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Navigating Adult ADHD with Dr. Scott Shapiro
191 Plays15 days ago
In this episode, Grant and Fata are joined by Dr. Scott Shapiro. Dr. Scott Shapiro, a leading expert in Adult ADHD trained at Harvard Medical School, provides specialized care in New York City, combining psychopharmacology, medical psychiatry, and Cognitive Behavioral Therapy. He also is a Corporate Executive Coach, helping professionals enhance their performance, productivity, and communication skills. Dr. Shapiro shares his expertise as a specialist in Adult ADHD, its treatment, and practical strategies to help individuals overcome their challenges.
We hope you enjoy.
Resources and Links
Doorknob Comments
https://www.doorknobcomments.com/
Dr. Scott Shapiro
https://www.scottshapiromd.com/
Dr. Fara White
Dr. Grant Brenner
Recommended
Transcript
Understanding Adult ADHD
00:00:00
Speaker
A lot of people go undiagnosed, even though in the and the press there's there's there's been a lot of attention to the over-diagnosis or misdiagnosis of ADHD. With adults who have ADHD, they do feel this inner tension and often leading to procrastination to avoid some of these feelings of anxiety or overwhelm. Hello, I'm Dr. Farah White. And I'm Dr. Grant Brenner.
00:00:28
Speaker
We're psychiatrists and therapists in private practice in New York. We started this podcast in 2019 to draw attention to a phenomenon called the doorknob comment. Doorknob comments are important things we all say from time to time, just as we're leaving the office, sometimes literally hand on the doorknob. and just Doorknob comments happen not only during therapy but also in everyday life. The point is that sometimes we aren't sure how to express the deeply meaningful things we're feeling, thinking and experiencing. Maybe we're afraid to bring certain things out into the open or are on the fence about wanting to discuss them. Sometimes we know we've got something we're unsure about sharing and are keeping it to ourselves and sometimes we surprise ourselves by what comes out.
00:01:11
Speaker
Welcome to
Introducing Experts in ADHD
00:01:12
Speaker
the Doorknob Comments Podcast. Today, we are here with Dr. Scott Shapiro, a leading expert on adult ADHD, trained at Massachusetts General Hospital and Mount Auburn Hospital, both affiliated with Harvard Medical School. He served as director of psychiatry at St. Vincent's Catholic Medical Center's Infectious Disease Unit in New York City.
00:01:31
Speaker
and worked with the Hallowell Center, a renowned institute for ADHD treatment. In his private practice based in New York City, Dr. Shapiro specializes in adult ADHD, providing care to patients across New York and New Jersey. He blends psychopharmacology, medical psychiatry, and cognitive behavioral therapy to create individualized treatments for ADHD, depression, and anxiety.
00:01:54
Speaker
Dr Shapiro is also an executive coach and organizational psychiatrist using his expertise to help executives leaders entrepreneurs and other professionals enhance strengths and performance he focuses on improving communication leadership productivity performance.
00:02:12
Speaker
and emotional intelligence. He has written extensively about adult ADHD, its treatment, and practical strategies to help individuals overcome their challenges. To access these articles, visit his website at www.scotshapiromd.com. Dr. Shapiro, it's been a pleasure getting to know you over these years, and thank you so much for joining us today. Well, thanks for inviting me on the show. I really appreciate it.
00:02:41
Speaker
it's It's always fun to talk with folks we know. I always like to ask people
Psychiatry and Medical Overlaps
00:02:46
Speaker
how they got into into this profession and kind of what it means. I'd love to hear from you. So the way I got into the profession is um a very interesting story. I knew that I was very interested in going into medicine and was planning on doing internal medicine.
00:03:07
Speaker
where I'm from, which is the South, specifically North Carolina. people don't during When I was growing up, I didn't really believe in therapy or or seeing a psychiatrist and there was a big stigma. However, when I moved to the Northeast, I decided that my true love and passion was psychiatry. And so I let go of some of those chains from ah from growing up and decided to pursue my true passion in pursuing psychiatry.
00:03:37
Speaker
it's it sounds It sounds like an important story. And I think a lot of people in our field you know have have come to it through their values, through courage, through heart. So I appreciate that. um And I read in your bio, you you had been the infectious disease, the the head of the department at St. Vincent's. but That's right. So during my training, um I was very interested in the overlap between medical illness and psychiatry.
00:04:07
Speaker
And so I did a fellowship in an area called Consultation Liaison ah ah Psychiatry, where people with medical illnesses have can have psychiatric issues that affect their medical illnesses, and their psychiatric illnesses can affect their medical illnesses. And that intersection I found very, very interesting. So when I was looking to move to New York, I was looking for a position that I could continue my interest in this overlap between medicine and psychiatry and went to St. Vincent's Hospital where there was a very large HIV and infectious disease clinic and I ended up working there for 10 years and it was fascinating because many people in that clinic often their psychiatric illnesses such as substance abuse or bipolar or schizophrenia that often would lead
00:05:07
Speaker
So there are risk factors for developing
Adult vs. Childhood ADHD
00:05:10
Speaker
HIV. Yeah, absolutely. It's an important field and the um the the role of, say, inflammation or the immune response in psychiatric illness is something that we've come to understand you know more deeply, but it's still um it's still very much important. um I'll be curious later on how that may come up with executive function and attention problems as well. When I think of St. Vincent's, you know I used to supervise there. They had a great department of psychiatry and a lot of interest, as you said, in infectious disease and HIV. Being being at the at the epicenter in a lot of ways, St. Vincent's um was down in the West Village. They they they closed. um And a lot of people you know found it very meaningful working there, I'll say.
00:05:59
Speaker
St. Vincent's was a great community hospital. Some some of the best, most committed ah doctors, nurses, staff. It really was was a doctor's hospital and in the people's hospital. yeah A lot of history. It was a great place to work. um I would love to jump into ADHD if that works for you. Yeah, let's let's talk ADHD.
00:06:24
Speaker
Okay, we're gonna talk about adult ADHD, which I think is certainly very common and can be very difficult for people. It's often goes unrecognized and un or undertreated. I know in my practice, I will often identify people who have ADHD for a long time, and it's often a heavy lift ah to get them into treatment. ah Once they're in treatment, it's often It's often a game changer, so I would love to hear from you. What what is adult ADHD and how is it different from childhood ADHD?
00:06:58
Speaker
Well, that's a great question. And you know one of the things that I love about working with people with ADHD, especially adults, is that it's very common. It often goes under undiagnosed, and that it's one of the psychiatric illnesses and diagnoses that is the most treatable and the most responsive to medication. In terms of how it's different from childhood ADHD, children often will have outward signs of impulsivity and hyperactivity. So you may see them climbing all over, you know, at school
Challenges of Adult ADHD
00:07:36
Speaker
or at home or on the subway. But when, as they get older, they've learned how to channel some of their energy. And so very often you will not see the hyperactivity and and impulsivity as much. um However, they often will have this restlessness, this sense of restlessness internally.
00:07:56
Speaker
And so they may feel like internally they're not sure where to start or they may feel overwhelmed by their emotions or their mind is going to a thousand different ideas or a thousand different projects but you won't see the hyperactivity and impulsivity as much. The other thing that's very interesting is that with adults, lives are a lot more complicated. They've got family, they've got lots of things going on with work, they've got their personal lives And adults often require using an area of um of cognitive abilities called executive function. And executive function, which is very interesting because it's not in the DSM-5 criteria, executive function is a cluster of cognitive abilities that includes organization, prioritization, time management,
00:08:56
Speaker
sticking to a project over the long-term and going to completion, emotional regulation. And so often issues with executive function as well as emotional regulation end up being a much bigger impairment and challenge for adults than it is with children. So sort of in a way like um if you had difficulty with the way you played sports, you had some trouble with coordination,
00:09:25
Speaker
It might be okay in grade school, but once you're in the major leagues, that underlying problem is harder to compensate for and and really comes out. That's right. And also the issues with executive function are really addressed very often in third grade, fifth grade, 10th grade by perhaps parents are more involved and kind of serve that executive function role. And also there's much more structure in school.
00:09:54
Speaker
you You have classes that you have to attend. You've got work that you have to do. So with that added structure, there's less pressure on someone's ability to have strong executive function skills.
00:10:09
Speaker
that makes a lot of sense. There's more support. And I hear that a lot when people enter adulthood, there's much less structure. And a lot of times undergraduate
Misdiagnosis and Coping Mechanisms
00:10:17
Speaker
experience doesn't seem to prepare people for that structure comes up quite a bit in the workplace, especially with younger generations. but That's right. and And often actually does start in college where for the very first time people are away from home.
00:10:35
Speaker
They may not have um advisors or parents who are staying on top of them in their schedule. And there's a lot more autonomy, a lot more distractions. And you can start seeing people starting to struggle in college, but especially once they get out of college and they're in the workplace.
00:10:53
Speaker
where expectations are a lot more ambiguous, tasks are not necessarily so clear depending on what type of management you have. So the struggles can really start manifesting as a bigger challenge in college as well as they start work, as someone starts in the workplace. Yeah, it can be a huge blow of course to self-esteem and the world is less forgiving as we get older. That's right.
00:11:20
Speaker
You mentioned this kind of impulsivity and and lots of different feelings of inner tension. Is there something people think that is before they realize it's ADHD? That's interesting. um A lot of people go undiagnosed, even though in the in the press there's there's there's been a lot of attention to the over-diagnosis or misdiagnosis of ADHD. With adults who have ADHD, they do feel this inner tension and often that can lead to
00:11:53
Speaker
problems with sticking to a task, to seeing a project through from the beginning to the end, and often leading to procrastination to avoid some of these feelings of anxiety or overwhelm. I would say procrastination is probably one of the top complaints that people have that see me. And they can feel anxious as well. So you can go off treating anxiety, but you might be missing the mark.
00:12:20
Speaker
Yeah, and and going back to you know what what do they sometimes think that they have, a lot of times they've seen psychiatrists before they see me, or they've seen a therapist, and they often or are misdiagnosed as having depression, or as having generalized anxiety, or really things such as personality disorders or OCD,
00:12:43
Speaker
um For many of the people with ADHD, they've developed coping strategies, especially the ones group who weren't diagnosed and are thriving in the workplace. But some of the symptoms that they have that are helping them cope are often working two and three times harder than their colleagues, and using strategies that from an outside perspective can even look like OCD, obsessive compulsive disorder.
00:13:09
Speaker
And is that because they are they sort of know that they have a tendency
Emotional Impact of ADHD
00:13:15
Speaker
or to, I guess, miss things or that they have trouble attending to certain details and so they are just double and triple checking themselves in a way? for so So people kind of have different paths that they've taken. For some people in terms of coping with the challenges they've they've had,
00:13:35
Speaker
um and it's gone undiagnosed, they can sometimes give up or procrastinate or avoid and just you know wanting to avoid that bad feeling of shame or defect in this or failure. But for other people, and you know for many different reasons, temperament or or how they were raised, they may be highly, highly motivated and realize that they're struggling and realize that they do need to check their emails three or four times where they do need to check if they have everything with them to go to work. And so they've developed coping strategies that for an apportion of the people can look like the obsessions and compulsions ah someone of someone with OCD.
00:14:17
Speaker
Yeah, in my experience, there's often an inner sense of shame or embarrassment because there's a mismatch right between what the person knows they're capable of and then this fear of making a mistake. And a lot of times, right, they've had negative experiences growing up because people have just kind of come down hard on them rather than recognizing they have ADHD. And of course that can lead to lots of what are sometimes called secondary problems with self-esteem and so on. I think we can come back to that I hear this question a lot. Does ADHD ever come on in adulthood or is it really always present from childhood? Because there's um this thing on social media like adult onset ADHD. Yeah, that' that's a great question. That's a controversial area and there's a lot of research in that. In my opinion and in the research that I've read and and in my experiences, I don't believe that ADHD comes on as an adult.
00:15:13
Speaker
the The prevalence of ADHD in adults is between four and 5%. Out of those people, only 10% ever get an accurate diagnosis of ADHD or ever get treatment. So, in my opinion, doesn't come on as an adult. If you really look back at their childhood or talk to parents or teachers or look at teachers' comments, you can see that the symptoms existed quite early.
00:15:42
Speaker
Sometimes people aren't diagnosed at an early age for lots of different reasons, but one reason could be of high intelligence that they may have very high intelligence. They're able to do well in school. However, when they enter a place like the, um, like the workplace and other skills are required, such as organization, planning ahead, time management, politics,
00:16:09
Speaker
then their coping strategies no longer or are helping them or effective enough for them to succeed. And so that's when they may seek out help and then get diagnosed. But again, when you carefully look back,
00:16:24
Speaker
at their history and dig into some of the symptoms they had in their younger years or family history of other siblings who may have had ADHD, you realize that it has been there and they were just using some coping strategies or you know have very high intelligence that they were able to compensate.
00:16:42
Speaker
Oh, it must be a relief to see people and be able to treat them for something that they've sort of been dealing with. I'm sure that it helps things tremendously like in the workplace. But are there other benefits that you notice either in terms of people's relationships, you know, when they do get treated properly? Do you do you see other things shift as you follow them over time?
00:17:07
Speaker
well Well, I do. I mean, it's very interesting. The people that often call me um are not necessarily the individuals themselves. Often it's a spouse so ah or a partner, so ah a boyfriend or a girlfriend or a husband or a wife, or even if it's a someone in their 20s, even their mother. HR sometimes, right? Or or h absolutely HR, that we've got a high potential here, but there's areas that they're struggling with.
00:17:34
Speaker
once they do get treated diagnosed and treated appropriately and also get the therapy to learn some of the strategies they that they missed out on. So it's not just the medications, but it's also the you know effective therapy to help them. It also absolutely helps their home life relationships. um If they're not in a relationship or if they're not in a family,
00:17:56
Speaker
helps them to take care of things that they really struggled with, keeping their home clean, doing their laundry, paying their bills, ah showing up for their friends. So um absolutely, a lot of other areas in their life do improve, such as relationships, um taking care of themselves, feeling like they're competent adults in the world.
00:18:17
Speaker
this
Comprehensive Diagnosis Strategies
00:18:18
Speaker
sense of self-efficacy. There's a significant amount of research on how ADHD affects close relationships. And you can imagine it's very easy to get into conflict. So if you forget someone's birthday and their attribution is you don't care about them, it's a very big reframe to say, Oh my gosh, that's ADHD. And you made this point that it's more than just medication, you know, because people develop these coping strategies. And if you only,
00:18:45
Speaker
change the medication, then they don't they don't do as well. you know So we'll we'll come to that. So what is the like the right way to evaluate and diagnose ADHD, given that there's often comorbidities, meaning other conditions at the same time? so So this is an interesting question. I know during my medical training and my psychiatry training, we were not taught very much about ah either childhood or adult ADHD. There may have been one or two lectures. And so many of my colleagues come to me and they ask me, how do you diagnose ADHD? The way you do diagnose ADHD is through the way you would diagnose bipolar or depression or anxiety is through ah and a comprehensive clinical assessment.
00:19:35
Speaker
So I have all of the patients that I see where I'm evaluating them for ADHD fill out a comprehensive um questionnaire um about their symptoms, but not just in terms of ADHD, but other potential medical disorders or co-occurring other psychiatric challenges that they've had like anxiety or obsessions or insomnia or substance abuse.
00:20:01
Speaker
And then when I meet with them, I do a clinical assessment to see what challenges they're having, including not just the symptoms in the DSM-5, but also symptoms with executive function and um an emotional regulation. And what's really important is that people with ADHD are just known to be poor self-reporters. So even if they minimize the symptoms that they have,
00:20:30
Speaker
I may speak to, again, a partner, a spouse, a family member to get more information because um very often an outside observer will notice the symptoms before the person themselves will notice the symptoms.
00:20:46
Speaker
The other thing that I use, which is not how you do the diagnosis, but can help provide extra information, are different questionnaires or scales. So there's something called um the Connor Scale, which um has a lot of research and validity to that, but and it's a self-report. There's also something called the Weiss Scale, which shows how severe the challenges are are occurring in the person's life.
00:21:11
Speaker
And I would say one of the most important things is to assess when the symptoms started and if there's some outside documentation. So I always request teachers comments and notes and grades from childhood. I'll ask for reports that the person may have from their managers from work. And if possible, he'll speak to family members as well. I find that's funny in psychiatry. And I wonder if that has something to do with the stigma for mental health.
00:21:41
Speaker
Because if you go to another doctor and they send you for a workup, an echocardiogram, ultrasound, an MRI, et cetera, people will do those things. I know sometimes they can be quite delayed, but a lot of times in psychiatry, I think there's a different um desire or set of expectations that things not not be as careful or comprehensive, but I think that is the cornerstone is, as you said, a careful clinical eval.
00:22:08
Speaker
wondering, you know, are there any ADHD lookalikes that aren't ADHD and when would psych testing come into play? So so both great questions. Let me answer the second question first. So a lot of people wonder shouldn't we do neuropsych testing isn't that more quantitative. And actually, I do not recommend, in many ah specialist and and researchers in adult ADHD also recommend that neuropsych testing is not indicated. It is a clinical diagnosis made by someone who has experience and knowledge and training in adult ADHD.
00:22:52
Speaker
that someone, if you send someone for neuropsych testing to say this is going to automatically make the diagnosis, you can send someone who has ADHD where the neuropsych testing comes back and the person, the testing show that they that they don't. And so you can If you're just relying on the neuropsych testing the diagnosis can be misdiagnosed and then I've also sent people who absolutely don't have ADHD from the assessment and from knowing them for a period of time where I've sent them to a neuropsychologist and they've been diagnosed with ADHD and yet if you look at the clinical assessment they don't have to ADHD.
00:23:33
Speaker
In terms of lookalikes, there are that's quite extensive. So if we were to just break it down into medical and psychiatric, there's a lot of medical lookalikes. People with menopause can have symptoms of problems with attention, a multitasking, organization, memory that can look like ADHD. For example, I've had many people over all the years that I've been working who Came to me and so and said look i know i have a hd i just need you to talk to me do the do whatever assessment you need and and give me the treatment and their symptoms started right around when they became perimenopausal and then went into menopause they their symptoms do look alike however if in there.
00:24:22
Speaker
childhood and teenage years that they did not have those symptoms, then it's not ADHD. And in terms of the diagnosis, that's not the that it's not ADHD. Other medical issues that can look alike can be things like um people who go for treatment for chemotherapy. So I've had people come to me and they call it chemo fog or chemo brain that can they can look exactly like ADHD.
00:24:51
Speaker
Ovarian cancer, especially, you know, that's something that's often diagnosed later, um often um not caught until it's too late. um Thyroid disorder, and I would say a big one, there's an overlap between, ah there's a high occurrence of sleep disorders in people with ADHD, but someone could have a severe sleep disorder and not know it, like see like sleep apnea, and that can mimic the symptoms of ADHD as well as problems with executive function.
00:25:21
Speaker
Yep. With certain cancers, there's something that, ah you know, as a CL psychiatrist or called para-neoplastic syndromes, that that's why it's really important to have a careful clinical evaluation. As a side note, that's one of the reasons why kind of fly by night online diagnosis may not be best serving people.
ADHD and Coexisting Conditions
00:25:41
Speaker
Absolutely. Absolutely. And a lot of that came out um during the pandemic.
00:25:47
Speaker
unfortunately where people were going online you know for five or 10 minutes getting a diagnosis and getting a prescription. Oh my God, you see this all the time. Fill in a form, talk to a professional, get a script. What is the brain fog that comes with depression and PTSD? yeah so How do you think about that? So going back to that to that question. So the rule is really that with ADHD, there's co-occurring other psychiatric issues. So there's a much higher prevalence of depression, of anxiety.
00:26:20
Speaker
of ptsd of bipolar disorder and how do you kind of distinguish the two and pull them apart and then how do you treat them one thing in terms of treatment in in my training i really learned um treat the depression treat the ocd treat the insomnia and they said and They said, well, if there's anything left over, you know maybe get to the ADHD. But very often, they never would really focus on the ADHD. In my opinion, very often, the person's most biggest challenge and source of suffering is really coming from the ADHD and not the depression and anxiety. And so in the majority of cases, i i my first ah target is really treating
00:27:06
Speaker
in diagnosing the ADHD, except in certain circumstances where it'd be contraindicated, such as um especially bipolar disorder. You know, I would treat the bipolar disorder first and then um treat the ADHD. And what's interesting is when you treat the ADHD, very often, even though it's a stimulant and you may think that the anxiety may get worse,
00:27:30
Speaker
in my experience and with a lot of research, the anxiety can actually get better. People's depression can can actually get better. Their relationships are improving and their performance is improving. But in terms of of distinguishing, do they have both or do they have one or the other? So if you were looking at ADHD and depression, you'd really look at the timeframe. How long has the depression been present? How long has the ADHD been present?
00:28:00
Speaker
if it's symptoms if the person has both ADHD and bipolar disorder. and by and In ADHD, you may have emotional dick dysregulation on a regular basis, but with bipolar, you have mood swings that go in and um episodes, like for three or four days with bipolar type two, or weeks to months in bipolar type ah type one.
00:28:25
Speaker
I think, you know, proper diagnosis and teasing things apart, you know, is probably the best thing that you can do for the patient to improve their life. But I'm wondering if we could talk a little bit about what it feels like, because I know that you have the sort of some psychodynamic background and what does it feel like for people to hear that a lot of the things that they assumed were laziness or, um you know, apathy are really actually part of, you know, a psychiatric disorder. Yeah, know or or you even like ah a kind of a moral failing, right? Yeah. Yeah. So I would say that the majority of people who were struggling and and not everyone with ADHD struggles in school or in college.
00:29:14
Speaker
but but they they do struggle at some point or else you know they wouldn't be coming through my door. But very often, people that are that are struggling with ADHD and weren't diagnosed, they may have had increased risk of bullying, they may have had um a lot of negative feedback from teachers that they have higher potential than they're performing, and absolutely a lot of negative interactions with parents.
00:29:41
Speaker
And so when they get the diagnosis, I would say the majority of the people do have a sense of relief, of validation, because maybe even for a couple of years they've had a sense that maybe this is what's what's going on, and a sense of of hope.
00:29:56
Speaker
that treatment as well as therapy could help them to feel better, to perform better, and for their personal lives to not have some of these challenges. There's also some other feelings too. um For some people, um and again, it depends where on the life cycle they are, but for some people,
00:30:20
Speaker
it can be a period of of feeling a lot of anger that many of the people that I've seen were actually, a teacher may have said, you know I think your child you should go get your child evaluated for ADHD, or they even were diagnosed, but treatment was never pursued because of maybe a bias with the parents. So there can be a lot of anger and regret when they find out the diagnosis.
00:30:45
Speaker
And then um for many people, there can be some, I'm saying regret, but a lot of regrets of, wow, you know people have been telling me something's going on, or I suspect things. you know Now I'm in my 30s or 40s. Well, what would life have been like if this was diagnosed and treated sooner? So there can be some sadness and grieving and and regrets. Yeah, I see that you know myself. and i do, you know, I used to try to tell people, well, we all sort of receive the treatment that we need when we need it, but you're right that sometimes, um and especially with this idea of people being able to access information, which I think is overall a good thing, but because it's led to a lot of these pop-up prescribing, I think that sometimes delays things um and people aren't getting the right kind of care when they should be.
00:31:39
Speaker
You know, and one thing that I think both of the all three of us are really talking about is really and it happens also in in people that are diagnosed and treated as children, but especially those that go undiagnosed and untreated. What we're really talking about is what and what's very prevalent is a sense of shame and failure and defectiveness.
00:32:01
Speaker
And I've written a few articles about this, that if you don't treat the shame and the defectiveness, then you're not really providing full treatment. um That many people may get the treatment um and they may, in terms of medications and therapy, but still in terms of how they feel like their core beliefs in cognitive therapy, you'd call this core beliefs, how they feel internally and what they feel their capabilities are can can really hold them back in terms of pursuing goals professionally, hobbies, ah relationships. So I definitely think I'm bringing up the idea and assessing for shame and defectiveness as well as treating it. And the ways that I treat it are using cognitive behavioral therapy
00:32:49
Speaker
in an out branch of cognitive therapy called a schema therapy that looks at lifelong patterns in the schema that can often um develop with someone who's undiagnosed with ADHD and untreated is the schema of um defectiveness and shame and and failure. Like their self schema or a sense of self, right? Absolutely.
00:33:14
Speaker
are Are there other forms of executive dysfunction? I mean, I think having an intense sense of shame about oneself causes executive dysfunction secondarily, but are there other any, are there any other formal diagnoses of executive dysfunction? Absolutely. You know, it's very interesting. Recently there was not, I mean, for many years, but even more so, there's been more interest recently that there,
00:33:40
Speaker
that people with other disorders can cause challenges with executive dysfunction. So um some of them, which is very interesting, and um is that you see them bipolar disorder. And bipolar disorder is something where the the more episodes you have before you get treatment, the more severe it can be. And they're starting to look at, you know are there different subtypes where you where there's more executive dysfunction or other cognitive problems than in other disorders?
00:34:10
Speaker
Um, depression can cause trouble with executive function, uh, severe sleep disorders. So, so many, many psychiatric problems and medical problems can absolutely cause problems with executive function. Well, what would your thoughts be about things like difficulty with reading comprehension or dyslexia?
00:34:30
Speaker
ah You mean in relationship to ADHD? Yeah. So that's when I think that neuropsych testing can be helpful. If someone if there is a suspicion of dyslexia or ah or a learning disability, um that's not something that would be assessed during a clinical assessment for ADHD, but could be discovered in an evaluation using neuropsych testing. um
Innovative ADHD Treatments
00:34:55
Speaker
But many people with ADHD do struggle with reading comprehension because of of of their working memory, which again is not a symptom in the DSM for ADHD, but challenges with working memory all right are a classic symptom that that go along with ADHD. And working memory is being able to hold information for short periods so that you can do other cognitive processes. So for example, reading, kind of holding that information briefly in the previous part that you read,
00:35:30
Speaker
so that you can comprehend as you continue to read, whether it's on an essay or an exam or or fiction. yeah that gets into making sense of things. It's it's ah maybe a different topic, but I'm quite interested in neuroscience and brain networks. And I'm someone who treats patients with transcranial magnetic stimulation and i'm treating folks with comorbid depression and ADHD. And even after one day of intensive or accelerated TMS treatments, they they report even after less than one day,
00:36:02
Speaker
resolution of the brain fog and immediate improvement in attentional function and it was curious i was looking it up and i found a study and i'm interested to see what other research is coming out from twenty twenty where they treated patients with a major depressive disorder with tms And after two weeks, they found there were statistically significant improvements in what's called their central executive network, which is is correct, ah which is directly connected with what you're describing. And it's the way like you might manage those memory resources. This is quite fascinating. But again, maybe a bit of a digression. No, that um that's that's very interesting. you I never thought of TMS as a potential treatment. There there is a treatment.
00:36:50
Speaker
um that's actually FDA approved that's called trigeminal nerve stimulation, which um has very few side effects and is effective. It's not something that um that I use to treat my patients, but it is, you know, one of the newer treatments. So it does make sense that, you know, TMS would also potentially be helpful.
00:37:10
Speaker
And I've even started seeing research to start exploring whether a new treatment that's very big in the news are psychedelics and whether psychedelics could potentially um be a part of the treatment for ADHD. Yeah, the the neuromodulation approaches are really interesting. We should definitely do an episode on those. Farad, do you want to move into talking about treatment a little more and more particularly coaching?
00:37:38
Speaker
um Well, I guess what I'm curious is ah about is what does it look like when you start to see when you start treating someone and you see some of their symptoms start to resolve, they're able to overcome some challenges. and one thing um that I don't know if you guys have run into it but I know there's a big stimulant shortage and I spend all my spare time calling pharmacies and um I'm wondering actually if I could get a few tips for if patients are between their medicine or
00:38:16
Speaker
you know, how do you support them all the way through? Because I know that you offer all these sort of wraparound treatments for it. So I'm curious about how they. So it's a great question. the The shortage has been absolutely challenging. And people function before they were on the stimulants. And if there is a shortage of Thankfully, for the most part, the majority of my patients have been able to find their their medications and get treatment. But I do think that just using medications you know isn't enough to treat comprehensively the ADHD. And so the type of strategies from cognitive therapy and schema therapy that I use
00:38:58
Speaker
is really to help them with whatever type of work. Well, one is in the workplace and one is in their personal life. And so in the workplace to really try to help them understand, but also create strategies for overcoming procrastination, working on projects such as a business plan or a ah developing a PowerPoint deck.
00:39:24
Speaker
So we work on very practical kind of nuts and bolts strategies of how to do their job. you know For example, if you're a lawyer, you need to keep track of your hours. And that's something that that many lawyers hate doing, but especially with ADHD, it's it's much harder. So really developing some some skills and strategies. And some of those strategies are things like you know it's it's There's a lot of neuroscience research that handwriting um helps with memory
Practical ADHD Management Tips
00:40:00
Speaker
planning and focus. So very often people who have been for years struggling with keeping track of their schedule and trying to use a Google Calendar, I'll encourage them to use an analog old school week at a glance. And very often when they start doing that and seeing their schedule in handwriting,
00:40:21
Speaker
their tasks that they need to do, that helps them. We also talk about very often they go into work and they're not sure. They've never kind of i've created a task list. So they go into work and for the first two or three hours are kind of, you know, maybe looking on Twitter or on Reddit.
00:40:39
Speaker
and um And then finally, when they realize much of the day has gotten by finally getting to some of their tasks. So we talk about starting to keep track of their projects, starting to keep track of their tasks, starting to break down things that may feel overwhelming, especially due to some of their schemas and core beliefs into smaller tasks so that they're more manageable.
00:41:04
Speaker
And one thing that I would say is one of the most effective skills and and kind of hacks to helping executive function in ADHD is is finding and like an activity partner. So not delegating it, but having the person work with someone else in the room, talking it out, working together. This has tremendously helped a lot of my patients. So so even the,
00:41:31
Speaker
You know, I would say that all the strategies I used are based within cognitive therapy. It definitely is much different it looks much different helping someone with ADHD than doing kind of three column techniques and trying to track their ADHD. You know, some of those types of exercises would be extremely challenging for someone with ADHD.
00:41:53
Speaker
Yeah of course and and just going back to the activity partner just for a second you know one time someone misunderstood it and thought that i meant to delegate and he was really struggling in his his small business because he wasn't getting to a lot of his work.
00:42:09
Speaker
um And so for for a month, he was starting to delegate things with his administrative assistant. And he came back and I said, no, I would like you to spend the first two hours of every day working with your administrative assistant to work on your most your highest priority task. And his sales just went way up and his productivity went way up. And he just he felt a lot better about what he was getting done.
00:42:34
Speaker
That is a great, do you have any, what are your top ways to help people? I know you've covered it implicitly, but specifically with procrastination. So so that can be a really hard one. um You know, there's so many different causes for procrastination and often people don't real and here again, this is something that I've written a few articles on strategies to overcome procrastination.
00:43:00
Speaker
there can be lots of different reasons that make people with ADHD or any of us procrastinate. And and the first thing is to realize is to understand what's causing the procrastination. Someone may again be working on an easier task or not doing their work or doing other things. And so one cause can be maybe they don't have all the information and they they're avoiding I'm talking to their manager because they don't want to look stupid again something that could activate or trigger the defectiveness so they don't have the skills or the information and that may cause procrastination another problem maybe that the. um
00:43:41
Speaker
ah The project or the task seems daunting or too overwhelming. So we'll talk about which parts of it seem daunting or overwhelming and some strategies to get around that. And one is breaking the task into smaller tasks.
00:43:56
Speaker
um i ah this i I think patients think this is a little bit funny, but I recommend that when they break down the task to start each task with a verb. um So it doesn't just say article or email, but it actually says for 15 minutes, research and write out your first paragraph. And then step two might be um read two more articles and and write out your outline.
00:44:22
Speaker
In a small example might be um how does you know and a lot of people with ADHD avoid this but how do you do your laundry with a long if you write on your calendar laundry on sunday it's much more fun and much easier just to go outside and take a walk in the beautiful weather or hang out with friends but if you break it down into tasks and it's really like five or six tests.
00:44:46
Speaker
go around your house and gather all the clothes, separate it in dark and lights, wash it, dry it, and then fold it. I mean, each one of those is really a microtest that you can put on your calendar, and it and it's and it's much less overwhelming to do. I mean, on a Friday night in 10 minutes, someone could go collect all their clothes. And then in terms of folding and realizing you don't have to go from the beginning to the end, that you could fold the clothes while you watch something on Netflix,
00:45:15
Speaker
you know two days later helps so a lot of the people overcome um the procrastination. So when someone's, and I would say this is the top issue that's getting in the way of people in the workplace, really understanding what's causing the procrastination. Is it overwhelmed? Is it not having enough information? Is it that it's tedious? And then really collaboratively discussing strategies to overcome that.
00:45:41
Speaker
Yeah, and what you're describing also makes it planning, right? They're planning the steps implicitly and they're avoiding this willpower trap. Like a lot of people say, I just need more willpower. And what you're also describing is like setting up the context so that it's likely to happen.
00:45:57
Speaker
rather than waiting and then getting into some kind of weird battle with oneself or attributing it or feed beating or beating you yourself up. I mean, beating yourself up. and Absolutely. making Making
Finding Reliable ADHD Resources
00:46:10
Speaker
attributions like, oh, I avoid things because when I was a kid, like I, yada, yada, yada, like sometimes people attribute their procrastination to a psychological problem. But if it's really ADHD, you have to approach it as ADHD.
00:46:29
Speaker
You covered a lot. um I think you were so, so helpful and so generous with your expertise. And so I want to thank you, you know, not only as a fellow clinician, but also on behalf of our listeners. And I guess what I'm wondering is practically speaking, how can people who might hear this um take the first step? You know, where can they find you or someone like you ah to get started?
00:46:58
Speaker
Yeah. So that's, you know, people are going to be listening to this podcast all over the country. And what I would recommend, especially maybe if someone's already seeing a therapist, is to first talk to your therapist, first talk to your psychiatrist. You know, one thing I didn't say kind of as a little disclaimer is that everything we've talked about is is really um educational and it's not meant to be medical treatments. So please do not change your medications or change your treatment.
00:47:26
Speaker
you know, but really go back and talk to your doctor. And then where can people find treatment, um especially maybe in places that aren't large, large cities, I highly recommend people to go to academic centers. So places where, and it may be a little bit of a travel, but now with telehealth,
00:47:45
Speaker
that's more possible. And so really looking at medical schools, training programs, um I think that you can really get access. And even if um your preference is in person, the telehealth can actually help you ah get treatment from someone who specializes in ADHD.
00:48:04
Speaker
and in ah And a big message I'd like to leave people you know who are taking their first step is that, yes, there can be a lot of steps um and it could be a little bit of a journey, as well as finding the the doctor and therapist that you work best with. But to hang in there and one of the strengths that people with ADHD have, yes, they procrastinate, but they can be very persistent, a little bit like ah ah like a dog with a bone.
00:48:32
Speaker
Tenacious so tenacious and to really kind of use that strength but when you when you when you reach out to a psychiatrist or a psychologist or a therapist to ask them how many do they specialize in ADHD how many people over the past year, how many of their patients, what percentage? And I would say to make sure that they say ah that they, out of the patients that they treat that at least 10 or 20% have ADHD. If they say, well, maybe one or two, that may not be the best person to see.
00:49:04
Speaker
That's very good guidance. I'll say it's also good to self-educate. There's a lot of good online resources. We mentioned your website. And as part of my social media research, I do sometimes watch short videos online. I'm reminded of a recent study where they found that only 21% of videos on TikTok about ADHD had credible information. And as it happens, last night I saw the kind of shorts where they're saying,
00:49:32
Speaker
Look at this picture. If you see this, you have ADHD. If you don't, you don't have ADHD. And so I think it's really important for consumers to properly vet the information that they're seeing and to go to credible resources like your website, scottshapiromd.com. Where else can people find you?
00:49:53
Speaker
So or so um I've got many articles on Psychology Today. I'm a contributor to Psychology Today. But I would say other websites um that are credible would be places like the Cleveland Clinic, Harvard Medical School, APSARD, which that's an acronym, APSARD, is an association that specializes in ADHD and related disorders.
00:50:21
Speaker
And then there's another website that I came across that's specifically for adults with ADHD that's called adultswithadhd.com. But I would go to these locations rather than TikTok because there's a lot of free information, blogs, as well as webinars that are available.
00:50:41
Speaker
Yeah, and I certainly appreciate it when those credible sources put information out on TikTok. I recently became a member of, and this may be of interest to either of you, FIDES, F-I-D-E-S, which is a a project of the World Health.
00:50:56
Speaker
organization to identify influencers who are credible and support them in sharing good health-related information in in mental health and in general health. So thanks very much. I think this has been really informative for me and I'm sure our listeners will appreciate it. Well, thank you. Thanks for inviting me. I always enjoy teaching, sharing information and sharing my experience. So this has been so much fun.
00:51:28
Speaker
Remember, the Doorknob Comments podcast is not medical