Archive for the ‘Blogs’ Category

HAPPY NEW YEAR 2014!!!!!

 

Happy New Year to all my fellow ADHD friends. Remember, you DO NOT have a disorder. I hate that. You have a very unique temperament and many gifts. The major problem is that this temperament is created in the prefrontal cortex of your brain. That controls “executive functioning”.. that means mainly the things you hate to do you probably won’t, because you have to have stimulation to make your brain increase dopamine, which drives us. So….when possible, delegate out the things that need to be done, but you hate to do and always procrastinate. Learning to compensate for our areas we lack interest in (or feel inadequate about, for that matter) is a SMART thing to do. Some people get down on themselves because of this.

 

Instead of being bummed about the things you don’t do, concentrate on your strengths. Embrace what you are good at and do it! Most people with ADHD are creative, likely to be entrepreneurs, innovators, challengers of the system, and passionate with their interests, whatever they are!

 

If you don’t have a person that is your own “personal secretary”, BARTER out your boring stuff!

 

Some of the people I love most dearly in the world have ADHD….So Happy New Year to all of you!!!!!!!

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We Will Remember Siggie – 2000-2013 RIP!

Pets play a major and significant role in our lives.

Many studies have indicated that having a pet in the home is particularly good for elderly people that live alone.  They become a part of our family.  Our Bassett Hound, named of course, Sigmund (but we called him Siggie,) died June 15th.  He was 13 years old.  Needless to say, our whole family, especially our daughter that raised him, miss him and have gone through a true grieving process over his loss.  Some people don’t think that their grief over a pet is appropriate, and/or embarrassing.  The truth of the matter is that grief helps us heal after losing a beloved pet, and we should all allow that process to happen.  Most of us will outlive our pets, so losing them at some point in time is usually inevitable.

Dr. Jones has always been amazed at how many pet owners do not think they should be devastated over the loss of a pet.  It is perfectly normal to grieve and to miss them, just like any family member that is lost!  He always assures them that it is okay and normal to be upset over their loss!

I am attaching our tribute video to Siggie.  I hope you enjoy it!      RIP Siggie, we love you!

http://video214.com/play/nUjXSEF4KERjetBHXgVG0w/s/dark[spider_facebook id=”- Select Form -“]<div class=”fb-like”” data<href=”http://developers,facebook.com/docs/reference/plugins/like”

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ADHD Resources

Book/Audio Suggested Reading:

  • Shadow Syndromes, by John Ratey, M.D.
  • Driven to Distraction, by Edward Hollowell, M.D.
  • Women With Attention Deficit, by Sari Solden
  • Crazy Busy, by Edward Hollowell, M.D.
  • Taking Charge of Adult ADHD, by Russell Barkley, PhD
  • Straight Talk about Psychiatric Medications for Kids, by Timothy Wilens, M.D.

Online resources:
http://www.chadd.org/
http://www.add.org/
http://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml
http://www.mayoclinic.com/health/adhd/DS00275
http://www.russellbarkley.org/
http://www.drhallowell.com/

 

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Perspectives by Penny – ADHD

ADHD… Perspectives by Penny

I hope I can accomplish through the privilege of writing this blog helping someone gain more insight into understanding the challenges of living with ADHD every day.

And I have to put this disclaimer in: these are all my opinions, not those of Dr. Jones.

“Our future lies in the hands of the creatively maladjusted” Martin Luther King Jr.

04-30-2013

Blog Entry 1 Introduction

I have worked with Dr. Jones for 17 years, gone to most of the CME courses he attends (continuing medical education), which has been literally hundreds of hours, and have a bachelors degree in Psychology and Marketing. I have developed slides for his presentations, as well as edited and help write his newsletters and website. I have also been on the board of directors of the Dallas chapter of CHADD which is a national ADHD organization. Their website is: http://www.chadd.org/

I think I have an extremely unique, multi-faceted slant on ADHD and stress related mental health issues. (I have also seen the pharmaceutical company industry very up close and personal concerning neuropsychiatric drugs.) So, I am starting my first blog with that subject specifically.

I have known and interacted with many physicians that treat ADHD. I have also had direct contact with the pharmaceutical companies all the way down the chain of hierarchy from their ivory tower corporate executives (they get the really big money), the specialists with “big credentials that answer questions for the few doctors that inquire”, the regional managers, and then the pharmaceutical reps that really work in the trenches with doctors and see the real world that clinical physicians deal with everyday.

I have attended countless meetings and conferences, including: data and research updates on new drug studies, pharmaceutical company “launches” of new products, physician speaker training meetings, and reviewed endless studies of medications relevant to treating psychiatrically related issues.

Because of negative press, the pharmaceutical industry has made an attempt to “self police” by creating PhRMA (Pharmaceutical Research and Manufacturers of America). This self-regulatory group was created by the pharmaceutical industry as an attempt to try to avoid complete control by the FDA (Food and Drug Administration)… (They would probably deny that observation, however).

The fact of the matter is, the reason pharmaceutical companies exist in the first place is capitalism, (which translates ultimately into profits made for the shareholders). This industry is unique because the “products” they produce effect real people in a very personal, crucial, and sometimes “life or death” way. This makes them extremely vulnerable to regulation, and public criticism and scrutiny. It also causes dissonance, and conflicts of interest between the industry, the consumers that use their products, and their shareholders. And, of course, there is a strong, hungry, greedy segment of the legal industry that is just salivating at the chance to sue them for some drug that proves to have a negative outcome because of unforeseen adverse side effects, (or, god forbid, deception through hiding adverse data in studies of bad or life-threatening findings.)

However, I am still NOT against capitalism, and that includes the pharmaceutical industry. One of the great freedoms we have living in America is that anybody can go from complete poverty to billionaire, and the only thing stopping any of us is our own drives and talents (in a perfect world we could also add “integrity” to drives and talent) .

I want to challenge anyone to tell me who else would bother to spend millions and millions of dollars trying to develop new medications that might end up proving through complex research and studies to be a wash, or, could possibly help people function and contribute to society, find cures for disease and illnesses, and even give someone more years to live than they would have had otherwise. The answer to that question is NO ONE I can think of. So without them, even with all the good and bad, they play an extremely important role in our lives because they research and study new and novel ways to, yes, make a profit, but also to literally save lives, and make life bearable/and or functional for those that often desperately need help.

As an aside, they also have many patient assistance programs that they should be recognized for. Most of them will supply free medications to patients in low income categories. A good source to find out if you are eligible for these programs is: http://www.needymeds.org/. This industry is in no way perfect, but they do not deserve to be “thrown under the bus completely” in my opinion.

My hope is that we can all put biases and blame aside and just at least listen to each other’s opinions and experiences. I certainly don’t have all the answers, but I do have insights into my own unique world that I hope you can at least consider. I want to always be open to new knowledge that will allow me to have a “shift of paradigm” if another point of view can sway my stigmas and biases. I think the rigidity and prejudices that continually cause us all pain and injustice need to be challenged. I don’t think any of us have all the answers to everything (to think otherwise is delusion and/or arrogance), and my personal goal is to grow and learn and be open to new ideas…and I hope that is your goal.

All of my blogs are dedicated to Jeff, Melissa, and Wayne, and ….Madison and Brooklyn, and of course Unkie, Kirsten and Will!

I love you all dearly!

Penny

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“REPORTS OF MY DEMISE HAVE BEEN GREATLY EXXAGERATED!” (Mark Twain) by Dr. Wayne Jones

I’m glad to be back! We have had technical issues with our site for several weeks. Everything should now be operational.

FYI, in case you didn’t catch this before,  I’m a “sport bitcher”.  I love complaining, and being sarcastic, especially  about “the system”.  After 52 years of observation and study of neuroscience there is only one thing I know for sure…if the government is involved it’s screwed.  (This is to be continued later.)

In order to bitch convincingly I stay well informed through informal as well as formal study every day.  I realized many years ago that every patient is a teacher,  so I spend many hours in the “classroom” every week.

To me the most important knowledge is where science meets practical day to day reality. The best medication in the world is irrelevant if it’s not available or it’s unaffordable.  Making the best possible treatments  happen or getting as close as we can is part of the art of medicine.

As I try to answer questions for my patients, as well as those that inquire on my website, I draw on many sources of information.  My facts will almost always be right.  Some of my ideas, assumptions, and beliefs may turn out to be wrong, but looking back at the the things I’ve written over the years I’ve found most of it is still right on target using the current scientific data and my own clinical observations!

I believe that the foundation of medicine/psychiatry is empiric science. That means we gather information and observations, and then develop hypotheses…and ultimately theories to explain them.  One thing that characterizes scientific ideas is that they can be proven wrong. We are constantly modifying our understanding of how things work.

When we look back 100, 200 years at what philosophers/scientists thought, we think, “are you kidding me?”  Well, guess what? …one hundred years from now we are not going to look so bright.  Unfortunately, the more we learn, the more we realize we don’t know.  An example within the last century is that we have gone from the solar system, to the galaxy, to billions of galaxies – each with greater and greater complexity and mystery.  As we have expanded outwardly we have explored the seemingly infinite micro-diversity of each cell and atom.  To paraphrase Socrates, what I know best is there are a lot of things I don’t know.

I see my job as educating patients about the pros and cons of each option and then let them make the decisions that effect their personal lives. Time will tell if we are going the right direction, and we will expect to make adjustments along the way.  As circumstances change, new insights are developed, new studies are conducted, and new options are available we will be better able to meet the needs of  each individual patient.  This should be very encouraging for those that are struggling to function well, feel good, and live better lives.

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Russell Barkley, Ph.D., is considered by many professionals to be the most authoritative expert (researcher), on the cognitive/behavioral aspects of ADHD.

Russell Barkley, Ph.D., is considered by many professionals to be the most authoritative expert (researcher), on the cognitive/behavioral aspects of ADHD.
In his book, Adult ADHD (2010), he details a study where he followed a group of non-ADHD young kids to age 30 and compared them to a group of ADHD kids. There were about 100 kids in each group.
The most striking finding in this study is that untreated ADHD impairs functioning in every area of life. They are less likely to be employed, and if employed, make less money, have had more jobs, have less education, worse grades, or took longer to get through school. They were also in greater debt, had more relationship problems, worse health, more traffic tickets, and other legal problems.
In my clinical experience over the past 40 years I have seen more people’s lives dramatically improve with ADHD treatment than any other mental health condition I treat, usually by prescribing a stimulant.
Long-term adherence to treatment is a problem with all medical and mental health problems, but many times it is because patients did not get the right medication(s) at the right dose(s). Sometimes cost is the primary problem but adequate generic medications and sometimes patient assistance programs can solve that issue.
We ADHD personalities are driven by interest rather than importance. We tend to be easily distracted and have way too many things on our mind at any given moment. ADHD medications can help us be calm and focused, and not only cope with our rapidly changing modern world, but actually thrive.

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“Badge of delusion”

 

Most people who read the editorial in the Friday March 27th Dallas Morning News will totally relate to the indignation toward the abusive behavior of a Dallas police officer, Robert Powell.  He showed such a lack of empathic understanding and social intelligence that it challenges our faith in mankind.

 

Most people will also feel at least some comfort as the editor did in the conclusion that although he will probably keep his job at least he will have to live forever with the self-knowledge “that in a matter of life and death, he screwed over a fellow human being just because he could.”

 

Unfortunately, this is living in a fantasy world where deep down everybody is a good person.  In my 42 years of practicing psychiatry I have never had an abusive person come in and say, “I am an insensitive, self-absorbed, abusive person and I really feel bad about it.  I suffer from guilt and shame and I want to do whatever I can do to atone for my bad behavior.  I know it’s wrong to get high on power trips and watching people squirm – I know it’s wrong to feel smug and righteous using the letter of the law to ignore extenuating circumstances, while jacking people around.”  And they also don’t say, “I know I should care what other people think of me, I should be able to put myself in other people’s shoes and be able to see things from their perspective.  I know I should have at least some spiritual connections and values outside of myself.  I shouldn’t rationalize and blame the victim when there’s a bad outcome.  I have to be true to myself – I was doing my job – the dude broke the law – everybody has an excuse.”

 

Reality is that it’s only those that are abused and victimized that live with the memory and pain forever.  

 See editorial http://www.dallasnews.com/sharedcontent/dws/dn/opinion/editorials/stories/DN-cop_0327edi.7341749c.html

 

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Panic and traveling

Question: Dear Dr. Jones, I treated with you about 15 years ago for agoraphobia–and was helped very much by your keen insight into this condition. Would you have time for a quick question? I’ve had a problem traveling long distances from home for most of my adult life. I’ve had periods of remission, lived well despite the condition, working as television reporter, etc. But the problem is, in short, I’ve always limited my travel fearing “the big one.” Now, I want to go to Europe before I’m too old to enjoy! Klonopin works well for me. Do you think if I just plain old up and flew off to Italy, I would not have a “breakdown” if I brought Klonopin?— even if when I got there, I became extremely panicked by facing such a long trip after a life time of fearing it? In case you advise to “work up to it” with smaller trips first–I do note that whenever I force myself to take a trip I always have some degree of panic/pain (although also enjoy the trip!) and one time I had violent panic one week driving 30 miles away–then, flew 1000 miles the next week with less fear! Then, came back and panicked again going 30 miles! For me, sucessive approximation doesn’t seem useful. Thanks so much for any information! Best,
Kate


Answer:

Dear Kate,

Congratulations for not letting Agoraphobia/panic attacks control your life
to any large extent. Although I can’t make specific treatment
recommendations, there are several general principles that apply to your
situation.

First, panic attacks associated with travel in cars, planes, etc., are the
claustrophobic kind which are related to hypersensitivity to increasing
levels of CO2 in your blood – conditioned fear responses and anticipatory
anxiety results in shallow breathing and a build up of co2. The best way to
prevent this is to breathe properly – out first…see my website section on
panic attacks for the full technique. http://test.askdrjones.com/wp-content/uploads/handouts/HO%20Anxiety%20Handout.pdf. Practice this periodically and always use this technique when you
start to get anxious or panicky.

Klonopin is the strongest panic preventer but like most medications needs to
be taken in the right dose. Panic patients tend to take as little as they
can get by with instead of as much as they need. Usual daily dose is 2-3mg
but can be higher. It’s ok to sedate yourself on long flights if necessary.

Desensitization is situation specific – so that being able to fly 1000 miles
doesn’t mean you can necessarily drive long distances. Avoidance or using
escape makes you worse, as does hanging in there but having a horrible
experience. Using proper breathing and or adequate medication to get
through it makes you better. Some people need to add an SSRI or SNRI to
facilitate full desensitization. Positive self-talk and having distractions
can also help.

Good luck!
Dr. Jones

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Best Medications Revisited

In December 2006 I participated in a survey of psychiatrists by a pharmaceutical company.  They asked me if I could have only five medications to prescribe which ones would I choose?  Since I have a cash only practice I have to go with the most effective medications long term.

Most medication studies are to meet FDA requirements, which means short studies (6-8 weeks), and they only have to show 50% improvement in symptoms and be statistically better than placebo (that may be associated with only 30-40% improvement).  These studies do not represent real world treatment – patients can’t be given any counseling and can only be on one medication. 

It is only through extensive clinical experience that we can learn which medications are best.

I think of the best medications as the ones that patients come back and say are great….that they have changed their life – side effects are minimal, and the highest standard is that they are still saying it after 6 months, 1 year, 5 years, etc.  If the medication starts working on day one that is a bonus. 

Great medications help you feel better, function better, be less stressed and help protect your overall health.  Great medications also enable you to focus on your life – career, relationships, hobbies, and not be constantly preoccupied by symptoms and survival.  You think – I wish I had this medication a long time ago. 

The main problem with the best meds is cost – especially if you don’t have good insurance – but usually there’s a way to get the medications you need or at least to find generics that are close to the best branded meds.

In my experience stimulants as a group have the highest batting average (the highest percent of the time a particular med works great).  I have patients that have taken them for over three decades.  I haven’t seen any long term problems from taking them.

I was initially trained in the 60’s.  One of the most helpful things I was taught – “if what you are doing isn’t working, do something else.  Even if it is wrong it will get you unstuck.”  This led me to trial and error and eventually to appreciate the value and relative safety of stimulants.

Amphetamines have been available for over 70 years and methylphenidate over 50 years so we have more experience with them than any other medication that we currently use in psychiatry.  Ironically, stimulants aren’t included in the top 10 most often prescribed meds by psychiatrists in the first quarter of 2008.  Despite the fact we have much safer delivery systems the FDA still regulates all the stimulants at a higher level – requiring a written prescription and maintaining a record of each prescription. This creates practical problems, inconvenience, etc.,  not to mention a certain intimidation is felt by doctors.  By contrast, the most abused prescription medications – pain meds – such as Hydrocodone – are much less regulated.

My top 5 list has changed some since 12/06 and hopefully will keep changing as we get even better medications.  For now it consists of the following:

#1     Stimulants – Vyvanse (preferred by 3/4’s of my patients who prefer amphetamines) and Adderall XR (preferred by 1/4 of my patients who prefer amphetamines).  15% of patients prefer one of the methylphenidates such as Concerta, Focalin XR, or Daytrana.

#2     Benzodiazepines – Alprazolam (Xanax and Niravam are my first choice).  Clonazepam, especially Klonopin wafers are a  close second.  

Alprazolam, in a recent study was the #1 med prescribed for stress symptoms by primary care physicians.  Psychiatrists in 2008 used Clonazepam #1, then Seroquel #2, and Alprazolam #3 for stress symptoms.   

#3     Sleeping medication – Ambien CR/Lunesta (I rated Ambien CR first in 06 only because 15-20% of patients have a bad taste the next day from Lunesta – but using a mouthwash with whitener morning and night usually prevents significant taste problems).  Both of these meds work great for most people.  They are both approved for long term use and provide normal sleep.  Short acting Ambien is still preferred by some patients and some take it because it is in generic and they can’t afford CR or Lunesta.  Short acting may not keep you asleep more than 5 hours and has some risk of side effect issues.

No sleep medications were in the top 10 meds prescribed by doctors in 2008.

#4     Antidepressants – Pristiq/Effexor XR – I don’t have enough experience with Pristiq (son of Effexor) to be confident that the majority of patients will end up preferring it to Effexor XR, but in theory it’s better, safer to use, easier to dose, easier to combine with other meds, especially Wellbutrin.  Wellbutrin is the only antidepressant that almost never has weight gain or sexual side effect issues (except for infrequent uses of MAOI’s like Emsam patch).  But Wellbutrin doesn’t have efficacy for the whole range of anxiety and depression symptoms so it would not be the preferred med if you could only use one antidepressant.

Cymbalta is the other antidepressant in this category.  It has more FDA approved uses including fibromyalgia, and generalized anxiety disorder and is very similar to Pristiq in its ratio of effect on serotonin and norepinephrine.  I rank Pristiq first because it has much lower protein binding and therefore gets into the brain faster and works faster.  Prestiq has essentially no drug drug interactions whereas Cymbalta inhibits metabolism of certain medications that can either result in unexpected side-effects or interfere with the activation of pain medications like codeine or hydrocodone. 

#5     Mood stabilizers – Abilify/Seroquel.  There is no perfect choice in this category.  I use these two the most but I also use a lot of Lamictal, Zyprexa (Symbyax) and Lithium.

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I have had chronic sleeping problems for 10 years. I am a 58 yo woman going through menopause. My mother is 90 and still on sleeping pills. Could my condition be hereditary? Which pill will give me 7 hours of sleep leaving me refreshed the next day?

See the Do’s and Don’ts of sleeping habits on my site:   

 http://askdrjones.com/wp-content/uploads/2006/06/sleep_dos_and_donts1.pdf

Make sure you are doing all the cognitive and behavioral things you can do to optimize sleep. 

You are in a high risk group for insomnia.  Sleep problems are more common in women than men, increase with age, and are aggravated by menopause.  The onset of your insomnia coincides with perimenopause.

Estrogen has many more potential benefits than risks for most women – especially brain benefits.  Unfortunately, if you still have your uterus you have to take some progesterone.  There are options like long acting intrauterine forms of progesterone that can minimize side-effects.  I am totally opposed to oral estradiol such as Estrace.  http://test.askdrjones.com/2007/04/28/say-goodbye-to-the-pill-ladies/

  Premarin or synthetic Cenestin by mouth and or estradiol cream/gel or patch is the best form.  The WHE study 5 years ago scared a lot of women about estrogen replacement therapy but the women in the study were on average 10 years post menopause and never used estrogen – that puts women at greater risk and may apply to you especially if you smoke.

One milder option is prescription DHEA which in women mainly turns to testosterone (good for bone and muscle) but then in the brain is converted to estrogen – avoiding the increased risk of estrogen related breast cancer.  

There are occasional women who benefit from natural progesterone (Prometrium) at bedtime since it has a natural benzodiazepine like sedative effect.  I recommend that you don’t take synthetic progesterone like Provera.  

Any form of alcohol can contribute to sleep problems because it causes arousal as it wears off.  If you do drink alcohol make sure it is not within 3-4 hours of going to bed.

We are fortunate to have very effective sleep medications that provide normal sleep.  The mildest, shortest acting is Sonata, usually 10mg-20mg lasts 4-5 hours.  Benzodiazepines such as Xanax, Klonodine, Ativan, etc., shouldn’t be used at bedtime because they decrease stage 4 sleep (the most important type of sleep), but they can be used for early awakening with inability to get back to sleep – since we get all our deep sleep in the first three hours.

Lunesta (2-4mg is needed) for sleep but may cause a bad taste in 15-20% of people (less likely if taken with orange juice).

In general, Ambien CR is better than Ambien tablets because they frequently don’t last long enough.  The generic form is probably weaker.  The CR form is not as strong as the tablets for inducing sleep but lasts longer.  Some people have to combine CR with the short acting tablets to get to sleep.

All of these sleep medications work better on an empty stomach – combined with good sleep habits as I stated earlier.

Circadian rhythm problems can also contribute to the problem.  Morning bright light and or evening melatonin or prescription Rozerum may also help. 

Adding Tenex or Clonidine, or occasionally Prozosin can be helpful.  Trazodone, Seroquel, or low dose Doxepin may help.  Neurontin (up to 800mg) or Lyrica also induce normal sleep.

Chronic insomnia can be very resistant because of all the anxiety and conditioned negative expectations.  It is harder to treat initially and gets easier as fear of insomnia subsides.  When problems persist a sleep study can help identify problems such as restless legs, myoclonus, or sleep apnea.

When all else fails there is a medication that usually works, Xyrem.  It is highly regulated because of previous misuse of it as GHB.

Because good sleep is so essential you have to persist until you find what works for you.  Don’t give up until you find the right medication at the right dose.    

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