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Suggest Treatment For ADHD, Depression And PTSD
Question:
Hello,
I am writing to you regarding potential conditions that my girlfriend might have, which may explain symptoms that I have observed over these 2 years.
She is a 42 year old woman who was born in the Philippines. She moved to NYC in 2001. English is her second language but she has very strong vocabulary skills.
During the time that I have known her, I have considered the following potential conditions:
- PTSD
- Mild Cognitive Impairment
- Adult ADHD
- Low grade depression
The symptoms that I have observed are:
- Nearly no recollection of childhood memories
> When I ask her a question about her childhood, she says, "I have to ask my sister."
- Social Anxiety
> She did not start dating until she was 37 years out.
> I have taken her out to meet colleagues. Quite often, she did not say one word the whole night.
> She has become much more outgoing interacting with my family, though.
- Short Attention span. Less Comprehension:
> Not so much lately, but we used to watch movies together and during a scene in the middle of the movie, she would point to the main character and ask what part that person plays.
> Because we have a communication difficulties, I have started to ask her to rephrase what I've said to ensure that the intended message was received correctly, for the most part.
> My anecdotal evidence seems to suggest that:
>> She remembers 35% of content delivered in a two minute time span.
>> Her comprehension of the content delivered is around 20%.
- Mildly inappropriate responses to situations.
> As an example, I might be speaking of something very stressful for to me. If I try to put on a "brave" face with a little smile, she will react as if I were delivering good news.
- Flat Effect
> She rarely demonstrates an emotional response to situations that normally elicits emotions.
> it seems like she has a complete lack of empathy for me. But if I say anything about how that affects me, she is easily brought to tears. Not for me but because it affects her low self-esteem.
She has seen a Psychiatrist and a Neurologist:
Psychiatrist:
- The Psychiatrist diagnosed her as having some form of Depression and some form of AsHD, without the hyperactivity.
> The Psychiatrist prescribed Prozac and Adderall for her. (She's been on this combination of medication for 2 months.)
> I thought the choice of Prozac was a little odd. I think that SNRIs alleviate symptoms of Depression more than SSRIs do.
> After she started taking the Adderall, I noticed an improvement in her focus. But by 8:00 PM, her focus became poor again.
>> That's when I found out that the doctor prescribed Adderall Quick Release, instead of Adderall Extended Release.
>> I asked her to ask her doctor to switch the Quick Release to Extended Release. However, my girlfriend only started taking the Extended Release on Saturday, December 6th.
Neurologist:
- The Neurologist thinks she has some type of Cognitive Impairment but he doesn't think it's degenerative. He said that it was most likely "chemical".
- She did not ask him what he meant by "chemical" so I contacted him to ask if he was speaking about neurotransmitters, specifically Norepinephrine. It's the only one that I know that could be associated with some of these types of symptoms.
- The Neurologist indicated he was speaking about Norepinephrine AND Serotonin.
- I know that SSRIs have a secondary effect of the levels of Norepinephrine in the brain, but, to me, it was an additional indication that switching to an SNRI was warranted. However, the Psychiatrist wants to stick to the current "cocktail".
I am starting to find it more and more difficult to believe that she has been diagnosed as having three different disorders, instead of one disorder which could explain all of her observable symptoms.
For full disclosure, over ten years ago I was diagnosed as having Bipolar Disorder. I am still in the recovery phase from a Panic Disorder episode that started in March of this year.
I am very concerned that when I asked her how she thinks she has been doing the last two months, she's doing much better. However, I feel as if things have gotten far, far worse.
I don't think she is receiving the proper diagnosis or treatment plans but I am not a doctor and I do not know where to turn next.
She asked me to call my Father's Neurologist at XXXXXXX Universities Neurological Institute for Aging, Memory and Behavioral Disorders.
The stress that I've been experiencing trying to live together has been creating a lot of mood lability for me, which I have not been able to manage effectively these last three months. But, today, instead of feeling stressed, angry and frustrated, I just became completely anxious that she might have a significant degenerative disorder.
Any feedback you could provide would be truly appreciated.
Sincerely,
XXXX
PS. I've try to describe things as well as I can. So please forgive some outright misstatements I may have made in this note.
Hello,
I am writing to you regarding potential conditions that my girlfriend might have, which may explain symptoms that I have observed over these 2 years.
She is a 42 year old woman who was born in the Philippines. She moved to NYC in 2001. English is her second language but she has very strong vocabulary skills.
During the time that I have known her, I have considered the following potential conditions:
- PTSD
- Mild Cognitive Impairment
- Adult ADHD
- Low grade depression
The symptoms that I have observed are:
- Nearly no recollection of childhood memories
> When I ask her a question about her childhood, she says, "I have to ask my sister."
- Social Anxiety
> She did not start dating until she was 37 years out.
> I have taken her out to meet colleagues. Quite often, she did not say one word the whole night.
> She has become much more outgoing interacting with my family, though.
- Short Attention span. Less Comprehension:
> Not so much lately, but we used to watch movies together and during a scene in the middle of the movie, she would point to the main character and ask what part that person plays.
> Because we have a communication difficulties, I have started to ask her to rephrase what I've said to ensure that the intended message was received correctly, for the most part.
> My anecdotal evidence seems to suggest that:
>> She remembers 35% of content delivered in a two minute time span.
>> Her comprehension of the content delivered is around 20%.
- Mildly inappropriate responses to situations.
> As an example, I might be speaking of something very stressful for to me. If I try to put on a "brave" face with a little smile, she will react as if I were delivering good news.
- Flat Effect
> She rarely demonstrates an emotional response to situations that normally elicits emotions.
> it seems like she has a complete lack of empathy for me. But if I say anything about how that affects me, she is easily brought to tears. Not for me but because it affects her low self-esteem.
She has seen a Psychiatrist and a Neurologist:
Psychiatrist:
- The Psychiatrist diagnosed her as having some form of Depression and some form of AsHD, without the hyperactivity.
> The Psychiatrist prescribed Prozac and Adderall for her. (She's been on this combination of medication for 2 months.)
> I thought the choice of Prozac was a little odd. I think that SNRIs alleviate symptoms of Depression more than SSRIs do.
> After she started taking the Adderall, I noticed an improvement in her focus. But by 8:00 PM, her focus became poor again.
>> That's when I found out that the doctor prescribed Adderall Quick Release, instead of Adderall Extended Release.
>> I asked her to ask her doctor to switch the Quick Release to Extended Release. However, my girlfriend only started taking the Extended Release on Saturday, December 6th.
Neurologist:
- The Neurologist thinks she has some type of Cognitive Impairment but he doesn't think it's degenerative. He said that it was most likely "chemical".
- She did not ask him what he meant by "chemical" so I contacted him to ask if he was speaking about neurotransmitters, specifically Norepinephrine. It's the only one that I know that could be associated with some of these types of symptoms.
- The Neurologist indicated he was speaking about Norepinephrine AND Serotonin.
- I know that SSRIs have a secondary effect of the levels of Norepinephrine in the brain, but, to me, it was an additional indication that switching to an SNRI was warranted. However, the Psychiatrist wants to stick to the current "cocktail".
I am starting to find it more and more difficult to believe that she has been diagnosed as having three different disorders, instead of one disorder which could explain all of her observable symptoms.
For full disclosure, over ten years ago I was diagnosed as having Bipolar Disorder. I am still in the recovery phase from a Panic Disorder episode that started in March of this year.
I am very concerned that when I asked her how she thinks she has been doing the last two months, she's doing much better. However, I feel as if things have gotten far, far worse.
I don't think she is receiving the proper diagnosis or treatment plans but I am not a doctor and I do not know where to turn next.
She asked me to call my Father's Neurologist at XXXXXXX Universities Neurological Institute for Aging, Memory and Behavioral Disorders.
The stress that I've been experiencing trying to live together has been creating a lot of mood lability for me, which I have not been able to manage effectively these last three months. But, today, instead of feeling stressed, angry and frustrated, I just became completely anxious that she might have a significant degenerative disorder.
Any feedback you could provide would be truly appreciated.
Sincerely,
XXXX
PS. I've try to describe things as well as I can. So please forgive some outright misstatements I may have made in this note.
Brief Answer:
Probable depression, dementia less likely, possible tests needed.
Detailed Answer:
Hello I read your query carefully and I thank you for taking enough time to give a complete picture of her condition.
In my opinion both depression and a neurodegenerative disorder could be responsible for her symptoms. However since there is a marked component of lack of attention I think it is hard to state that she has a cognitive impairment and I think depression is the most likely diagnosis considering also there is some response to treatment at these early stages.
Another reason I think depression is more likely is her age. While neurodegenerative disorders can't be excluded at a young age, other diagnoses are more probable in a person under 60. Also in cases of neurodegenerative disease at a young age it is usually a case of familiar history of the condition (since you were pretty thorough I'm assuming you would have told us if she has relatives with neurodegenerative disorders at an unusually young age in her family).
Regarding the treatment I suggest you continue for the moment with the current regimen. There is not such a clear cut difference between SSRI and SNRI, even though theoretically they don't affect the same neurotransmitters it's a matter of delicate balance where the change on the pathways of one neurotransmitter is not isolated but influences other pathways as well.
However because the two conditions are not always easily distinguishable, if in time her response to treatment is not satisfactory, I think a MRI exam should be scheduled to exclude atrophy or other type of changes in the brain. Also I think she should be tested for other possible treatable causes of dementia and depression like hypothyroidism and Vitamin B12.
I hope to have been of help.
Probable depression, dementia less likely, possible tests needed.
Detailed Answer:
Hello I read your query carefully and I thank you for taking enough time to give a complete picture of her condition.
In my opinion both depression and a neurodegenerative disorder could be responsible for her symptoms. However since there is a marked component of lack of attention I think it is hard to state that she has a cognitive impairment and I think depression is the most likely diagnosis considering also there is some response to treatment at these early stages.
Another reason I think depression is more likely is her age. While neurodegenerative disorders can't be excluded at a young age, other diagnoses are more probable in a person under 60. Also in cases of neurodegenerative disease at a young age it is usually a case of familiar history of the condition (since you were pretty thorough I'm assuming you would have told us if she has relatives with neurodegenerative disorders at an unusually young age in her family).
Regarding the treatment I suggest you continue for the moment with the current regimen. There is not such a clear cut difference between SSRI and SNRI, even though theoretically they don't affect the same neurotransmitters it's a matter of delicate balance where the change on the pathways of one neurotransmitter is not isolated but influences other pathways as well.
However because the two conditions are not always easily distinguishable, if in time her response to treatment is not satisfactory, I think a MRI exam should be scheduled to exclude atrophy or other type of changes in the brain. Also I think she should be tested for other possible treatable causes of dementia and depression like hypothyroidism and Vitamin B12.
I hope to have been of help.
Above answer was peer-reviewed by :
Dr. Vaishalee Punj
Answered by
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