Conversations, with Dr. P Organizing Problems in Mental Health Part 1. Q and A
Conversations with Dr Puhalla Getting Started Part 1. Organization of Problems.
You start off by saying “I want you to know what I know.” especially about common mental health problems that are biologically based, that often start in childhood and that shouldn’t be missed, what are some of these problems?
I start by looking at the following six problem areas, concentration, motor and vocal tics, anxiety, depression, thinking problems, unstable irritable, angry , rageful moods. These can be diagnoses in themselves or can combine to form complex diagnositic pictures with very different medication approaches helpful for some and yet make others markedly worse.
Can you further explain and expand on this list?
For the sake of making sense out of these common problems that can have many causes from a biological and specifically biochemical origin I start by looking at these problems or symptoms that could have specific medication treatments that could change a person’s life, sometimes literally save it. Those cluster around the above problems in the following way and each having its own biochemical treatment approach. 1. Concentration deficits without any of the others problems being present, 2. Involuntary Motor movement like eye blinking, facial grimacing, and vocalizations like throat clearing and coughs, called Tics, 3. Anxiety symptoms like worry, compulsions, fears, panic, social anxiety and other forms of avoidance, 4. Stable Depressive symptoms including their physical counter parts like headaches, stomach and intestinal problems, 5. Thinking problems that can be very subtle and seemingly mild, like thinking too fast or slow, being a little off with logic, going off on tangents, yet having devastating effects, 6. Unstable moods, irritability, anger and rage, that may have associated with it brief periods of depression or again its equivalents like headache and stomach-bowel problems, and to this expanded basic list I add a seventh or 7. an “Atypical” Category for people who have some of the above yet don’t fit into the above.
How can these be expanded to diagnoses, specifically as it may involve a child or teen in school?
Let me start by naming some problems that correspond to seven symptom diagnostic clusters, that help me organize my thinking that may show themselves by poor school performance and other school related problems, with a representative example disorder, 1. Concentration difficulties that could be seen in ADHD or Attention Deficit Hyperactivity Disorder, 2. Motor movements, vocal sounds like throat clearing, associated with over activity, and compulsions, and poor learning secondary to attention problems as seen in Tourette’s Disorder, 3. School refusal, a multitude of physical complaints like stomach and intestine problems, as seen in Panic Disorder, 4. Inability to get out of bed in the morning, no energy, lack of drive and motivation, falling school grades, as seen in Major Depressive Disorder, 5. Unexplained changes in personality, withdrawal from others, declining interest in school, and outside activities, as seen with Thinking problems that are often the first symptoms or Schizophrenia, and other disorders that effect thinking and relatedness, 6. The miserable, angry, irritable child or teen, who has mood swings, and fluctuating school performance as seen in the unstable mood disorders, of the Bipolar Spectrum, and lastly 7. a proposed diagnostic cluster that can look like any of the above and present with some of the above problems, yet fits into none of them, and has atypical responses to usual treatments especially medication that I call the “Atypical Child-Person”.
So your saying a child or teen with some problems in school academically or behaviorally or with school attendance can have some or all of these disorders, this is more complex than I imagined, how does one go about sorting all of this out?
This is the art and science of medical-psychiatric diagnosis, consisting of three minimum parts, 1. symptom picture, 2. history of the problems including family history, and 3. treatment response. Start with the complaints that the person or the family is presenting, listen carefully, look at some symptom screening check lists, take history from every one involved, take more history, don’t jump to any conclusions about a diagnosis, but make a provisional diagnosis based on the symptom picture, the history of the problem, as seen in the individual and their family, and when every one is ready after medical, environmental, drug and alcohol, and psychological factors have been ruled in or out, and factored into the picture, consider a carefully managed medication trial.
Is there a best place to start or does it depend on the complaint?
One always starts where the patient and their family is at, and not with some preconceived idea about what may be going on, or what somebody else may have said or concluded. Start at the beginning especially with the chief complaint and the story around the complaint. The story around the chief complaint is the history, see if the chief complaint exists by itself or with other complaints that may not be chief or primary but yet may be equally if not more important when it comes to diagnosis and picking a treatment. A good place to begin to illustrate this is with concentration problems, do they exist basically alone, than it may be the diagnosis is ADHD or do they exist with an unstable mood, or significant anxiety or depression or motor or vocal tics, or with problems with thinking, then one of the other diagnoses may be causing the concentration problems not ADHD and the treatment and the prognosis is vastly different. One could start with any diagnositic entity but because of its relative simplicity from a biochemical point of view and its excellent treatment response, the differential diagnosis of ADHD can go far to illustrate principles of diagnosis descriptively and biochemically and adequate treatment.
It sounds like this is one of those diagnosis, that is ADHD, that shouldn’t be missed?
It is, and it is still misunderstood, overly diagnosed, under diagnosed and mistreated and yet it is such a wonderful thing to see a child or person with uncomplicated ADHD be treated adequately and their life is changed for the better. This in one of the most satisfying and remarkable treatments in all of medicine.
I’ll be looking forward to more discussions with you just about ADHD.