What can it be, besides ADHD?

Your child is bouncy. He doesn’t seem to pay attention; she forgets to follow through on tasks. The book bag is a disaster area; necessary books never seem to make it home; and you regularly have to turn around and go home to pick up shin guards or ballet shoes.

Well, what can it be, besides ADHD – the psychiatric diagnosis of Attention Deficit/Hyperactivity Disorder, diagnosed off a checklist and sometimes suspected of being over-diagnosed?

The symptoms associated with ADHD can be due to a wide variety of issues; here are a few:

Stress at home or in the environment. If you are having marital or other family difficulties, your child is stressed – whether you know it or not. Research indicates that a, adults are pretty lousy of telling when children are anxious or worried and b, the children of adults with marital problems, when tested in research studies, have high levels of stress chemistry metabolites in their urine.
Maybe it’s not at home; maybe it’s the environment. Live in a noisy and/or high crime neighborhood? Is your child bullied or afraid of being bullied at school? Sources of ongoing stress will interfere with the parts of the brain that are important to focus, attention and memory.
Insufficient sleep. Is your school-age child getting 9 or 10 hours of quality rest per night? Falling sleep by television, computer, or with a cell phone close at hand? These will all interfere with quality and quantity of sleep.
What are overtired kids like? You know what you do when you’re driving late at night and you are too tired to be driving – so you bounce in the seat, sing too loudly and pretend having the windows open will magically keep you alert? Yeah, well…meet the 3^rd grade kid who is up too late because of football or soccer practice a few times a week and fidgets around looking dazed in class.
Insufficient exercise. The recommendation for children is two hours of physical activity a day – real activity, not standing-around-hoping-coach-lets-me-play-this time activity.
Boredom. Brains + boredom = either shutting down and not trying at all OR driving grownups and other kids bonkers. Look out for the introverted or shy child who may shut down and go into dreamland; a lot of gifted children are very introverted and self-contained, and unlikely to be overtly disruptive. They simply tune out.
Frustration. A child who is having difficulty – perhaps an undiagnosed or insufficiently supported learning disability – will often give up and stop trying. Remember that children personalize things; if they are struggling and the grownups act like they “should” be able to “get it,” the child assumes the adults know best and that the child must be flawed/”stupid” etc.
Your (or some other involved grownup’s) inconsistency. If you flipflop on rules, fail to follow through, and run an unpredictable life for yourself and your child, it’s not fair to look at the child who seems scattered or (more likely) is gambling on this being one of those times when you are too stressed or preoccupied and let things slide, and blame the child.

You’ll notice that none of these issues can be blamed on the child. These are all grownups-need-to-pay-attention flags, not “naughty kid” flags. So, before you assume your child has a brain disorder, rule out the many factors that we grownups often unwittingly inflict on children and see if, with a few months of more consistent attention to these risk factors, your child’s behavior and morale improve.

Dr. Lori Puterbaugh

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

Avoidant Personality Disorder, Social Anxiety, or Just Shy?

Simple shyness? Social Anxiety Disorder? Avoidant Personality Disorder? What’s the difference? Are we just pathologizing normal behavior? Why so many labels?

Well, the labels exist to help professionals differentiate between constructs. That’s what most diagnoses are: categories put together by committee, identifying particular experiences or patterns of behavior, thinking and/or feeling that tend to co-occur. That’s an extreme simplification, but it’s a good jumping-off point for us.

Shyness is normal-people-speak. It’s the way we describe someone, or ourselves, when we are a little reluctant to “blow our own horn” or “put ourselves out there” (whatever THAT means). A little shyness means some mild worry about doing the right thing, not embarrassing ourselves, and wanting to avoid being a nuisance.

Social Anxiety Disorder (SAD) is a psychiatric label that covers a level of shyness that interferes with someone’s daily life. That’s the test: whether the person’s regular life is constricted by worry about saying/doing the wrong thing in social settings and a tendency to avoid social gatherings or work or school related activities. It’s anxiety: there are both physical symptoms of fight-or-flight (elevated heart rate, for example, or more perspiration) and psychological symptoms (worrisome ideas about being in the spotlight and doing something “stupid,” for example). People with SAD usually have close relationships and get through daily life pretty well, with bumps along the way when big events or unusual circumstances – public speaking at a work meeting, for example, or large gathering – looms.

Avoidant Personality Disorder (APD) is sometimes confused with SAD. ADP is markedly different, though, because it encompasses a global low self-esteem and fear of being judged and found wanting in just about every way. So, for example, the person with some social anxiety has close friendships but might feel a bit anxious about going to a wedding reception with a lot of people s/he doesn’t know. The avoidant person has few close relationships out of fear of people finding them just not good enough to be friends. The APD person suffers anguish before annual performance reviews, and even gentle constructive criticism is received as devastating evidence of how deficient they are.

The fear is not “just in their head.” Fear is always a full-body experience. When a situation seems to be a threat (for the person who suffers with APD) to be judged and found wanting, the body responds before the logical, higher brain has even identified what is happening. So the amygdala has sounded the general alarm – the endocrine system flies into action, and as a result logical assessment is curtailed. Telling someone whose heart is pounding, whose blood is full of adrenaline and a massive dose of glycogen and is primed to run away that they are just overreacting is not helpful. Learning how to manage this, how to recover from the old messages of being “less than” and “not good enough,” is a process, not an instant fix. It can be healed.

There’s much more to these labels and to the details of treatment, of course, but perhaps the useful take-away today is: help is available. A lot of people will find that solid self-help approaches based in cognitive-behavioral therapy research (David Burns, MD’s books are excellent examples of these) quite sufficient for mild to moderate social anxiety. When that anxiety is all-pervasive, and there are few relationships out of fear of being found wanting, and loneliness and fear of being judged rule one’s life, the additional support of a counselor might be more helpful than trying to struggle through alone. Ironically, group psychotherapy can be quite effective for these difficulties – but it’s hard to find them.

If you know someone who is struggling, try to help them get help.

Dr. Lori Puterbaugh

Why are personality disorders so difficult to treat?

Well, there’s a complicated question! This post attempts to present an overview response.

A personality disorder, like just about all mental disorder diagnoses, is made based on a checklist of complaints, symptoms, and observations. However, personality disorders are very different from what we normally think of as emotional problems.

Consider, for example, depression. “Depression” is diagnosed when 2 weeks have passed and certain criteria have been met (and there’s no “pass” given for grief or other traumatic events in the new diagnostic manual, although we’re supposed to note it in the records). Most people know when they’re sad, irritable, unhappy, and hopeless. It feels awful and they want to get that bad feeling off of them. Some people might not think of it as “depression.” They might identify it as a “low time,” or it might be grief, or a normal adjustment to a new phase of life such as marriage, an empty nest, or graduating from college. It might be a normal but very painful response to some new curveball life has thrown at them: an illness, a layoff, retirement, etc.

A personality disorder is different because it is pervasive; like the personality of any person, it is part of everything. Your personality impacts how you interpret everything that happens, the way you react to people and events, the emotions you experience. This goes for healthy people as well as those whose patterns are far enough from the big, wide range of normal to merit a “disorder” status. So, when someone seems to have a personality disorder (say, narcissism), they are not experiencing their diagnosis as a messy, icky experience to be stopped. They are rolling along (over other people) and having their life. Everything comes through a lens that assures them that they are special, entitled to preferential treatment and to have their way, and, well, let’s face it, just better than us. Problems are experienced as due to the outside world and their own role in those problems is not apparent.

From a therapist’s perspective, when someone comes in with depression, even if that’s not what they, or we, might call it, they know they are unhappy and they want very much to feel like themselves again. They are hopeful that a counselor can help them push through this difficult time.

When someone who meets criteria for a personality disorder comes to treatment, it’s usually because of some other issue, such as work or relationship problems. Remember that each of us is walking around, seeing the world through our own eyes and interpreting everything we experience, including our own thoughts and feelings, through our unique mental structure. You build that mental structure from the earliest moments of life. Is the world safe? Are my needs met? Are the grownups who tend to me patient, gentle and kind? Babies are already sorting out information and creating a set of basic assumptions about the world that will become essential aspects of their personality. It’s so deep, it’s hard to not take for granted that our way of making sense of things isn’t necessarily the only, or best, way. So when patterns of problems arise with colleagues, bosses or family, it’s hard to believe that the problem is fundamental to our mental structure; it defies logic and could be very insulting. The person may be suffering terribly, every day. This is definitely the case with some of the personality disorders, such as Borderline Personality Disorder, Avoidant Personality Disorder and Dependent Personality Disorder. Whether these or any of the personality disorder diagnoses, the person did not choose this burden and it isn’t their fault. However, presenting it as an internal problem – to them – can feel like blaming and attacking – which is definitely not the therapist’s intention.

Imagine if something terrible happened to you: a tsunami. Your workplace is destroyed. You lose your house. You lose your stuff. You catch a mosquito-borne illness and suffer long-term ramifications. It’s a series of terrible events and you find yourself traumatized and perpetually anxious. Is that anxiety your fault? Certainly not. Just so, the early life experiences that set people up for the challenges we call personality disorders are not their fault. However, it’s a problem that they can learn to heal, but that can sound like blaming the victim. Thus, if someone meets criteria for a personality disorder, trying to sell them on dealing with the personality disorder is pretty much like saying, “Look, an awful lot about the way you think and respond to things is kind of messed up. But, never fear! Together we can bulldoze your personality and how you think, feel and behave, pour a new slab, and then we’ll rebuilding you from the ground up. You’ll learn new ways of thinking, feeling and behaving.”

Even when it’s dressed up in tactful, compassionate psychological language, that, my friend, is a very hard sell indeed.

Dr. Lori Puterbaugh

Oh, the drama!

It’s about 2/3 of the way through the spring term, so it’s time again for my intro psychology students to learn about the various personality disorders, as defined by the American Psychiatric Association. One interesting one – and not necessarily in a good way – is Histrionic Personality Disorder (HPD).

Traditionally, HPD was estimated to occur in perhaps 2-3% of the population. You know these folks; you’ve known them all your life. They’re exciting, intense, and fun; the life of the party, the center of attention…and they can’t turn it “off” when appropriate. It’s the “friend” who wears a very well-fitted white dress to your wedding; the family member who always has to make it “about them,” when it’s very, very much about someone else; the middle-aged parent who is trying to compete with a teenaged child to the point of embarrassment (for the child, that is). They lack empathy for anyone but themselves, but can emote with the best of them. Recent studies indicate that incidence of HPD is exploding – with some estimates as high as 27% of the young adult (under 35) population now meeting criteria for the psychiatric diagnosis. It’s thought that the two-generation long emphasis on having high self-esteem absent any achievement of good character or performance might be involved, as well as the current culture that elevates attention (any attention) as better than just chugging along, living your life happily with the people you love.

Which of our grandparents would ever, in million years, have imagined everyday people talking about how many “followers” they have, as if they were Jesus?

Like almost all psychiatric diagnoses, HPD is defined by a checklist; meet enough criteria according to the clinician holding the checklist, and you’ve earned the label. Of course, someone with HPD isn’t coming for therapy for help with HPD. Others may come for help with them, or it may become apparent within the context of counseling for some other issue: relationships, work conflicts, etc. It’s sad, really, that it can be so difficult to realize one needs help, because at the root of this is a small child, still jumping up and down crying out, “Mommy! Watch this! Mommy – look at me!” and that small child in the unconscious just doesn’t realize that all the jumping up and down cannot make them feel “seen,” and they need to find other ways – more adult, meaningful ways – to feel connected and recognized. After all, everyone wants to be seen by eyes that love them; didn’t the film Avatar touch on that well, where the most intimate thing people could say to another living being was, “I see you”?

Like some of the other personality disorders, particularly Antisocial Personality Disorder, Borderline Personality Disorder, and Narcissistic Personality Disorder, the person with Histrionic Personality Disorder will seem fine…in fact, better than fine. All four can be very charming, interesting, and fun. They can seem special and their attention can make the next victim caught in their vortex feel special until all heck breaks loose.

Be compassionate but beware. No matter how wonderful, loving and patient you are, healing the wounded heart under HPD is not a one-man or one-woman task.

Dr. Lori Puterbaugh

What are you waiting for?

The American Association for Marriage and Family Therapy asserts that the typical couple coming in for counseling has had difficulties for over five years…which makes me wonder, what are they waiting for?

There are a lot of seemingly perfectly sensible reasons to postpone counseling when things start to go awry:

“It’s expensive.” This is true; counseling does cost money and relationship counseling is an out-of-pocket expense. Still, most therapists are cheaper than two retainers, two divorce attorneys, a mediator, a parent coordinator, etc…

“I don’t want to be told what to do.” Well, a good therapist isn’t just going to tell you what to do. A therapist is going to be asking a lot of questions, having you fill out a lot of questionnaires, and trying to develop a very clear picture of your relationship’s specific strengths and the particular types of problems each of you identify. That way, research-recommended approaches can be matched to the problem(s) of the particular couple.

Fear. Don’t a lot of people fear that it’s going to be like that old Simpsons episode, where, after Marge vents for hours, the therapist turns to Homer and says something to the effect of, “I’ve never said this before, but it really is all your fault.” That’s not what happens in real life.

Shame. So many people suffer with shame over the difficulties they are having. Marital difficulties feel like a failure. Yet, if marital problems were some rare, shameful thing, why are there so many marital therapists? We have our own doctoral programs, professional licensure, and organizations. Beyond that, other non-specialists in the mental health professions also offer couples counseling. Shame can be overcome by getting help and feeling less alone in the suffering.

The Ostrich. Just try to ignore it and hope it goes away: the addiction, the affair, the endless disputes about parenting or money or values and ethics. Some things, ignored, will go away: a minor cold, a pimple, a minor aggravation of the day. Other things, though, just fester and turn into a nasty emotional infection: resentment, trauma, guilt, hurt.

If your relationship is suffering from feelings of distance and disconnect, or seems to be a vortex of repetitive arguments, counseling could be very effective. Often, five or six appointments, spread out over four to six months, can make a world of difference when both parties are willing to work at changing patterns of behavior and experimenting with new ways of interacting.

It’s important to find a counselor who is a good fit. Call a few of us; talk for a few minutes; get a sense of style and see who seems like a good fit for the two of you.

Be bold. Push past shame and fear; challenge your inner ostrich. Then start to feel happy again.

Dr. Lori Puterbaugh

Toxic Myths, revisited

A lot of people ask about toxic myths: what does that mean? Why “myths?” (I’d like to say, well, buy the book, and sometimes do).

The toxic myths are examples of lies dressed up as truths. Our culture is seething with them, but in Toxic Mythology, I only addressed a few.

For example, consider the myth that people can compartmentalize their lives. Someone can, within this myth, be an absolute scoundrel in their personal life but supposedly be capable of being completely trustworthy and honorable in their public/vocational role. Conversely, they can (per the myth, at least) be a sociopath in their professional life but be kind, tender and good in private.

So…if you buy this myth, you have to be willing to:

Vote for someone who swears to uphold a particular principle while having a personal and/or professional life littered with betrayals and a habit of acting on expediency, not principle;

Believe your child who promises she didn’t really cheat on that exam or plagiarize on the paper (despite the software evidence) after same child was grounded for “borrowing” money out of your wallet without permission.

Keep on an employee whom you overhear lie to customers because you haven’t caught that employee lying to you.

Convince yourself that your gossipy acquaintance never, ever would talk about YOU behind your back.

Does any of that sound reasonable? Of course not; these are, however, the toxic myth in action. Our culture tells us that it’s perfectly reasonable to believe that compartmentalization of character is possible and (further) that we should be “judgmental.” That’s another myth for another day.

Dr. Lori Puterbaugh

Cognitive Behavioral Therapy: So Much More than Positive Thinking

It’s more than just positive thinking

A smart, thoughtful person mentioned the other day, in conversation, that Cognitive Behavioral Therapy (CBT) seems to be just “the power of positive thinking.” That’s probably what it sounds like when it gets boiled down to a sound bite…but in reality, it’s so much more. There are many excellent resources out there, so I won’t attempt to tackle the whole topic here. A brief example, though, on the difference between CBT and simple positive thinking, might help.

In CBT, we are indeed looking for patterns of negative thinking. These are identified, and then we dig down to the underlying thoughts. From there, the challenging and reforming of particular thoughts begins. Then comes the hard work of rehearsing those new thoughts.

Consider, for example, an adult who is very anxious about grades in college. This student is up late studying, preoccupied with grades, and anxious to the point of headaches and nausea before tests. The student feels terrible, of course. The top layer of thinking probably includes themes such as, “I have to do well,” or, “This is too important to fail.” The level of distress the client feels, though, seems out of proportion; the client is sick and nauseated over A- or B+ grades. Digging deeper, the client turns out to have buried beliefs such as, “Perfect or failure – no in-between,” or, “Hero or zero,” or, “No one loves a loser.” Thus, the A- feels like a failure and even a threat to love and security. Those aren’t conscious thoughts: no reasonable grownup thinks, “Oh, no one can love me because I got an A-!” It’s more of a personal belief, often acquired early in life, which became the background to many experiences.

You can see that trying to be “positive” about the top layer thoughts might seem silly: “Oh, it’s fine to fail,” or, “It’s OK for me to not do well.” The client cannot buy into that. However, a deeply held belief – that one is either perfect or a complete and utter failure – merits serious attention, and probably underlies many difficulties for this client. Thus CBT starts it work – which is much more complex than presented here – by seeking the foundational troubling beliefs that are leading to the negative thinking.

As I noted – this is a cursory glance at one aspect of CBT. It is a well-researched method of treating anxiety, OCD, depression, and other difficulties. If it seems as if it might be helpful for you, please see appropriate professional guidance.

Dr. Lori Puterbaugh

Review: The Collapse of Parenting: How We Hurt Our Kids When We Treat Them Like Grownups, by Leonard Sax, M.D., Ph.D.

A friend recommended this book and this past weekend I read a large portion of it. It’s aimed at parents and others who are directly involved in raising children, and cites some pretty striking research about the negative outcomes of giving children more freedom and flexibility than they can handle. Children being given the control over their lives that ought to be reserved for responsible adults are far more likely to develop anxiety, depression and obesity; they have less attachment to their families and adults in general, and are more likely to turn to peers for advice. Their peers, of course, are not apt to know any more than them about making wise choices about life.

It’s a conundrum for some: after all, kids have to learn how to make choices, but they can’t handle the full variety of options that many parents want to give them. Learning how to present a narrow, fair range of choices is, apparently, a challenge for parents who are desperate to be liked. This craving for their children’s approval underlies a lot of dysfunctional, but seemingly well-intended, parenting. I described a parent’s style as a “democracy” (the children are school age) and the parent took it as a compliment…as if being democratic with children, where no one is really in charge and knows best, was a good plan.

Do kids need choices? Absolutely. Do they need – or can they even handle – the full range of options that an adult might handle? Absolutely not.

For parents, teachers, grandparents and others who work with children, this book is a friendly, accessible but thoroughly footnoted guide.

Dr. Lori Puterbaugh

…and still more decisions!

Decisions, decisions!

Our nephew and his wife are considering relocating. Given their jobs, they are employable just about anywhere – so the choices are as vast as these United States. They’ve created a spreadsheet to rate the places they are considering on a variety of factors: climate, culture, length of commute, ease of accessing travel to family back home…we’re looking forward to seeing how they narrow their choices as they visit cities and rate them across variables.

It’s a useful way of making difficult choices where there isn’t an obvious “right” or “wrong” choice to make. Take the job that makes less money but is more satisfying and allows for more flexibility, or take the higher-paying job that provides better long-term financial security? Take a second job or scale back on expenses? Move far from family or stay close? The problem, of course, is even ranking how important the factors are, really, in the first place.

Maybe deciding on a job isn’t the right example for you. Perhaps you have to decide on whether to downsize or stay put, or which school to attend. Whenever there are multiple factors to compare, weighing the factors in importance to you can help narrow the choice. Writing it all down – in a chart, or listing – can help, because then it’s in front of you, not rattling around in your head, where it keeps butting into whatever else you’re trying to manage in life.

Then, too, sometimes making decisions is complicated by stress and fatigue. If you’ve ever felt overwhelmed and too hungry to pick something to eat, you’ve been in this state. Likewise, trying to figure out what task to handle first, when everything seems overwhelming. Just doing something – even if you change your mind and revert to a different task – is better than paralysis.

Some people are able to make decisions quickly and easily; for others, the fear of making the wrong decision impacts even minor choices where “wrong” would be, at best, a minor disappointment. If you’re the kind of person who gets stuck in decision making, experiment with some other ways to organize the choices: a spreadsheet or simple paper and pencil chart or list, or focus on what is most important to you as a factor, or, for minor issues, take action and see if that is the better option or if starting in the wrong direction helped you discern, quickly, the right path to take.

Of course, if anxiety is interfering with basic decision-making, please consult a professional.

Dr. Lori Puterbaugh

Decisions, decisions!

Choices are good, right? Until they’re bad.

Too many choices becomes overwhelming. We can see the results of seemingly endless choices and information when we, or someone we know, gets lost in hours/days/weeks-long process of sorting through online reviews and information in the attempt to make a decision that might have been made over a dinner conversation twenty years ago. Grownups have problems with this, and yet so many parents inflict too many choices on their children.

It’s important for children to learn to make choices and endure the consequences in small, safe, age-appropriate doses. It’s also important for children to feel like the grownups are running the show. Offering opportunities to make choices – within defined parameters – and then sticking with those choices, are great learning experiences for children.

Consider asking a five-year-old:

“Would you like applesauce or yogurt for a snack?” versus, “What would you like for snack?”

What are the odds the child isn’t going to go for fruit or low-fat dairy and will instead choose something the parent wasn’t planning to provide? With so many modern parents afraid of upsetting their children and overly eager to have their children’s approval, children are left without anyone big and safe to place limits around their world. Temper tantrums, anxiety, and entitlement are often the results.

Children benefit from parameters and calm grownups being in charge. A calm, in-charge grownup can offer safe, appropriate opportunities to learn decision-making skills and learn to live with the consequences.

Dr. Lori Puterbaugh

drloriputerbaugh

Psychotherapist, Author, Teacher

Tag Archives: self esteem

What can it be, besides ADHD?

Why are personality disorders so difficult to treat?

Oh, the drama!

What are you waiting for?

Toxic Myths, revisited

Cognitive Behavioral Therapy: So Much More than Positive Thinking

Review: The Collapse of Parenting: How We Hurt Our Kids When We Treat Them Like Grownups, by Leonard Sax, M.D., Ph.D.

…and still more decisions!

Decisions, decisions!