Sunday, November 19, 2017

Comments by Barliman

Showing 13 of 13 comments.

  • In the end these brain volume issues really apply only to small and quite specific areas. They really are visible evidence of different ways of processing information (which may be maladaptive).

    The real trouble is that because ADHD is defined by psychiatrists they take arather limited view of it- neglecting the physical signs which should by all irghts be identifiable in a neurological condition. Things are less backward in Europe though:

    A Swedish study:

    http://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2009.03407.x/full
    “Reliability and validity of the assessment of neurological soft-signs in children with and without attention-deficit–hyperactivity disorder”

    Additionally we are getting stronger and stronger evidence of problems like oculomotor problems – which are stimulant responsive:
    https://www.ncbi.nlm.nih.gov/m/pubmed/12672781/?i=4&from=/24691355/related
    Altered control of visual fixation and saccadic eye movements in attention-deficit hyperactivity disorder.

    Oculomotor Abnormalities in Children with Attention-Deficit/Hyperactivity Disorder Are Improved by Methylphenidate.
    Bucci MP, et al. J Child Adolesc Psychopharmacol. 2017.

    https://www.ncbi.nlm.nih.gov/m/pubmed/28452866/?i=1&from=dopamine%2C+fatigue%2C+oculomotor%2C+exercise
    Which is:
    Effects of Dopamine and Norepinephrine on Exercise-induced Oculomotor Fatigue.

    So lets think about this- attending with the eyes (reading) is a major part of the disability in ADHD,
    it is correlated with ocuomotor deficiencies that are improved with stimulants
    The same set of problems can be demonstrated in athletes who are exercised past their fatiguing point.

    So we have a plausible mechanism for oculomotor symptoms as a cause of ADHD symptoms, we know that they are ameliorated by stimulants. We also know that at least in the earl stages of treatment they substantially improve attention and learning (until you learn too much, read too much and exacerbate the problem.

    If we take this a little further we see that behavioural optometrists use a questionnaire that asks many questions that overlap with ADHD questions.

    Now these oculomotor problems are treatable by behavioural optometrists and by people who specialise in neurological rehabilitation/ functional neurology, most of whom are highly trained chiropractors.

    I have discussed the issue with one of them (when I was seeing him for treatment for my ADHD/Oculomotor issues [now almost full settled]) and he agreed with my reasoning that given the serious oculomotor fatigue and problems with training in bad habits during neuro-rehabilitation, the use ofsimulants then may be indicated.

    That’s pleasing really- hitting relevant mechanisms, and aiming to minimise duration of treatment.

    however, I do not think there is any sense in denying the problem exists, and zi think there is no sense at all in labelling a condition as a neurobehavioural condition without doing a proper physical examination. This approach is rare in psychiatry though.

  • Lisaloo1969,
    it is not quite as simple as you suggest- the experiences are usually not of non dual awareness. The majority of nyam are far from that and most of them are more likely symptomatic of autonomic imbalance.

    I have been meditating off and on for about 7 years with slow but steady increments of benefits. I can’t sit for too long because I have a bad back, and after a certain time persisting with the one position becomes just too painful to be beneficial. it is better to fall back and find the point at which the pain arises and work with that. This approach has helped me identify and manage the postural imbalances that drive the pain (an incorrect posture inevitably loads one muscle group excessively and that drives pain).

    The points that concerned me about the story you linked to were
    1) No attempt to screen applicants and see they were fit for a 10 day intensive both in previous psychological history, in meditation experience ( this is an arbritrary guess on my part, but maybe the ability to do 2-4 hours meditation 4 days in a row might be a suitable qualification?) and in grounding in Buddhist philosophy.
    2) No experienced teacher to warn students of what was a healthy, normal experience and what was not), and to take daily reports of their progress. The latter is a standard practice in many Buddhist monasteries.
    3) No debriefing.

    One aspect that worries me (I am a medical practitioner) is that meditating with pain for a long while can drive a severe stress response- and in a suitably vulnerable, anxious individual this may drive an anxiety state into a frank psychosis.

    A second point which may need to be considered (less applicable to Vipassana, which is done eyes closed) but strongly applicable to eyes open sitting meditation and to Tai Chi retreats, relates to the question of vision.
    At the very periphery of our visual field there is a margin in which one cannot see a stationary object, but can see a moving object. Now it turns out that movement in that marginal area will always trigger a strong stress response This is good thing as this reflex will save us from being run over and I understand that no less an authority than the Dalai lama has said that this kind of core survival reflex is not expected to be removed by Buddhist practice. However the trick is that in a crowded meditation or Tai Chi room there is continuous subtle movement at that margin- and that might be enough to tip a fragile individual into psychosis.

    Really I think that this might be more likely to trigger psychosis than spontaneous experience of non dual awareness– after all most of us get little hints of that quite frequently (ie that moment when you found yourself skiing perfectly– the moment before you thought to yourself “Hey, I’m skiing perfectly”— and crashed”.

    However the points raised in the article you linked to were well made, and I for one will take them up with my teachers, one of whom is heavily influenced by Goenka.

  • The studies you mentioned lead to an interesting conclusion:
    If the rate of ADHD diagnosis is related to age of entry to school, and ADHD is being conceived as a neurodevelopmental problem, then this logically suggests that school is not a good environment for the development of young children. That seems like a logical conclusion to me.

  • Steve,

    thanks for the links- I was only aware of the Australian one- and there are questions about the independence of one of the people involved in it. I will look into them.

    It disturbs me that so few practitioners are aware of the nature of DSM. All you have to do is read the introduction– but it seems that that is rarely done.

    The “chemical imbalance’ model is just nuts ( unless you are talking about depression due to hypothyroidism or some such problem). The proponents of that model can never account for the fact that these neurotransmitters subserve multiple functions in many parts of the brain, and that in most cases chemical therapies are “shotgun treatment”. In that regard I suspect that the stimulants are the most pathway specific medications, as the dopaminergic pathways are quite limited in the brain.

    I do think that there is value in making the syndromal diagnosis- simply because it predicts a lot of the sort of problems that the individual will experience. In particular people with ADHD are being told they are being wilfully lazy, and to just try harder. That sort of help usually makes the problem worse and it betrays a fundamental misunderstanding of the nature of the problem.

  • Steve, how many times have the studies regarding age at diagnosis been replicated?

    I do agree that there is a real issue with kids going to school too early and spending too much time seated doing work that they could compete in 1/4 of the time if they did it a year later.

    Equally, the structure of DSM is not powered to identify causes. I’m sure that a significant group of the kids who experienced many adverse childhood events would be classifiable as having ADHD if they were fully assessed.

    I remember a paediatrician commenting that an ADHD diagnosis should be the start of investigation- not the end.

  • You can’t do a scan in an individual to come up with a specific label because the labels are based on clusters of behaviours.

    So a syndrome like ADHD is always going to be heterogenous and there will be great variations between individuals.

    However, as I said, finding neural correlates is important and helpful as it allows us to tailor interventions down to specific rehab exercises, and that decreases the need for medications.

    Plenty of kids with ADHD grow out of it for many years, but the underlying problems do tend to crop up again in middle age, as we age, and as we are forced to work in sedentary positions Not only that but they also show up in other ways- like a chronically overactivated stress syndrome, and as chronic pain as the body takes more and more wear and tear from one’s clumsiness.

    I can only agree that the use of labels in psychiatry is often clumsy and over -rapid, but that does not mean the labels are useless.

  • You seem to have missed the whole point of my comment.
    I am saying that the ADHD label is a real label describing a discrete problem, that does have distinct features that can be linked to particular areas of the brain.

    I do not agree that stimulants are the best solution in most cases. In fact I support the treatment recommended by Biedermann- manual therapy where there is an identifiable suboccipital problem, but I would add physical rehabilitation to address the physical issues like coordination and ocular congergence issues.

    Stimulants can help, but not all people benefit from them. The real issue is that psychiatry has got dumbed down to medication only treatments or preoccupied with complex and often unhelpful talk therapy ( I hate to think how much I personally wasted going down that path).

    I had intended to follow my previous post up with a comment that the issue with ADHD being a psychiatrist’s diagnosis is that they have a VERY limited repertoire of treatments and they tend to overuse their tiny arsenal of medications when usually non medication approaches are better.

    The problems caused by unreliable attention have actually been the subject of discussion for some millenia, and if you look carefully you will see that what the Buddha said boils down to “suffering occurs because of inadequate attention (to the nature of reality).

    I have highlighted the common issues with coordination and also the fact that these link well to predictable brain areas. If you cannot understand the subcortical (and therefore utterly unconscious) nature of ADHD symptoms it is difficult to offer any useful advice to us which does not sound like more of the same abusive nonsense tht we have been subjected to since we entered school.

    However having an understanding of the nature of the problem in brain terms actually points to better solutions:
    We have clear evidence of the value of meditation in reducing anxiety and stress, and good evidence of brain changes that correlate to that activity. If we broaden our view a little, some other meditative practices like Tai Chi (which involves slow and precise movements repeated until they are perfect and the underlying posture is also perfect) are working on the areas of the brain which are not working so well.

    This sort of knowledge is empowering- not disempowering.

    The latest material linking brain areas with particular problems is extremely useful, but it is not the last word. My own position is far from the “Scientism” point of view (which I am utterly at odds with) that the brain is the seat of consciousness. We have more than enough material from near death experience studies to support the continuation of consciousness after the cessation of neural activity.

    However ADHD is a behavioural disorder, and all behaviour is expressed through the nervous system, so the nervous system is of interest to those keen to deal with the problem, rather than just take positions.

  • Here is the catch ceebee, the behaviours that are a problem in ADHD are not voluntary. They do not occur because they are being rewarded. They usually are not even driven by threat in the environment- (though that can worsen them). The behaviours represent escape of behaviours, and that escape will happen pretty much as soon as our back is turned and our awareness focusses on another subject.

    We do actually know better, we don’t like them, but it is very hard to suppress them.
    Yes- things like hostility in the classroom or home will effect us, as will inadequate physical exercise and too long at the computer– they will affect anyone- but we tend to be the first affected. All this creates considerable stress and worsens the problem, but correcting those will not fix the problem.

    We are told to just pay attention and be disciplined- but paying conscious attention is effortful and there are a limited number of things anyone can attend to at one time. What is really going on, as best as I can understand that the routinising of subbehaviours (components of larger behavioural repertoires) has not worked well.

    You can take the simple example of clumsiness as a good analogy (and also appropriate given the prevalence of clumsiness in ADHD). If you are clumsy, and trip on things all the time, you have to pay more attention to walking and that limits what other things you can do when walking. The same with typing or handwriting- more effort has to go into the basic act of getting the thought on paper- and that leaves much more chance of losing track of your train of thought.

  • As a rule we don’t even have an adequate definition of “mind”!
    Then there is the confusion as to whether mind and consciousness are simply emergent properties of matter, or whether they have a reality at another level.

    I prefer the Buddhist definition of “coarse mind” ( the consciousness that is wedded to this body) Subtle mind (the consciousness that passes from birth to birth) and very subtle mind- or pure awareness.

    Now plenty of people won’t subscribe to the idea of reincarnation, but I like the idea of consciousness being entangled with the body. In that sense the entire distinction between mental illness and bodily illness becomes much more subtle. In fact it is subtle- as can be seen by the number of phrases for mental illnesses and emotional states that reference the body- ie a jaundiced view, bitter and twisted, the straight man.

    However these problems would still exist even if we used some other label for them. There are good descriptions of the ADHD phenotype in the 18th Century by Alexander Crighton (a Scottish physician) and Melchior Adam Weikerd (a German physician), and a probable example from Hippocrates too. We do not gain much by simply relabelling them.

  • As with all research we see the biases of the author coming out in statements like “Their data, the authors wrote, confirmed that patients “with ADHD have altered brains; therefore ADHD is a disorder of the brain.””.

    In fact ADHD, like all other DSM categories (I believe the term diagnoses is semantically incorrect) consists of a population defined by their common behaviours.

    We have plenty of evidence of neuroplastic brain changes, so inevitably a set of commonly repeated behaviours will result in predictable changes in the brain. In making the comment above I believe the authors simply unconsciously expressed the biases inherent in their professional orientation.

    There is a great deal of confusion about ADHD, but as I say it is defined as an inherent part of the DSM, and no amount of tinkering with the definitions will make it go away unless we jettison the whole DSM and all the diagnoses. That’s not practical, as all these definitions have clinical utility. My ADHD was finally picked up 9 years ago- at age 45. It would have been helpful to know about it earlier. Though it has not prevented me from working as a doctor, it has caused an awful lot of misunderstanding in interpersonal situations and made work much harder. In adults most of the impulsivity and hyperactivity diminish greatly, but the inattention remains, and causes a great deal of difficulty with mislaying necessary items and being disorganised. These inevitably create the impression that one is an uncaring partner.

    The neuropsychologist Leonard Koziol has written extensively on the role of subcortical structures and cognition, including a book called “ADHD as a Model of Brain -Behaviour Relationships” his comments about the diagnosis ADHD are interesting:
    First, ADHD is a behaviorally defined diagnosis as it is charac- terized in the DSM system. And in this regard, we com- pletely agree with Carmichael and colleagues’ (this issue) bold statement that from a neuropsychological perspec- tive, ADHD does not exist. There are absolutely no broad-based neuropsychological test batteries that can ever lead to that diagnosis nor is there any ‘‘litmus test’’ for the disorder called ADHD (Koziol, Budding, & Chi- dekel, 2013; Koziol & Stevens, 2012). However, the fact of the matter is that from the behaviorally defined DSM system, ADHD does exist.
    and….clinical neuropsycholo- gists are compelled to agree with the proposal that history, observation, and behavioral rating scale data are the primary methods for diagnosing ADHD (Barkley, 2006). In fact, we go a step beyond that viewpoint in stating that these simple behavioral meth- odologies are the only justifiable means for making that diagnosis. This conclusion is based on one simple fact: If a clinician is bound by the DSM system
    ( “Attention and other constructs:Evolution or Revolution” Koziol et al APPLIED NEUROPSYCHOLOGY: CHILD, 0: 1–9, 2015)

    Now while the category ADHD, which is behaviourally defined, is a useful construct as far as it goes, it is also misleading as it focusses attention only on behaviour. It is now becoming accepted that cognition essentially involves the internalisation of movement and developing the skill to execute ever more complex movements- so why is this area not investigated?

    It is already well known that there is a significant overlap between dyspraxia, dyslexia and ADHD, but these disorders are separately classified. They should not be because all three disorders share a common neurological basis with problems in the planning and perfection of routine movements (cerebellar), and the routine switching between tasks at will (basal ganglia).

    Furthermore, when you look around you will find that therapists dealing with ocular convergence and coordination issues in children use screening questionnaires that actually borrow many of the same questions that would be used to diagnose ADHD. A classic feature of cerebellar issues is difficulty adjusting movement to the requirements of the moment- with a tendency to overshoot or undershoot the target- and that issue is most marked

    Additionally the German Orthopedic surgeon Heiner Biedermann (book- Manual Therapy In Children) headed a multidisciplinary team looking at the consequences of birth injuries to the upper cervical spine, (which is common, and becoming commoner as babies get bigger). He found that the injuries tended to persist due to ongoing instability in the upper cervical spine, and the children would develop dyspraxia and dysgnosia (a broader term than dyslexia) as well as common postural issues. He found that these children were effectively behaviourally indistinguishable from other ADHD children, but that early manual therapy was effective in greatly reducing the ADHD symptoms, and usually in ceasing medication.

    The association of the upper cervical region is interesting because most of the proprioceptive (body position) information comes from the muscles at the top of the neck, and there is ample evidence that abnormal tension in these muscles can impact on eye coordination and dynamic visual acuity. Biedermann’s book also covers other types of incoordination.

    Since my diagnosis I have seen several hundred ADHD adults, and have had the chance to physically assess them. Issues with balance and coordination are virtually universal, and of varying severity. Many ADHD adults have developed mastery in one sport or another, but have frequent injuries, and also have a history of frequently tripping on minor floor irregularities or bumping in to furniture- usually in their home or workplace (where they are less vigilant). A thorough physical examination will almost always reveal mild cerebellar signs, and problems with eye movements. However the signs are more mild than we as doctors are used to looking for in more severe cerebellar disorders.

    So the point is that while the label ADHD is useful it is limited by the fact that psychiatrists mostly think about thoughts and cognitive processes. The way this plays out at the moment is that it obscures the real physical issues that are driving the problem.

    Stimulants are often helpful, especially when the situation is spiralling out of control, but their effect is not long lasting, and tolerance will inevitably develop.
    Addressing the underlying problems is going to be a more permanent solution – good manual therapy to correct underlying postural issues, rehabilitation of the coordination problems ( and I would include specific play therapy like one to one work to improve ball handling skills- which will allow ADHD kids to enjoy sports, as the clumsy ones usually get excluded) and a substantial reduction in the amount of seated time in class, and in front of screens will all help.

  • Re Alan Wallace’s book- pages 105-107 (Stage 6: Pacified Attention). Alan directly references “The Vajra Essence”- and enumerates a long list of anomalous psychophysical experiences that can occur.
    “while many of us would likely respond to some of those disagreeable experiences by stopping the practice or seeking medical help, Dudjom Lingpa actually calls them all signs of progress…. whatever comes up was already there, previously hidden by the turbulence and dullness of the mind”.
    We can see already from the tone of the paper that there is a tendency to look upon these experiences as pathological or harmful, and this may be the trap in the approach of Western psychology which adopts and teaches mindfulness practices, often without being aware of the fine print.

  • The point of the recently developed therapies involving meditation is specifically to move away from any religious framework, and nobody is forced to engage in them.

    Most of the therapies involve being able to establish a calmer mind with less unnecessary wandering and less tendency to get trapped in obsessive negative thinking. They also involve greater awareness of body sensation, and learning to be calm and non-reactive to bodily sensations.

    This is important as it is now well established that most of our actions and responses are driven by emotional reactions- that these emotional reactions all have a distinctive key signature of body sensation and those sensations feed in to our brain where they will drive actions which are sometimes too impulsive and potentially harmful to ourselves and those around us. These therapies will not cure everything (acute mania, severe depression, and florid psychosis would all be major barriers to success).

    However they are distinct from TM- which as i understand it is only based on achieving stable attention.

    Meditation really only becomes religious when it is coupled with religion specific practices. I agree 100% – those have no place in therapy. It sounds like your experience was pretty awful.

  • These experience are well known in Buddhism, and in Tibetan are called Nyam. They are well described in Alan Wallaces book “The Attention Revolution”.

    They differ from Schizophrenia in that they are transient, and have many psychosomatic symptoms and provided one does not either become obsessed with reproducing them or frightened by them (avoiding attachment and aversion) they will pass and the meditator will settle to a normal mental state afterwards. Usually you need to be meditating a lot to get them- -ie 4-8 hours a day on a retreat going for some days.

    They are actually regarded as a good sign- that your mind is still enough to pick up on these things (which I suspect would only come to you in dreams).

    If they occur on retreat you have the advantage of being able to discuss them with your teacher- but they could be frightening if you did not have that support.

    I do use a Buddhist based meditation technique (Mindfulness Integrated CBT) as a therapy in come cases, and it interests me (as a Buddhist) that there is little discussion of these possible symptoms, as some patients do get very inspired and go off and do lots of meditation without supervision.

    Equally, I suspect that as one progresses further down the meditation path, one may get little hints of the experience called emptiness, or Sunyata. That may well be unsettling as well- again highlighting the need for support.

    So- appropriate support by an experienced teacher is always important, as is access to ongoing advice and support if the patient wishes to pursue an ongoing practice, as many do. However the possibility of some of these difficult experiences is NOT a contraindication to using these therapies.