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Psych Q&A: ADHD vs. Asperger’s, Hormonal Imbalances, Why Living Location Matters, and Bad Therapy

21 Nov

A friend teaching an abnormal psych course at a local community college asked me and a couple of my cohort members to serve as an “expert panel” for her class. I told her I’d be happy to help as long as the word “expert” stayed firmly between a pair of quotation marks. Her students ask great questions. Here are a few of them, with my two cents in response:

“On paper, ADHD and Asperger’s seem very different.  However, can a misdiagnosis happen to these patients?”

Kids with ADHD often miss the social cues their peers are able to catch, which can result in poor understanding of appropriate social behavior. They tend to have a hard time forming age-appropriate friendships, and eye contact is often poor. For these reasons (and possibly because Asperger’s is something of an “in vogue” diagnosis at the moment), we have quite a few parents who come into my departmental clinic for a child Asperger’s eval and leave with an ADHD diagnosis. In structured diagnostic observations, it’s usually not difficult to differentiate between the two. Kids with ADHD are more interested in reciprocal social interaction than kids on the spectrum, are more expressive, gesture normally, use normal intonation, and don’t have a clearly defined special interest. Autism spectrum disorders and ADHD are frequently comorbid, however.

“It seems like lots of disorders involve mood swings.  Are patients ever treated for hormonal imbalances?”

Psychologists who have had  exposure to integrated care models and cross-disciplinary research (and these days, most psychologists have) are very likely to consider the possibility of medical causes, although they can’t administer medical treatments themselves. When conducting intakes with clients in my departmental clinic, I usually ask about personal/family history of both medical and mental health conditions and any current medication or substance use. If a client has no relevant medical problems or family medical history, and did not begin using a new type of hormonal birth control or treatment around the time mood issues began, I usually abandon hope that a simple hormonal issue is implicated, especially if there’s a family history of mood disorders. (To be honest,  I’m always secretly hoping that clients struggling with fatigue or apathy will turn out to have hypothyroidism, because it’s so beautifully easy to treat. Unfortunately, hypothyroidism is much less common than mood disorders, and this rarely happens.)

 “Does where you live matter for developing mental illness?  Like in the city vs. suburbs, or East Coast vs. West Coast?”

That’s a tough question to answer. Cities often provide better access to care than more rural areas, so mental illness may be more quickly diagnosed and treated there. Poverty is more likely to be seen in inner cities or rural areas than suburbs, and since poverty is associated with increased risk of mental illness, you might see better mental health in suburbs if only because the people who live there tend to have a higher socioeconomic status. Supportive social networks serve as a protective factor, so living in isolation might put a person at higher risk for mental health problems than living near or among other people. Seasonal affective disorder (which isn’t a disorder in itself, but a depression modifier) is more common in less sunny states (like Washington state… might explain why no one in the Twilight movies ever seemed that cheerful). If you can find a relatively sunny place to live near people you like, a job with a middle-class salary, and good access to mental health care, your risk for mental health problems will be lower, although you’ll still be stuck with your genes.

“Does therapy ever make a person worse?  How often?  Why?”

Therapy can sometimes make things worse. I have no idea how often this happens, or how you’d track it. Sometimes it comes down to therapist variables – a therapist may behave unethically (it’s rare, but therapists do occasionally take advantage of clients), leading questions or comments might be directed toward a suggestible client, or a client may be so put off by a therapist’s personality, technique, or ignorance to cultural variables that he doesn’t seek psychological services he needs in the future. Sometimes it comes down to errors in treatment: some interventions are helpful for some disorders but contraindicated for others (ex: behavioral activation in the form of intense exercise can produce great results for a person with anxiety or depression, but it’s a bad choice for a client with an eating disorder). Psychology has a long history of unhelpful and dangerous treatments, including but not limited to rebirthing, “boot camp”/”scared straight” interventions for conduct disorder, recovered memory techniques, conversion therapy, and so on. Researchers can do a pretty good job of identifying treatments that don’t work, but it takes a lot of time and money to do this. As a client, you always have the right to ask your psychologist what techniques he/she plans to use and whether there’s research support for them. If a technique isn’t research-supported, it doesn’t necessarily mean it will be harmful, but it has yet to be proven that it works. On the whole, research indicates that therapy is an effective treatment for psychological disorders, and people with mental health conditions will generally benefit from it. You’re more likely to get worse by not going to therapy than you are by going.
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