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Bipolar, Cobra and ADHD: Are We Killing a Hognose Snake?
Virtual ADHD Conf Starts Monday
October 3, 2009ADHD Medications: Neurotransmitters to the Rescue
November 2, 2009Is That Bipolar Mind Cobra In Your Face? Then What Do We Do Now?
Out in the metaphoric mind-woods? Think you have the diagnosis right? Let's take a few more minutes to get the specific, correct identification. See what you think about this brief video, and don't look at the info on it – in a minute I'll tell you a personal story about this snake – and the relevance of misidentification.
OK, picture this: You already know I'm a Boy Scout, looking regularly to help old women across the street, son of a physician, looking, even in childhood, to save my fellow man from the challenges of personal catastrophe.
So as a kid, out on a Scout camping trip in southeast Missouri – out in the deep sticks – I had a run in with a big snake… but permit me first to set the scene.
A Few Notes on Southeast MO 1952-1956
I lived in Dexter, right there on Thrower St where the Union Pacific RR made a sharp turn, and we could regularly hear the whistles of the passing trains as they rounded that corner heading South. It was a small town, country life, and after the war, WWII that is, a hobo would occasionally come down Thrower, knocking on doors looking for a little cleanup work and a sandwich. I started early thinking about where they were going and how they got to our front door. They never had much to say. By that time in my life, about 12 yrs old, I had traveled over most of the western states in a 39′ Chevy Coup we called Sue, so the nomadic dreams were already well oiled from pre-school.
Cotton Picking Vacation
If you look on the map at that Dexter link and see the hill and woods on the left, and the flat square areas of farmland to the right… that flat space is what they call the Cotton Belt. We were released from school to stay home in the fall for ~ 2 weeks every year to go out and pick the cotton [‘cotton picking vacation'] before the days of mechanical harvesters – in the early 50's [more later in another post]. Those picking sacks came in two sizes: short and long, the long was about 10.' Work all day, might make between 3-5$. Not fun.
We could look out from our back yard vantage point and see for miles across those flats and farms. That flat area and the ridge that supported Thrower was the old bank of the Mississippi River from thousands of years ago. Linnae May Wiley lived across the street on Thrower, she had no indoor plumbing, chopped cotton [weeded with a hoe] and picked it for a living, and cooked pig brains for breakfast. She was mysteriously quiet, very pleasant, and could move down that cotton row like a ghost. She hooked us up with work gigs.
The Cobra Looms in the Woods
On the occasion of this camping trip I already have a reputation with my friends having killed a pygmy rattlesnake at Scout Camp that previous year, was seriously chasing merit badges, and was a little older than some of the other kids on this trip. Interestingly, I told them on the car ride down there that I had just heard on the radio that a Cobra had escaped from the Springfield MO zoo [true reportage], and wondered privately what I would do if I came across a Cobra. Reassured, I knew that Springfield was on the other side of MO, and didn't sweat the outing – looked forward to it.
Then in the woods, quite innocently walking along, we hear a very large hissing noise, and looked just a short distance ahead to see a hooded snake [see video] looming and hissing, ready to strike. I quickly decide – this is the Cobra! I know snakes, and know that no American snake has a hood and hisses like that. So what would be the smart thing to do? … Yes, my fiends, you guessed it – it would have been best to simply walk away. Good sense.
The Moment of Recognition
But no, I have to save humanity. So I get everybody back, work around the hissing situation, imagining what it will be like if he is faster and I get bit – break off a big stick, and proceed to kill the snake. It was a proud moment. No one of my friends and I had every seen anything like it before. Parker saves Missouri from extremely fast traveling venomous Cobra. Is there a merit badge for Cobra killing?
Hognose Humiliation
Readers, you know the rest of the story. One of our troop counselors gave me the news… the only American puff adder is the non-venomous Hognose snake, an excellent rat killer, and a friend to man. So, just what is the point?
Consider this contemporary moment of more challenging precise identification and recognition…
Looks like Bipolar, but no….
Thursday of this week I saw a 45 yo bedraggled, unemployed woman who:
- Dropped out of high school her freshman year because she was doing so poorly – after making great grades through grade school.
- Has had time in jail for cocaine possession and abuse, – abused alcohol, marijuana, and cocaine since early adulthood.
- Goes to the bathroom, passing a monolithic stool once a week under great duress – this pattern for MANY YEARS!
- Suffers with profound estrogen dominance, long history of PCOS, significant perimenopausal symptoms.
- She thinks of suicide almost every day, but will not harm herself because of religion.
- Has regularly failed antidepressants and distrusts doctors – SSRIs make her spaced and irritable.
- Can't hold down her job tending bar now that she is a felon.
- Sleeps about 2-3 hrs/night every nite
- Does not eat protein, no breakfast, poor lunch,
- Hasn't had any Vit D level taken, but is now well into her long standing pattern of seasonal affective disorder as well
- She looks hypothyroid and hands are cold hair is thinning, and she is significantly overweight.
- She has been severely abused by her first husband and has scars on her face to show.
- She is totally alone and required to see a psychiatrist only to fulfill probation requirements.
And here is the punch line: She has been, as many are, misidentified as Bipolar – the venomous, recalcitrant kind! Refractory to antidepressants means bipolar to so many. Looks like a hooded Cobra to me… and by the way, refractory to mood stabilizers.
I don't need to say much more – except that I guessed her [typical ADHD] school history in detail before she told me, she is medically sick, markedly sleep deprived and not taken care of – and estrogen, depression and ADHD all can significantly contribute to moods, – she has been ADHD since symptoms in the 6th grade. She has been, in a very unhappy way, left for years to hang in a metaphoric tree, the way I left that harmless snake as a kid because I didn't know the details before I walked in and killed it.
ADHD has NEVER REMOTELY been considered by anyone treating her. She has thought she had ADHD for years.
No this missive is not motivated by guilt, I got over that snake mistake long ago. But that Hognose snake did change the way I think about things – and missing the abundance of diagnoses that have been missed here, is simply catastrophic for this woman. Time for a little redefinition of what we are doing in the process of homogenized psychiatry, chasing superficial appearances, chasing labels that hiss – entirely missing the mind and the person.
Drop me a comment if you read this, your thoughts may tease out something I'm missing,
cp
32 Comments
[…] of human life exists as separate perceptions in the lives of every human being, and disdains homogenized solutions. Psychiatric interventions require far more customization, less managed-care […]
I have found that the mislabeling goes both ways. I was treating a young man for substance dependence and was very cognizant of his behaviors in group and individual therapy. He had been diagnosed with ADHD since childhood and couldn’t maintain abstinence, even on his ADHD meds, he was looking for a way to calm or excite. I explained to him that I believed he was misdiagnosed all these years, not having ADHD, but having Bi-Polar. He was actually relieved because he felt that none of the ADD meds he had been on all his life worked and he was ruining his relationship w/ his significant other and his little girl. He ended up getting incarcerated, but I received a call from his mother, who informed me that he was seen by a psychiatrist who concurred with my diagnostic change and that he was finally getting the help he needed. The symptoms of these disorders can overlap and appear at times quite similar. I think that it is important that diagnostic tools are utilized correctly w/o an immediate label, that colleagues are involved in assisting as offering a second opinion when so many disorders can be this or that. Nothing is clear cut in the world of mental health and that of substance abuse. As providers we must always look at history, current and past behaviors, symptoms, chemical usage,trauma etc.
Kristine,
Thanks so much for your thoughtful and insightful reply… completely agree! The earlier comments by Lorre also addressed this issue over on the ‘other, ADHD side.’
So much of what we do in our offices does require a profound measure of humility in the face of our own ideas not working. If we aren’t ‘getting it’ with a good response to the interventions strategies on the table, we clearly must fall back and regroup. Most important in all of these comments for any of us is the development of thoughtful feedback loops as you have with your patient.
And one further ‘anti-reductionistic’ point, germane to both sides of the question, seen in my own office if I am off the mark: It could be that dreaded multi-headed Medusa Snake – also recognized as Both-and-Then-Some. I have many folks who suffer with comorbid ADHD and Bipolar, and significant metabolic/immune/endocrine issues. Any of the comorbid challenges from gluten sensitivity to estrogen dominance can completely corrupt any informed psych intervention strategy.
Excellent points Kristine, – thanks for your comments.
cp
I am always quick to defend the Bipolar position (maybe from years of having to stand up for myself and the discrimination that goes along with the label I was given years ago.) After watching your video Dr Parker I definately can relate to the cognitive anxiety description. I guess it’s possible I have minimized the effect that just ADHD alone can have. I need to expand my thinking a little because there’s a lot to learn here, and it might break some of the denials in my own life. I’m definitely glad I stumbled upon this blog!!!
Thanks Lorre,
Glad to hear how that additional info sheds some different light on the subject! For my own part, keeping an open mind is essential, because any of us can get caught in overly simplified thinking in these complex presentations.
Be well,
cp
If you “stumbled upon this blog,” you have very good instincts, Lorre! 🙂
I had to search assiduously to find an expert as knowledgeable Dr. Parker on so many aspects of brain health and function.
g
I agree, and I am fortunate to have him for my doctor since I’ve seen a few comorbidities!! Thanks again!
You guys are too kind, – it’s a deep pleasure to have the opportunity to share my time with folks who truly get it!
cp
With the obvious interest in this slithery subject I thought best to link to a brief review of exactly what I am talking about regarding the most missed subset of ADHD, one of two not yet in the books: Thinking ADHD Explained on Video Here on YouTube. See what you think and drop a note. [6.5min]
cp
Great story and post, Dr. P. I am very grateful to have you as a troop leader in this endeavor! I hope you cover the bipolar co-morbidity issue in detail in your upcoming book.
On a related topic, you often speak of Clint Eastwood/Gran Torino depression. Do you also see in your office what I call Willy Loman/Death of Salesman depression (say 55+ (males especially?)) – which may be the result of depressive tendency combined with decades of experiencing “chronic sense of underachievement”, self-concept of “failure” due to undiagnosed ADHD, never quite making it as they thought they would in early life – enabled by mother-like spouse who kept things together?
This is how I conceive by father’s suicide at age 65.
David –
Good call, – have been interested in Loman for years… “a handshake, a shoe shine and a smile.” ;-(
That “chronic sense of underachievement” has also been an interest for years, and is inevitably amplified by the passage of time, and the blind spot on missing the ADHD, that cognitive trip-wire. Indecision promotes the eternal cognitive question of “Just who am I?” – and is never fully answered because the mind simply can’t organize itself well enough to have an opinion, a boundary, or a belief in anything other than bling, and that golden ring on the carousel of life. I’ve met some serious players who simply had no clue about these matters – arrival at a station in life is no reprieve from innocence and pure street stupidity.
Internal doesn’t work, might as well chase approval and external noise since the brain makes no sense, and spirituality remains in question until the lights are almost out. Black and white can kill you.
And if there are no answers, only approval, you feel quite dead anyway. Too bad guys just couldn’t be deep in our father’s time – it was not the Warrior Ethic. Who wants to chase Mastodons when your wing man is ‘self reflective?’ Sorry to hear your dad missed his shot and couldn’t see the big picture.
Thanks for reminding us about Willy, another indecisive, lost soul – trying hard with no real connections. Willy does remind us to turn on the lights.
cp
Maybe we can get Clint (and/or Willy) and you on this program next year. http://www.framesofmind.ca/blog/
They have had almost nothing relating directly to ADHD in 8 years.
You come up, do a compulsive brain day, conference, some professional training etc., evening screening, you and a panel..maybe some great fly fishing on the side……..
I’m at least half serious…
Would love to do this one, looks like a great series. We could invite Clint and have him talk about the character and type-casting. He’s a great guy, don’t have time at this moment to link to a previous CorePsych Blog post talking about my brief meeting with Clint… he is a great guy, gets it, and would probably love to hang out on this subject.
cp
Dr P — I posted your link on FB and here is one of my friends’ comments:
“Reading this struck me on two levels — first being my encounter with the rare Oklahoma Cobra when I was about nine years old and playing on the railroad tracks. I ran like hell then stopped, realizing it had to be a hog nose snake. I went back and caught it and brought it home. My mother was not charmed by this curious reptile and I was not allowed to adopt it.
“Second is that bipolar was briefly my diagnosis before I insisted on further testing which showed I had ADHD.”
Thanks g, interesting response confirmed by street country wisdom.
– those Cobras seem to be lurking everywhere out there – if it has hissing and mood swings it must be a Cobra. But it’s not snake oil!
I just saw another new patient today, new to the Tidewater area, treated since 16 yo, now is 25, treated since the onset with antipsychotics and mood stabilizers. – Had classic Thinking ADHD since the first hospitalization, and now manifests ‘unmanageable cognitive abundance’ – She also has the gamut of medical issues with no substance abuse but clear PCOS, estrogen dominance, bowel transit time of >than 48 hr, ordered thyroid testing, adrenal review, other hormones, D3, B12, and – yes started her on Vyvanse and Pristiq, and will be very interested to see the outcome on her neurotransmitters. No one asked her any of the hormone questions, and no one had ever asked her cognitive history.
She does manifest cognitive dependence on her husband as she freely admits he is her ‘thinker.’
Your friend had better sense at nine than I did and twelve, and I was a learned scout!
cp
Dr. P wrote: “No one asked her any of the hormone questions, and no one had ever asked her cognitive history.”
ACK! Physicians, heal thyselves. How do we even begin to tackle healthcare reform when we have such deep and treacherous knowledge gaps?
Hormones and cognition, oddly enough, are sub sub specializations with no certification!
cp
I am curious about the “since the first hospitalization” qualifier. Are you implying that the severe episode, which I presume led to the hospitalization was a demarcation point or even the cause for a sudden emergence of the “classic Thinking ADHD” (i.e. brain damage)?
I am think,think, thinking of more to say on this…..
Sorry on this one David, was writing away, and didn’t say it precisely.
She suffered from the cognitive anxiety all the way back into our first recognition of it [in her case] in 7th grade. The presentation of the cognitive abundance, the cognitive anxiety, the relentless worrying, the refractory depression is the symptom picture that so often is misidentified as the bipolar cobra. If you have a racy mind in this country it = bipolar. The characteristics of that racy presentation, the history, the context, and the mind activity outside the crisis are all often overlooked in the acuity of the moment. That hood and hissing make it a cobra. Pull out the gun, momma.
Over time, the cobra alert is sounded from doc to doc, and without a detailed background that looks at brain function vs appearances, it is so completely easy to err on the side of not adding to the patients problem by making her worse with stimulant meds. Many of the docs in the trenches with ADHD are strong on these matters, and at the meetings also get pretty hot about this problem.
I may be writing about it, but the other line officers see it as well. The problem is with the docs who aren’t accustomed to this frequently seen manifestation, and the ‘public safety’ becomes the issue. I do hope this dialogue changes the field guide for these observations. Many good folks suffer downstream for *years* with misidentifications.
cp
Dr Parker, I still think she’s Bipolar. Why does one diagnosis have to exclude another? It sounds like she’s both. The sleep issue stands out to me. Also, you said she did well in school until high school.
Whether your snake was a Hognose or a Cobra it was still a snake. But if you let down your guard and conclude it’s only a Hognose that venomous Bipolar Cobra might surface to bite you. If you eliminate the diagnosis of Bipolar and only treat the ADHD, especially if she has a substance abuse problem as well, the stimulant treatment might send her off balance and trigger a relapse as well. If I was in the business of killing snakes I’d err on the side of caution until I knew for sure what kind of snake I was dealing with.
Speaking from experience as a chemically imbalanced Bipolar, ADHD, ex substance abuser, with low thyroid, (who was a straight A and B student until 9th grade when I dropped out of school because of depression, mood swings, acting out, and stimulant drug abuse) sometimes it isn’t always black or white. Sometimes the truth is somewhere in the middle. I know in my case I need the foundation of a mood stabilizer in order for my other meds to work. If I only took a stimulant drug, I think I might spiral out of control-no sleep, cycling moods, etc.
Dr Parker, It sounds to me like you were a Hero, anyway, when you killed the snake. In your mind it was dangerous, and you killed it anyway. You would have felt a lot dumber if you had told everyone it was a Hognose and it ended up being a Cobra and hurting someone.
Really, these are all labels anyway. The bottom line it sounds like she is very malnourished-and needs Tyrosine, Taurine, Trytophan/5HTP, etc. Lots of B vitamins, and all that neuro testing you do to determine the imbalances. If she can’t afford it at least recommend the supplements-
I feel like I’m stepping on Superman’s cape here!!! Far be it from me to advise YOU!!! I’m only speaking from my experience-I just don’t understand the new trend with doctors to throw out the Bipolar diagnosis so quick. It has served me well for 25 years to treat whatever this is we want to call it, but Lithium seems to help!
Thanks Dr Parker, for at least being willing to fight these snakes for us!!!!
Lorre,
Very well said! and so much in line with my own basic philosophy anyway, labels do leave us with reductionistic thinking – and she could very well have a touch of the bipolar bug – comorbidity may prove the lesson here.
The real issue is not the demons name, but the missed opportunity on the ADHD focus and thinking issue since childhood that has significantly contributed to her problems. I confess that I am a bit quick on that ADHD conclusion, simply because it is so completely commonplace, seen almost everyday in my office. Thus this post.
And, since I am truly not Superman, I rely on the foundation of good feedback loops with everyone to keep me straight if I overlook any details – especially folks like yourself who have seen it all, have great depth of possible considerations, and even understand those neurotransmitter possibilities!
Really appreciate your comment, excellent points, and thanks for keeping me in balance – out of that ‘other’ categorical label trap!
I will keep readers here posted on the outcome of this interesting challenge – time will tell.
cp
Hi Lorre,
Many people with ADHD have BIG challenges with sleep. If the diagnosing professional doesn’t know this (and many don’t), bi-polar seems like an easy call. But sometimes a wrong call.
Thanks Gina,
I ordered your book a few minutes ago and look forward to reading it. Both you and Dr Parker have stimulated my thinking on this subject and I really appreciate it.
Good move, Lorre,
Gina makes sense, and her book Is It You, Me or Adult ADD? takes the ADHD discussion into specifics of what to do with challenging relationships, and how to work your own program.
cp
Thanks-it will be helpful for me…and dealing with and understanding my son!!!
Thanks Lorre. I hope you like the book.
Learning about ADHD and other neurogenetic cognitive conditions has completely changed the way I interpret many people’s behaviors. It can be a solid bridge to understanding.
g
Oh boy, I wish you’d write a post on that topic (“dry drunk” with underlying diagnosis).
It’s amazing how the mythology around that has permeated our culture and is so widely accepted as fact — especially in the therapeutic community!
Oh yes, I’ve heard of that complication. Too much investment in unsubstantiated (and sometimes self-serving) dogma, and insufficient interest in science.
g
It is my firm assertion, yet not completely a categorical one, that the refractory dry drunk pattern is:
a. Not purely psychological
b. Not a withdrawal phenomenon per se
c. Not a psychological dependence on the drug,
but is, rather, a clear manifestation of underlying biological dysregulation of some sort.
I’ve seen so many that finally connected with treatment, some quite silently and senior officers of AA etc, just don’t want to blow their cover for taking any meds whatsoever, even tho they are dramatically improved.
We’re still living in those years when we had no evidence, didn’t know brain and body, so there were no other options, – except coffee and cigarettes!
cp
Thanks g,
Good point, will have to get that dry drunk post out soon – mythology does blossom without the opportunity for science, and even in the context of half science. This other comment by Lorre helps shine the light around that question even more with comments on the neurotransmitters and excellent thought about comorbidity – the ‘dry drunk’ post is clearly on my to do list, thanks.
cp
Gina,
Thanks so much! Great fun to change the subject back to rigors of everyday existence.
The part that I didn’t hit, an additional complicating factor, is what the recovery community and her Community Drug Counselors will do with the stimulant medication recommendation. The traditional folks are moving even more slowly, and have their own well deserved bias against care that at times is too aggressive on the other end – so she can be dropped by either side. We’ll see.
cp
Love your snake story, Dr. P., and that poor woman. Let this be a lesson to those abstractionists who dismiss ADHD as overdiagnosed, a pharma invention, etc. — real lives hang in the balance.
I’m so grateful you grew up to find a better outlet for your urge to save humanity because it so needs some saving, especially in the brain department.
“chasing labels that hiss – entirely missing the mind and the person” — profound indeed!
Gina