Table of Contents of the Chart Notes of Neil D.
Intake Note: Long term problems with concentration, day-dreaming.
Session Two: Dramatic change with Adderall 25 mg twice a day. Much clearer thinking, much better organized. To increase dose of Adderall to 30 mg twice a day.
Session Three: Slightly higher dose made him too serious, too rigid. Dose reduced to 25 mg twice a day.
Session Four: Smoking and drinking muddy the effects of the Adderall. Doing well on 25 mg twice a day, is able to think more clearly, process two thoughts at the same time.
Present
Illness:
This 30 year old married father of two is
a photographer for an advertising
agency. About a year
ago, Mr. D was given a book by a co-worker about ADD and recognized himself
as a classic case.
He recalled that in grammar
and high school, he
didn't pay attention and day-dreamed during class.
Even in second grade, he had a hard time.
"It was torture
getting anything done" – he would put off writing papers until the very last
minute. He couldn't start taking
exams until he was sufficiently anxious. These
problems have continued all his life.
He has had
“highs” when he stayed up all night – during these times he found himself
enormously creative, energetic, thought rapidly.
He also gets “hyper” from time to time. When he is “down”, he feels he doesn't want to do
anything. No family or personal history of bipolar disorder.
At the time of his last physical exam, about a month ago, his blood pressure was normal. He sleeps well, has a few beers once a month. Alcohol focuses him, sometimes results in his hyper-focusing. (Note: The effects of alcohol on ADD are variable.) He drinks three cups of coffee a day, smokes marijuana rarely. He has always felt that substances (coffee and nicotine) might help him with his concentration problems. (Coffee plus stimulants often make patients more edgy and jittery. Caffeine and stimulants are not a good combination.)
Diagnostic assessment:
Attention deficit hyperactivity disorder, inattentive type
Possibility of cyclothymic disorder (Note: cyclothymic is another word for
mild bipolar)
Prescription written:
Adderall
10 mg. Start taking one per day for at least three days, then slowly increase up to
three times a day
if there are no disturbing side effects. See if higher doses are more helpful.
Plans and instructions:
Patient told of usual effects of Adderall and possible side effects.
Patient given information sheet on Adderall and ADD
Appointment in two weeks for follow up on effect of medication.
Date: Two weeks after previous session
Medication taken during the past week:Content
of contact:
Two weeks ago, Neil took the Adderall 10 mg
one or two days once and
noticed nothing. He then got a chest
cold and sore throat and stopped the medication.
A week or so ago, he started it again. He took 20 mg for two days, and it did nothing. He increased the dose to 30 mg twice a day on the third day. At this dose, he felt very clear at work. The change was very dramatic. The effect was not as obvious the next day, but he noted that "everything seemed to line up."
He was able to "respond to information, see it, register it, move it" as he wanted. He was able to think of things in the foreground of his mind while keeping others in the background. He felt very in control of issues that had irritated him: he could view them in his mind and not get angry, just let them occur to him and then let them float away. This effect wore off as the medication wore off.
However, he couldn't eat because he had a nervous, excited stomach, and he didn't sleep much. (He said that not sleeping has always led to his feeling clear minded.) One night, he took 30 mg at 6 PM and didn't sleep the whole night. The next day, he felt depressed, dull even though he took the Adderall.
He lowered the dose to Adderall 30 mg once in the morning and once around 2 PM and has felt and functioned very well with it.
He has
used less his
coffee over the past few weeks. This has made him a bit less
alert.
Assessment:
Better but some problems remain.
Continue on same dose of Adderall and reevaluate in a few weeks after he has
gotten more used the medication.
Next
appointment:
Three weeks
Date: Three weeks after previous session
Medication taken during the past week:
Content of contact:
For a week or so, Neil took 30 mg of
Adderall twice a day but phoned to tell me that he was becoming too serious minded. He takes the first
dose when he gets up then another between 12:30 and 1:30. When he gets home around
6 PM, he feels wiped out. Each dose seems to
last about
five hours. (Note: Hyper-seriousness is a not uncommon reaction to
taking too high a dose of stimulants. Patients may have to experiment taking the medication in
varying dosages or at varying times of the day or even days of week to achieve
the proper combination of focus and relaxation.)
He reviewed the pro's
and con's of the Adderall so far:
Pro: he can "point (his) attention
and focus better", can better sequence projects, stay on task. His planning
is better.
Con: he is less
talkative with coworkers. He is less
spontaneous so finds his wife's easy going looseness hard to take. He feels he was too rigid for a while:
things
had to go as planned or he gets
frustrated.
He is eating and sleeping normally.
I suggested that he decrease the daily dose slightly.
Next appointment:
Three
weeks
Date: Three weeks after previous session
Medication
taken during the past week:
Adderall 20 mg at 8 AM
and 1 PM while at work.
As soon as he turns
his attention to the disorder in his life, he becomes almost compulsively neat.
He has not had coffee
in six weeks. He used to drink it all
day and felt wasted and lethargic by the end of the day. He has also
stopped chewing tobacco. He found that smoking and coffee distracted him from and muddied the effect of the
Adderall. He sees them now as crutches,
offering a way to
pause and gather steam to be more proactive. When that didn't work any more once he was on the Adderall,
at first it was frustrating.
He has now found himself going ahead with his life in a more focused way, defining and moving towards goals. Before it had been easier just to check out and float with life. It was too frustrating to fight against disorder in his life and mind and easier "to just degenerate."
He now has the ability to process more thoughts at the same time.
Sleep OK, no change in weight or appetite.
Only recently, after
taking the meds for two months, has been able to get a big picture of how he is
doing. Right now he is trying mainly to
take the meds regularly and be less rigid, more loose in his life.
Next
appointment:
Two months