Ben Hunter, MD

For the Committee on Work and Organizations, Group for the Advancement of Psychiatry

Bob, aged 50 years, worked as a factory manager for a large corporation but had problems getting along with peers and managers. Ultimately, he was fired for initiating safety policies without consulting with his supervisor and mandating compliance in his subordinates, who complained, leading to his termination. In his spare time, Bob renovates and sells (ie, flips) houses.

He went to his psychiatrist because of PTSD symptoms that he alleged were caused by the harassment he was subjected to and to wrongful termination by his employer. He wants his psychiatrist to complete his forms for disability. Bob had been discussing his problems about getting along with coworkers and superiors but said that he had finally “realized that the issue is my job. I’m always stressed and working full time has eliminated any space to work on myself and decompress. I just found out that I’m eligible for permanent disability with full pay based on my tenure-isn’t that wonderful?”

If this was so wonderful, then why was Bob’s psychiatrist filled with countertransferential dread? The concept of patient-defined disability seemed problematic. Work was indeed a source of ongoing angst, but Bob had been employed for years. Even if his current work environment was truly damaging, he was clearly capable of performing another substantial job, if not presently, then at some point in the future.

Patients who confess to struggling at work feel differently than patients who request disability. As the psychiatrist’s countertransference reaction revealed, the problem is one of role reversal between the treater and patient. Patients do not make functional assessments on themselves, professionals do.

If a psychiatrist determines that a patient is profoundly functionally impaired as demonstrated by the patient’s report of symptoms and the manifestations thereof, such as difficulty performing job tasks, evaluation for disability is the next step. The disability evaluation should be performed by a third-party mental health professional, as the treating psychiatrist has an inherent conflict of interest: his or her task is to advocate for the patient’s mental health, not disability compensation-to listen and understand, to demonstrate empathy, and to alleviate suffering. The task is also to instill hope and confidence, and to restore functioning. In many cases, deeming a patient “disabled” can be highly counter-therapeutic.

But what to do when the patient says that he needs disabled status? When, despite your professional opinion, the patient is convinced that work is not, in fact, a source of meaning and value and an excellent venue for working through relationship and life issues? When the patient believes that he is incapable of working, but you believe otherwise? Disagree or refuse his request, and the therapeutic alliance will be severely strained if not broken. The patient very well may displace his sense of work-related victimization, helplessness, and rage onto the provider, which can prove damaging for the psychiatrist as well as the patient.

What if a psychiatrist agrees with the patient’s professed disability and submits the required paperwork? This situation is no less problematic. Regardless of explanations to the contrary, the psychiatrist communicates that the patient is sick, ineffective, and at least temporarily broken and that he or she, as the treating psychiatrist, is incapable of healing the patient and therefore has given up. In the case of long-term disability, as with the patient above, the statement is more profound given its implied permanence. Thus, treaters have the options of either opposing disability, thereby damaging the therapeutic alliance, or supporting disability thus professing pessimism about the patient’s odds of recovery and removing work and its inherent value from the patient’s life.

The only reasonable option, particularly for long-term disability assessments, is to refer a patient for a third-party assessment. Occupational or forensic psychiatrists are an excellent option because they understand psychopathology and the functional and prognostic implications of disease. Unfortunately, this was not possible in the case that led our discussion. The paperwork specifically required that the treating psychiatrist deem the patient disabled, to the point of stating that third-party assessment would not be acceptable. The psychiatrist was handcuffed.

The psychiatrist, who did not agree that PTSD was the appropriate diagnosis for the patient, elected to provide fair warning, making explicit the dangers of filling out the paperwork. He warned that he would, in essence, be admitting defeat, and that the patient’s sense of trust in his psychiatrist and the field would waver. He explained that the patient’s core sense of brokenness and impotence would be confirmed, by a professional no less. He told the patient that removing work would remove a source of purpose, half of Freud’s “love and work” equation for mental health. Furthermore, he expressed confidence in his own ability to help the patient heal, his hope that this man would improve his maladaptive behavioral patterns and improve his ability to work effectively. He allowed the patient to make the decision, invoking informed consent.

What ensued was a therapeutic failure. The patient chose disability, and for 2 weeks, he felt significant relief. Shortly thereafter, he became cripplingly anxious, unable to plan and utilize his newfound free time effectively. Every unfilled minute reinforced his avoidance. He felt more broken than ever, separated from the herd of functional peers, a weak man who had admitted defeat, a man who no longer contributed to his society, his family, or his own well-being. Profound shame overcame him, followed by extreme anger misdirected towards the people and system he perceived to be driving his pain. Foremost among these abusers? His psychiatrist, who was “fired” less than a month later in favor of a “more supportive” physician down the road. The psychiatrist, viewed by the patient as adversarial, now experienced a profound feeling of impotence and guilt.

Although in some cases, a determination of disability is justifiable, necessary, and humanitarian, far too often, disability requests end in shared grief between patient and treater. This is a cautionary tale, but an avoidable one. Treating psychiatrists must continue to advocate for boundaries and avoid assuming a dual role of treater/evaluator with its inherent conflict of interest. Employers and insurance companies that insist on treating providers serving as disability assessors must be challenged. Patients must be encouraged to return to work, to have faith in themselves and their ability to recover, and to trust the system.

This continuing series of articles will explore the key issues psychiatrists must bear in mind when a patient requests disability. Given the ubiquity and complexity of this situation, the following topics will be explored in future issues:

• The overall concept of disability and definition of its six components

• Comprehension of the event(s), situation(s), and dynamics that precipitated the disability request in addition to any psychiatric diagnosis present in the patient

• How to perform a functional analysis, which determines, from the psychiatric viewpoint, whether a patient is truly limited or disabled from performing a specific job

• How to develop a plan that therapeutically addresses the problem(s) driving the claim of work incapacity, the goal being to facilitate the patient’s return to work

• An understanding of the risks inherent in assuming dual roles of disability evaluator and treater for the same patient; these risks are magnified if disability is denied or reversed and the patient asks the treater to assume the role of forensic expert.

 is Committee Chair, Work and Disability Consultant Private Industry, the Courts, and the Legal Profession; 

 is Department Psychiatrist, Boston Police Department, Consulting Psychiatrist, Boston Fire Department, Work and Disability Consultant, Private Industry and Government; 

 is Adjunct Professor, Department of Psychiatry, University of Southern California; 

 is Clinical Assistant Professor of Psychiatry and Behavioral Sciences, Chicago Medical School; 

 is Cotswold-Looney Fellow Emeritus, Group for the Advancement of Psychiatry.

Articles

What to do when a patient says they need disabled status, but you believe otherwise?

A Complicated Case of Psychiatric Disability

This activity offers CE credit for:
1. Physicians (CME)
2. Other

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

To goal of this activity is to understand the sources of treatment-resistance in ADHD and how to ameliorate them by optimizing treatment.

At the end of this CE activity, participants should be able to:

• Identify the sources of treatment-resistant ADHD in adults

This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

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Ben Hunter, MD, has no conflicts to report.

Anthony L. Rostain, MD, MA, reports that he is a consultant to Shire, Ironshore, Arbor, Lundbeck, Major League Baseball, National Football Leagues, SUNY/Upstate.

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The prevalence of ADHD in adults is estimated to be 4.4% in the general population with ranges of 12% to 40% in patients with other psychiatric disorders, depending on the primary diagnosis.

 Increasing recognition of ADHD as a source of functional impairment in adults has meant that its treatment is moving from the domain of specialists into the office of general psychiatrists. This shift necessitates facility in the use of available pharmacologic and psychosocial treatments. But what happens when the initial treatment approach does not provide adequate results? Through discussion of three cases, in this article we identify sources of treatment resistance and provide suggestions for optimizing treatment.

John was a 19-year-old college freshman with a diagnosis of ADHD established in middle school who presented to the Penn ADHD Program with concerns that his stimulant medication was no longer working. He had been on the same daily dose of extended release mixed amphetamine salts (MAS) 20 mg in the morning along with 10 mg immediate release MAS in the afternoon since 11th grade, with generally good results until recently. John was enrolled in a very rigorous program in college that required him to read 250 to 300 pages of technical writing and to write up 2 lengthy lab reports and multiple homework assignments on a weekly basis. While he expressed a great deal of interest in his courses, it quickly became clear to him that the academic load was more than he had expected.

During his intake, John reported difficulty staying focused during lectures and lab sessions, often to the point that he would lose track of the course material. After class, John had trouble getting started on his assignments, often spending long periods of time internet surfing and chatting online with friends. He admitted that he had been spending excessive amounts of time socializing with his roommates and playing his favorite video games until late at night. He reported some continued benefit from the medication but noted that it was wearing off by the end of the morning instead of lasting through his afternoon classes and study sessions.

Despite recommendations for improving his scheduling and sleep hygiene plus an increase in MAS dosage to 20 mg of extended release twice daily, John continued to fall behind on his assignments and struggled to pass his courses. He had begun missing his morning classes because of his late-night gaming activities. When asked how the medication was working, he admitted to having increased his dose to 80 mg daily including a 20 mg dose at 8 PM. Much of the time, he was going to bed after 2 AM and not waking until after 10 AM, thereby missing many of his early morning classes.

Nonadherence and executive functioning difficulties

College students with ADHD face multiple challenges with respect to self-regulation, time management, and completion of complex academic tasks.

 The supportive “scaffolding” they were provided at home is no longer available in the college setting. Moreover, the perpetual distractions of social life and online activities make it difficult for college students like John to complete their assignments in a timely fashion. In response to his executive functioning challenges, John began overusing his stimulant medication partly out of the mistaken assumption that it would help him get organized and do his work more consistently, and partly out of a wish to extend his work day. Unfortunately, this strategy did not work because medication alone cannot overcome executive functioning deficits and unhelpful habits like procrastination and poor sleep hygiene. John was advised to make use of the college’s learning center services including tutoring and ADHD coaching.

• In the case of treatment resistance in college students, assess patient executive functioning, encourage utilization of learning center services and ADHD coaching, and investigate the possibility of medication misuse in order to enhance cognitive performance.

Clarifying diagnosis, changing area of study, managing expectations

John began taking advantage of college student support services and with the help of an ADHD coach, he began attending classes regularly, developed a more effective time management system, and was able to establish a healthier sleep-wake cycle. Despite these interventions, John remained overwhelmed with the high demands of his academic course of study. He was unable to maintain an adequate GPA to remain in the program and was asked to take an academic leave of absence. During his time away from school, he underwent psychoeducational testing and was found to have dyslexia and mild auditory processing difficulties. He was able to use this information to change his area of study and to receive academic accommodations when he returned to school. John took advantage of the school’s learning resources, developed better ways of getting started on his work in a timely fashion, and began to get better grades in his new major.

• When patients exhibit learning and executive functioning difficulties, it is important to re-evaluate the underlying diagnosis and to encourage them to make professional decisions on the basis of new clinical information in order to optimize their likelihood for success and mastery.

Mary was 46 years old when she presented at an outpatient intake appointment. She reported longstanding difficulties with attention, task-completion, and organization. Looking back, she recalled these symptoms as early as grade school, describing herself as a “daydreamer” who would occasionally be punished by her teacher for lapses in attention. Through middle school and high school, she sensed that it took her significantly longer than her peers to complete assignments, particularly those requiring extensive reading, which often took multiple passes for Mary to comprehend. However, she was generally successful until college, when the course demands at a challenging private university overwhelmed her inefficient learning habits. Mary failed several liberal arts classes and dropped out after less than one year.

Mary met her husband soon after leaving college and became a homemaker. Despite a less strenuous cognitive workload, she continued to feel inefficient and disorganized. Mary described a daily routine of “flitting from one thing to the next” without actually completing any individual project, often forgetting to address multiple items within a given day if not explicitly recorded in a to-do list. After neuropsychological testing confirmed the results of scales completed by Mary and her husband, ADHD inattentive type was diagnosed, and Mary was started on methylphenidate ER.

Mary tolerated methylphenidate and was titrated to 36 mg with 50% improvement in symptom reports, but further titration was limited by “jitteriness.” Mary’s sense of despair was palpable on her subsequent visit. Her psychotherapist corroborated a theme of feeling fundamentally flawed and “broken,” more prominent over the past 3 to 4 weeks. Mary noted that she was having increasing difficulty starting tasks, and on several days over the past week, she had returned to bed after getting the children off to school.

ADHD is highly comorbid, showing particularly strong associations with mood and anxiety disorders.

 Clinically, it is often difficult to differentiate between depression or anxiety causing executive dysfunction versus untreated ADHD causing disorders of mood and anxiety. In Mary’s case, it initially appeared that her past depressive symptoms had been secondary to the self-esteem issues and sense of unmet expectations that result from functional impairment as a result of poor attention modulation. However, with Mary’s stimulant dosed adequately and improvement in symptoms specific to the diagnosis of ADHD, the imperative became addressing residual depressive symptoms. Mary was started on sertraline and titrated to a dose of 150 mg, at which point she noted significant reduction in both her depressive and inattentive symptoms. Notably, Mary’s self-esteem, motivation, and ability to initiate tasks improved markedly.

• Stimulants are highly effective in treating “uncomplicated” adult ADHD.

 In the case of treatment resistance, re-screen for comorbid medical or psychiatric disorders and treat underlying/comorbid disease optimally before making further adjustments to stimulants.

Despite a robust response to methylphenidate and sertraline, Mary continued to report difficulty falling asleep. She described herself as lying in bed with her “mind spinning,” an endless loop of repetitive thoughts and scenarios she felt unable to turn off. A review of Mary’s daily routine revealed that she typically dosed her stimulant around 6:30 AM, leading to the conclusion that its effects were likely wearing off in the early evening. Methylphenidate immediate release 5 mg was added at 4:00 PM with close monitoring to ensure this did not add to Mary’s sleep difficulties. As suspected, she reported a reduction of anxious inattentive thought processes around bedtime. The methylphenidate IR was titrated to 10 mg, and the dose was slowly moved back to 5:00 PM, at which point she was consistently able to fall asleep at her target time of 10:00 PM. With improved sleep on top of her established gains, Mary had remission of both ADHD and MDD symptoms.

• If patients report difficulty falling asleep due to “racing thoughts,” “inability to shut down the mind,” or other similar complaints, consider extending dosing into the evening to cover reemerging inattentive symptoms driving insomnia. Stimulants have been demonstrated to positively affect architecture in the often-disrupted sleep of patients with ADHD.

James was a 38-year-old consultant in the alternative energy industry transferring care from his primary care doctor, who felt unable to adequately treat James’s multiple psychiatric comorbidities. James’s history revealed ADHD, combined type, diagnosed and treated with multiple different classes and doses of medications beginning in elementary school. He was currently prescribed lisdexamfetamine (LDX) 40 mg daily with marginal reported improvement. In addition, James met criteria for persistent depressive disorder and generalized anxiety disorder with panic, stating that his current dose of fluoxetine 20 mg, started one month earlier, “did nothing.”

It was noted that James was boisterous and challenging during the interview. He openly expressed irritation at the psychiatrist’s refusal to add immediate release stimulants to his LDX without first optimizing long-acting therapy.

Unrealistic expectations of medications and/or physician

James made numerous phone calls between psychiatric appointments, requesting increased doses of stimulants in each case, clearly expressing anger that he would be required to schedule office visits for such changes. During these phone calls, he was encouraged to allow time for adequate trial of each dose and was reminded of the initial treatment agreement stating that doses would not be increased over the phone. James responded well to the established boundaries, and his demanding behavior ceased relatively quickly.

Through further discussion, it became clear that James was expecting more coverage than any regimen could reasonably achieve. A review of his dosing and daily activities revealed that he was attempting to work, or otherwise remain highly cognitively engaged, for 16 to 18 hours every day. James was disabused of this misguided treatment goal and reminded of the substantial benefits of healthy diet, exercise, sleep, and general self-care. A more modest expectation of 12 to 14 hours of daily coverage was set.

• Inability to extend focus and concentration past normal human capacity is not treatment resistance. Early discussion of appropriate expectations for stimulant therapy, along with clear prescribing boundaries, are critical when treating challenging patients.

Despite improvements in his daily routine, James continued to demonstrate residual symptoms at the current dosage of stimulant. His LDX was titrated in 10 mg increments until he reached a dose of 100 mg (100 mg LDX is equivalent to 40 mg MAS delivered over 12 hours), which James felt was effective and resulted in demonstrably less irritability. James was examined closely for adverse effects at each dosage, and none were observed, including at the highest dose.

A commonly-observed phenomenon in patients referred to our clinic for treatment resistance is underdosing of stimulants. There is little evidence to corroborate the concern many clinicians feel in titrating these medications. As with antidepressants or other psychiatric medications, there is wide variation in the metabolism of these compounds and it is sometimes beneficial to exceed FDA dosing recommendations, ie, when the benefits of increased doses continue to outweigh adverse effects and health risks.

• Close monitoring is paramount when prescribing high doses of stimulants; check vital signs, consider an EKG, and screen closely for side effects.
• If not already attempted, a “class switch” (from amphetamine salts to methylphenidate, or vice versa) should be considered before moving to supra-FDA dosing.

Treatment resistance in adult ADHD can stem from several sources including treatment nonadherence, misdiagnosis, patient misconceptions, insufficient use of environmental restructuring and psychosocial interventions, and symptom persistence despite adequate treatment trials (bona fide resistance). Nonadherence in adult ADHD is extremely common and is linked to the symptoms of the disorder itself: namely, forgetfulness, disorganization, and difficulties with self-control. As it has been observed, the key problem facing adults with ADHD is “turning intentions into actions,” so even the most motivated patients often have trouble following through on medical instructions.

Misdiagnosis often involves overlooking factors besides ADHD that may be impairing an individual’s ability to function. As the first case illustrates, hidden impairments like learning disabilities and auditory processing problems can significantly hinder academic success in college or graduate school. The second case exemplifies how comorbidities like depression and anxiety can interfere with optimal treatment. It is easy for clinicians to underestimate the extent to which patients’ distorted thinking about ADHD and its treatment can influence outcomes, as the third case illustrates. Providing ongoing psychoeducation and challenging unrealistic beliefs and expectations are the best ways to improve this situation. In a similar vein, emphasizing the importance of integrative care via environmental restructuring and psychosocial interventions (such as CBT and ADHD coaching) is another means to reduce treatment resistance. Increasingly, these approaches have been shown to add additional value to medical treatment for adult ADHD.

It is important to remember that even with optimal treatment and adherence, a good deal of the impairment that results from ADHD is not effectively ameliorated. This stems in part from the underlying pathophysiology of the disorder which is both complex and yet poorly understood. Another mediator is the limitation of current interventions to repair the disordered brain processes that are constitutive of ADHD. As with many other neurodevelopmental disorders, treatment is primarily symptom-focused rather than curative. Despite these challenges, forging effective clinician-patient relationships, addressing expectations in a straightforward manner, fashioning a treatment plan with realistic goals, utilizing integrative methods, and maintaining a focus on promoting coping with the disorder are useful guides to intervention.

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. Washington, DC: American Psychological Association; 2010.

This CME identifies the sources of treatment-resistant ADHD in adults and focuses on preventing misdiagnosis and optimizing treatment.

Author | Ben Hunter, MD

Articles

A Complicated Case of Psychiatric Disability

Addressing the Challenges of Treatment Resistant ADHD in Adults