
to not being mature enough to make such difficult decisions ;9. They
changed the vote because of the draft, and pretty soon everything had
been lowered except for drinking privileges.
I myself think that rights and privileges should go in lock-step, and
that it should be illegal to prosecute someone as an adult for a
crime (say) unless you've formally granted them adult status in the
society beforehand. That just shows you how much of a radical I am.
SB
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Review of Imaging in ADHD (Re: Dexedrine and feeling drained)
Date: Wed, 18 Apr 2001 13:07:24 -0700
CBI wrote in message <9bj1bc$ih1$1@slb3.atl.mindspring.net>...
>
>"Ann" <annbal@thecia.net> wrote in message
>news:q7qpdt4hssob0svflr4h5m4br6o3n2hggs@4ax.com...
>> "CBI" <replytothegroup@spamblock.nospam> expounded:
>>
>> >Well, there we have it. Steve posted about 6 or 8 times to this thread
>> >today. There is not a single reference in one of them. He never puts
>> >forward his position as to why ADD is not a disease, much less define
>> >what a disease is or give supporting documentation that they are valid
>> >requirements. I guess I was not the one to wimp out after all.
>>
>> Why is it so important to you that ADD (sic) be a disease? I am not
>> diseased. I have a brain that's wired differently than others. It
>> works in an abnormal manner. Call it an abnormality if you must.
>> But it isn't a disease.
>>
>
>Actually, Steve is the one hung up on the label. I personally don't care
>if you call it a disease, syndrome, quirk, or abnormality. The point is
>that it is a legitimate diagnosis that can be arrived at with a high
>degree of certainly and does cause a significant amount of problems in
>many people that can be alleviated through treatment.
>
>Steve questions whether it exists at all or is just one end of the normal
>spectrum.
>
>--
>CBI, MD
COMMENT:
CBI has expressed concern that his nose hasn't been rubbed
firmly enough in the morass that is the American Psychiatric
diagnosis and treatment of in children with psychoactives. And
that I don't have enough references. So here are some more
abstracts, which I am going to take the
liberty of commenting upon, as I go.
First, we are going to look at this high degree of certainty
which CBI seems to feel exists out there.
Pediatrics 2001 Mar;107(3):E43
Prevalence and assessment of attention-deficit/hyperactivity disorder
in primary care settings.
Brown RT, Freeman WS, Perrin JM, Stein MT, Amler RW, Feldman HM, Pierce K,
Wolraich ML
Department of Pediatrics, Medical University of South Carolina, Charleston,
South Carolina.
[Medline record in process]
Research literature relating to the prevalence of
attention-deficit/hyperactivity disorder (ADHD) and co-occurring
conditions in children from primary care settings and the general
population is reviewed as the basis of the American Academy of
Pediatrics clinical practice guideline for the assessment and
diagnosis of ADHD. Epidemiologic studies revealed prevalence rates
generally ranging from 4% to 12% in the general population of 6 to 12
year olds. Similar or slightly lower rates of ADHD were revealed in
pediatric primary care settings. Other behavioral, emotional, and
learning problems significantly co-occurred with ADHD. Also reviewed
were rating scales and medical tests that could be employed in
evaluating ADHD. The utility of using both parent- and
teacher-completed rating scales that specifically assess symptoms of
ADHD in the diagnostic process was supported. Recommendations were
made regarding the assessment of children with suspected ADHD in the
pediatric primary care setting. PMID: 11230624
COMMENT: if you can't tell whether or not your disease prevalence rate is
4% or 12%, you've got a problem. You certainly don't have a high
degree of certainty. Some doctors see three times more of a disease
than others do? Is that "certainty" in your universe, CBI?
NEXT:
Child Adolesc Psychiatr Clin N Am 2000 Jul;9(3):541-55, vii
Epidemiology of ADHD in school-age children.
Scahill L, Schwab-Stone M
Yale University School of Nursing, New Haven, Connecticut, USA.
Lawrence.Scahill@Yale.edu
"Attention-Deficit/Hyperactivity Disorder is a relatively common
condition of childhood onset and is of significant public health
concern. Over the past two decades there have been 19 community-based
studies offering estimates of prevalence ranging from 2% to 17%."
COMMENT:
Oh, my. Here's one where the spread is even worse. One community
has 850% more of this mental disorder than another? Say what?
CONTINUING THE ABSTRACT:
"The dramatic differences in these estimates are due to the choice of
informant, methods of sampling and data collection, and the diagnostic
definition."
COMMENT:
Golly, isn't science wonderful? But, after all that, there's a high
degree of certainty.
CONTINUING:
"This article provides a critical review of the community-based
studies on the prevalence of ADHD in children and adolescents. Based
on the 19 studies reviewed, the best estimate of prevalence is 5% to
10% in school-aged children. PMID: 10944656
COMMENT:
The best estimate of these authors, who are trying not to embarrass
the profession, in other words. Just take 19 studies which show wildly
disparate results, and kick out the ones that don't fit. That'll convince
CBI this is an objective and repeatable thingy/pathology.
See, now everybody sees the same thing. And when they don't, well,
we don't pay any attention to them. It's sort of an attention deficit when
it comes to the epidemiological studies. As I've said before, perhaps
Ritalin could be used to get doctors to focus more on the way things don't
really fit here.
NEXT issue of appropriate treatment with stimulants, which CBI seems
to feel is rapidly getting solved by recognizing the kids who have the
disorder that we were missing.
J Am Acad Child Adolesc Psychiatry 2000 Aug;39(8):975-84; discussion 984-94
Stimulant treatment for children: a community perspective.
Angold A, Erkanli A, Egger HL, Costello EJ
Department of Psychiatry and Behavioral Sciences, Duke University Medical
Center, Durham, NC 27710, USA.
OBJECTIVE: To examine the use of prescribed stimulants in relation to
research diagnoses of attention-deficit hyperactivity disorder (ADHD)
in a community sample of children. METHOD: Data from 4 annual waves of
interviews with 9- to 16-year-olds from the Great Smoky Mountains
Study were analyzed. RESULTS: Over a 4-year period, almost three
quarters of children with an unequivocal diagnosis of ADHD received
stimulant medications. However, girls and older children with ADHD
were less likely to receive such treatment. Most children with
impairing ADHD symptoms not meeting full criteria for DSM-III-R ADHD
did not receive stimulant treatment.
COMMENT: well, we can certainly fix that. I think that's what CBI was
talking about when he said things would double.
Abstract:
>Stimulant treatment in this group was significantly related
to the level of symptoms reported by parents and teachers and was much more
common in individuals who met criteria for oppositional defiant disorder. <
COMMENT:
The irony. It used to be that when little Johnny wouldn't do anything
you told him, you wondered if he might be on drugs. Now, when that
happens, you put him on drugs.
ABSTRACT
>The majority of individuals who received stimulants were never reported by
>their parents to have any impairing ADHD symptoms.
COMMENT:
Hmmmm, not sterling evidence that psychotropics are being used
for heavy-duty life-problems, as our local authoritarian maintains.
Seems like the kids who are getting this stuff are exactly the group
I suggested were getting it.
ABSTRACT CONTINUES
>>They did have higher levels of nonimpairing parent-reported ADHD
>>symptoms, higher levels of teacher-reported ADHD symptoms, and
>>interviewer-observed ADHD behaviors, but these typically fell far below
>>the threshold for a DSM-III-R diagnosis of ADHD.
COMMENT: <Sigh> What can I say?
ABSTRACT CONCLUDES: with the CONCLUSIONS
>> In this area of the Great Smoky Mountains, stimulant treatment
>>was being used in ways substantially inconsistent with current
>>diagnostic guidelines.
SARCASTIC COMMENT:
But it's not in CBI's part of the country, so we're to believe.
This is just a little evil place in the Smokies where they use
Ritalin however they like. An aberration. The rest of the
country is firmly in control of the SCIENTIFIC pediatricians.
Right, CBI?
SBH
From: "Steve Harris" <sbharris@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Dexedrine and feeling drained
Date: Thu, 19 Apr 2001 16:34:22 -0700
CBI wrote in message <9b8is2$q5v$1@nntp9.atl.mindspring.net>...
[Harris]
>> Why do we have 20 times more of it than in (say)
>> England?
>
>We don't.
>
>Different surveys spanning decades and several different countries have
>shown that the prevalence of ADD is remarkably stable across location and
>time at about 6% for boys and 3% for girls. [Szatmari J Child Psychol Psych
>1989; 30: 219-30, Strother Ann NY Acad Sci 1973; 205: 6-17, Safer Pediatrics
>1996; 98: 1084-88, Safer JAMA 1988; 260: 2256-58]
Yet when I quote studies showing prevalence rates going all the way
between 2% and 17%, depending on study, you say these are
due to "population differences." I think you're going to have a
hard time having it both ways. It either differs a lot between populations
or it doesn't.
>> Do you think they have worse doctors there,and are missing 19 out
>> of 20 cases? Golly.
>
>Of course not.
Well, then, what is the problem with English psychiatrists?
Are they just stupid? Missing the obvious clinical picture? What?
Let me get your "of course not" clearly: you're saying their doctors are
as good as ours, but they hardly ever see our most common
diagnostic indication for stimulants and hardly ever use our most common
treatment for it. That's pretty tricky.
J Psychopharmacol 2000 Mar;14(1):67-9
Psychostimulants and psychiatrists: the Trent Adult Psychiatry
Psychostimulant Survey.
Bramble D
Department of Psychiatry, University of Nottingham, Queen's Medical Centre,
UK.
This study reports upon the results of a postal questionnaire survey
of 107 adult psychiatrists which investigated their current use of
psychostimulant pharmacotherapy and their attitudes towards the
diagnostic status of attention-deficit hyperactivity disorder (ADHD)
in adulthood. Of the 88 respondents, only a minority of 11 (12.5%)
used psychostimulants in their usual practice, albeit very
infrequently (one or two prescriptions per year on average).
Methylphenidate hydrochloride ('Ritalin') was the prescribers' most
popular agent and 'narcolepsy' was the most frequently cited clinical
indication for psychostimulants. ADHD appeared to represent only a
very small area of current clinical activity and a minority of
clinicians expressed the view that it did not exist in adults. It is
concluded that psychostimulant therapy is relatively undeveloped in
British adult psychiatry and that the clinical speciality generally
appears to be unprepared for the growing numbers of adolescents with
ADHD who are currently managed by child psychiatrists and who may
require ongoing psychiatric care, including psychostimulant therapy.
PMID: 10757256
From: "Steve Harris" <SBHarris123@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Review of Imaging in ADHD (Re: Dexedrine and feeling drained)
Date: Sat, 21 Apr 2001 05:48:29 -0600
"CBI" <replytothegroup@spamblock.nospam> wrote in message
news:9bqv7t$e6g$1@nntp9.atl.mindspring.net...
> But it gets worse. The system you advocate has been tried here in
>the US. It is the reason the FDA was created in the first place.
No, the FDA was created to some something about adulterated foods and patent
medicines. It didn't outlaw narcotics. Most of its regulatory power over
pharmaceuticals came from the 1930's elixer of sulfonamide disaster (a
product with a poison in it-- ethylene glycol), and in the 1964 Kefauver
amendment after thalidomide.
The narcotics laws were in general all targetted at minority groups that
people feared. Mexican workers taking jobs in the depression for pot (mid
and late 1930's), opium smoking for Chinese (the earliest drugs laws in the
country, going back to the 19th century), cocaine and heroin laws in the
30's to keep down the lower clases in the inner cities. Many of the
non-smoked opiate laws went along for the ride due to international trade
treaties aimed at the opium wars; otherwise I doubt they would have passed.
Many of drugs didn't get outlawed until fairly recently-- LSD in the 60's,
MDMA in the 80's. And all basically for political reasons. And some of these
didn't get passed by congress-- we're now at the point where you things are
illegalized by pure administrative decission. The congress or legislature
need not even be involved in an issue of personal privacy that they wondered
would even be consitutional to pass 70 years ago. Oh brave new world that
hath such bureaucrats in it.
>What will happen is that people will get most of their info from
>advertisements. Charlatanism ran wild the last time this was done. The
>other problem that gave impetus to the creation of drug regulations and
>would likely happen again was antibiotic resistance. Everyone with a sore
>throat or cough will start popping not just penicillin but the latest and
>"strongest" antibiotics with pharmacists only too happy to recomment and
>sell them as they are much more expensive.
So what's new? It happens now, except they pay the doctor his cut. Have you
seen the video about how Max the Zebra Earned his Stripes? By giving the
monkey Zithromax for his earache....
>Ever wonder why doctors are dicouraged from selling drugs from
> their offices? It is thought to lead to ethical problems.
It's still done, particularly at Urgent Cares, though. Nothing illegal about
it in any state. Any doctor can dispense. Your HMO does it. Your hospital
does it. The problem with the group practice doing it is not ethics but
inventory problems. The doctor can't make any better profit at it than the
pharmacist, who has a much larger and better operation. The doctor does
worse than the corner drugstore, which is in turn being wiped out by the
mailorder chains. The idea that ethics is somehow involved in all of this is
laughable. It's business.
SBH
From: "Steve Harris" <SBHarris123@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Review of Imaging in ADHD (Re: Dexedrine and feeling drained)
Date: Sat, 21 Apr 2001 05:59:02 -0600
"CBI" <replytothegroup@spamblock.nospam> wrote in message
news:9bqdbe$lfl$1@slb5.atl.mindspring.net...
> No, I wouldn't argue that. But making current prescription drugs over
>the counter is a separate issue that will not affect this.
>
> --
> CBI, MD
You won't get an argument from me on the antibiotics. It's pretty silly to
need a prescription for most non-scheduled substances, though.
You need a scrip for Vioxx and not Motrin? For Claritin and not Benedryl?
For Prilosec but not Cimetidine? For a scopolamine patch but not a nicotine
patch? Stupidity.
At one time the idea was that the dangerous stuff would have some
restriction so you'd have to talk to some professional. But that could as
well be your pharmacist when it comes to your antihistamine or antacid or
whatever. Our current system is basically reactionary and is all out of
whack. The dangerous stuff is on the shelves. The really selective and
lastest stuff is still Rx. If they can sell you insulin without a scrip,
they should certainly be able to sell you an ACE inhibitor or Prozac. And,
of course, one day they will. I'm old enough to remember the cogent
arguments about why nicotine patches and cimetidine and vaginal yeast creams
should all be prescription. They were great arguments except for one thing:
when it came down to $, they didn't mean a thing.
SBH
From: "Steve Harris" <SBHarris123@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Dexedrine and feeling drained
Date: Sat, 21 Apr 2001 06:04:28 -0600
> > Well, then, what is the problem with English psychiatrists?
> > Are they just stupid? Missing the obvious clinical picture? What?
> >
> > Let me get your "of course not" clearly: you're saying their doctors are
> > as good as ours,
>
> Yes.
>
>
> > but they hardly ever see our most common
> > diagnostic indication for stimulants and hardly ever use our most common
> > treatment for it. That's pretty tricky.
> >
>
> I would imagine if you surveyed adult psychiatrists in the US you might
> get a similar response. Try looking at the pediatric population.
>
>
> > J Psychopharmacol 2000 Mar;14(1):67-9
> >
> > Psychostimulants and psychiatrists: the Trent Adult Psychiatry
> > Psychostimulant Survey.
> >
> > Bramble D
> >
> > Department of Psychiatry, University of Nottingham, Queen's Medical
> > Centre, UK.
> >
> > This study reports upon the results of a postal questionnaire survey
> > of 107 adult psychiatrists
>
> See above - ADULT psychiatrists.
>
>
> > which investigated their current use of psychostimulant
> > pharmacotherapy and their attitudes towards the diagnostic status of
> > attention-deficit hyperactivity disorder (ADHD) in adulthood. Of the
> > 88 respondents, only a minority of 11 (12.5%) used psychostimulants in
> > their usual practice, albeit very infrequently (one or two
> > prescriptions per year on average). Methylphenidate hydrochloride
> > ('Ritalin') was the prescribers' most popular agent and 'narcolepsy'
> > was the most frequently cited clinical indication for
> > psychostimulants. ADHD appeared to represent only a very small area of
> > current clinical activity and a minority of clinicians expressed the
> > view that it did not exist in adults. It is concluded that
> > psychostimulant therapy is relatively undeveloped in British adult
> > psychiatry and that the clinical speciality generally appears to be
> > unprepared for the growing numbers of adolescents with ADHD who are
> > currently managed by child psychiatrists and who may require ongoing
> > psychiatric care, including psychostimulant therapy.
> >
>
> Please read the conclusions of your own study.
>
> Steve, you are making it too easy for me. I don;t even have to try to come
> up with references that support my point. You are doing it for me!!!!!
>
> --
> CBI, MD
I left the conclusion in for a reason: it's so clearly ridiculous. Adult
psychiatrists of the UK! Prepare yourselves for the onslaught of children
growing into adults and still needing a drug you haven't thought to
prescribe them, because you didn't ever notice the adults populations you
treat also have this disease. Open your eyes! The need for speed in a large
fraction of your patients was there all along. Don't you feel like doofuses?
(Signed)
Your Smarter American Colleage
(With my Novartis Pen)
From: "Steve Harris" <SBHarris123@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Review of Imaging in ADHD (Re: Dexedrine and feeling drained)
Date: Thu, 26 Apr 2001 03:47:49 -0600
"CBI" <replytothegroup@spamblock.nospam> wrote in message
news:9bqc50$443$1@slb6.atl.mindspring.net...
> "Steve Harris" <sbharris@ix.netcom.com> wrote in message
> news:9bnpgh$uu8$1@slb0.atl.mindspring.net...
> >
> > CBI wrote in message <9blg9i$b84$1@slb6.atl.mindspring.net>...
> > >"Steve Harris" <sbharris@ix.netcom.com> wrote in message
> > >news:9bkuo7$ht4$1@slb1.atl.mindspring.net...
> > >>
> > >> Simply because I've pointed out that Ritalin gives advantages to
> > >> (some) normal and near normal kids,
> > >
> > >Reference please.
> > >
> > >--
> > >CBI, MD
> >
> >
> >
> > I already gave you a reference that Ritalin has the same effect in
> > normal kids as it does in ADHD kids, and you said you'd never implied
> > otherwise. Below is another.
> >
> > Are you going to really going to argue that improvement in focus and
> > attention is not an advantage when it comes to mental tasks? Where
> > are you going with THAT?
> >
>
> You claim that normal kids are taking it for the improved focus. I asked
> for a reference. What is the problem?
>
> --
> CBI, MD
The problem is that you don't seem to believe anything I post. Rather like
the APA doesn't believe the DEA about diversion. The DEA has the arrest
records, but that doesn't matter. And if you wont' believe the stuff that
criminals you catch tell you, the only thing left to do is interview people
anonmyously about illicit behavior.
1: J Am Coll Health 2000 Nov;49(3):143-5
Student perceptions of methylphenidate abuse at a public liberal arts
college.
Babcock Q, Byrne T
Massachusetts College of Liberal Arts, North Adams, USA.
With the ever-increasing diagnosis of attention deficit hyperactivity
disorder, methylphenidate has become readily accessible in the college
environment. Several properties of methylphenidate indicate abuse
liability. A survey regarding the recreational use of methylphenidate
was distributed to the student body at a public, liberal arts college.
More than 16% of the students reported they had tried methylphenidate
recreationally, and 12.7% reported they had taken the drug
intranasally. Use of the drug was more common among traditional
students than among nontraditional students. Among traditional-age
students, reports of methylphenidate use were roughly equivalent to
reports of cocaine and amphetamine use. Environmental conditions
characteristic of college student life may influence the recreational
use of the drug.
PMID: 11125642
From: "Steve Harris" <sbharris123@ix.netcom.com>
Newsgroups: sci.med,alt.support.attn-deficit
Subject: Re: Review of Imaging in ADHD (Re: Dexedrine and feeling drained)
Date: Sat, 16 Jun 2001 14:57:36 -0600
"CBI" <00doc@bigfeet.com_make_it_bigfoot> wrote in message
news:9gfqqd$me4$1@slb2.atl.mindspring.net...
>
> "Herman" <hfebelingjr@lycos.com> wrote in message
> news:afBW6.2070$WB1.660495@typhoon.tampabay.rr.com...
> > Sorry IF I'm reopening a can of worms here, but when I read the below
> > I felt that I had to reply.
> >
> > As I recall seeing a story not that long ago on one of the major
> > networks news "magzine" shows about how kids both still in High
> > School, and college were taking Ritalin as a "study" aid and in the
> > case of the kids still in High School they were taking it from the
> > kids who had it perscribed to them to help them with their ADD/ADHD.
> >
> > Herman
>
> No one ever claimed that Ritalin is never diverted or abused. The
> diversion and abuse of Ritalin was not central to either Steve's or my
> discussion.
Which is a good thing, since diversion appears here to stay. A high-school
principal here in Utah lost his job last year for stealing Ritalin out of
the school safe. Self-medicating his undiagnosed ADHD, so he said. So far,
juries haven't thought he looked enough like a "drug addict" to put him in
jail. We're pretty good at telling just plain folks from no-good drug
addicts here in Utah. Yes we are.
From: "Steve Harris" <sbharris@ix.RETICULATEDOBJECTcom.com>
Newsgroups: uk.politics.drugs,talk.politics.drugs,uk.people.health,
bionet.neuroscience,sci.med
Subject: Re: ADHD Drug Treatment May Prevent Future Drug Use
Date: Sat, 16 Aug 2003 19:20:44 -0700
Message-ID: <bhmotn$f0f$1@slb1.atl.mindspring.net>
"Jasbird" <Jasbird#dead-mail-box#@myrealbox.com> wrote in
message news:aantjvkdm2n8bjst14s0vmrrnail8o9ih2@4ax.com...
> If ADHD doesn't exist then please explain why children diagnosed with
> ADHD who were not treated with stimulants are twice as likely to later
> become addicted to alcohol or other drugs.
Perhaps because this wasn't a randomized prospective study.
Let alone a blinded placebo controlled one. The group whose
parents cared enough and had the resources enough to treat
them, are certainly not the same kids, socioeconomically, as
the ones that didn't get treated.
Do not infer truth from post hoc uncontrolled epidemiology.
Such studies would have you believe you need to attend
church regularly to get well. Do you think medicare should
pay for church attendance as medical care?
SBH
From: "Steve Harris" <sbharris@ix.RETICULATEDOBJECTcom.com>
Newsgroups: uk.politics.drugs,talk.politics.drugs,uk.people.health,
bionet.neuroscience,sci.med
Subject: Re: Severe Attention Disorder Linked with Drug Abuse
Date: Mon, 18 Aug 2003 10:28:47 -0700
Message-ID: <bhr2g9$14r$1@slb3.atl.mindspring.net>
"Jeff Utz" <kidsdoc2000@hotmail.com> wrote in message
news:bhqej7$h57@library1.airnews.net...
>
> It has been known for a while that kids with ADHD have higher risk
> taking behaviors, including alcohol and drug abuse.
Therefore to treat this, we prescribe them a class of drugs
which is widely abused.
And "abusers" of this class of drugs (defined as people who
don't have a prescription), we jail. Do they have untreated
ADHD? We don't want to know. Especially people who believe
there is such a thing as ADHD don't want to know. They
metaphorically stick their fingers in their ears and say
"la-la-la-la-la", when you bring up the topic.
SBH
From: "Steve Harris" <sbharris@ix.RETICULATEDOBJECTcom.com>
Newsgroups: uk.politics.drugs,talk.politics.drugs,uk.people.health,
bionet.neuroscience,sci.med
Subject: Re: Severe Attention Disorder Linked with Drug Abuse
Date: Mon, 18 Aug 2003 16:02:52 -0700
Message-ID: <bhrm2n$6rd$1@slb9.atl.mindspring.net>
"Pete nospam Zakel" <pxhxz@cadence.com> wrote in message
news:3f415471$1@news.cadence.com...
> Note that one study shows that kids with ADHD who are treated with that
> class of drugs end up with a risk of alcohol and drug abuse equal to
> those without ADHD.
>
> Doesn't that indicate that perhaps the treatment is working?
>
> -Pete Zakel
> (phz@seeheader.nospam)
One study shows that women who live in big cities are 3
times as likely to get breast cancer as women who don't.
Do you think this means all women should move to the
suburbs?
SBH
From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,misc.health.alternative,sci.med.diseases.cancer,
talk.politics.medicine
Subject: Re: cancer drug warrants healthy skepticism
Date: 11 Oct 2005 13:48:52 -0700
Message-ID: <1129063732.450359.172090@f14g2000cwb.googlegroups.com>
Steph wrote:
> "Twittering One" <twitteringone@aol.com> wrote in message
> news:1128272766.142529.272630@g47g2000cwa.googlegroups.com...
> > Can I get some of what you'e smoking...................?
> >
> > I do not smoke, drink, or do recreational drugs.
> >
> > I do take ADD medication, and I exercise, and
> > I believe in talk therapy.
> >
>
>
> A fine example of the fact that all lunacy is not substance-induced, I
> guess....
COMMENT:
Not really. "ADD medication" is a "substance." Likely to be some
sympathomimetic like Ritalin. Too much of that, and you'll start
babbling. Pretty much as the twitterer does....
From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,misc.health.alternative,sci.med.diseases.cancer,
talk.politics.medicine
Subject: Re: cancer drug warrants healthy skepticism
Date: 11 Oct 2005 17:12:18 -0700
Message-ID: <1129075938.105614.83060@g14g2000cwa.googlegroups.com>
O'Hush wrote:
>> > COMMENT:
> >
> > Not really. "ADD medication" is a "substance." Likely to be some
> > sympathomimetic like Ritalin. Too much of that, and you'll start
> > babbling. Pretty much as the twitterer does....
>
> I have ADHD. I babble when I *don't* take Ritalin. I recently tried
> exercise alone to treat my ADHD and was politely informed by my study group
> that I had begun to repeat myself and monopolize conversations, so I'm back
> on the Ritalin. I think it's possible that Twittering One has another
> diagnoses in addition to ADHD which may explain the behavior you see here.
>
> --Patti
Possibly-- I've seen it both ways. Some people babble when focused,
some don't (may be a male vs female thing).
Cocaine? Very big with the ADHD crowd. And certainly causes babbling
in many. Too much coffee?
Actually, my real bet is Twitterer has a varient of Tourette's, and her
ADHD drugs are just making it worse.
SBH
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