Precise neuroscience evidence dramatically changes health delivery, health applications. Dr. Charles Parker, ADHD Medication Rules: Paying Attention To The Med For Paying Attention
Six years ago I read Driven to Distraction and diagnosed myself as being ADHD. I shared my findings with a psychiatrist. He handed me a small card that had five questions on it. I answered the questions, we talked about my answers, we talked some more and then he agreed with my diagnosis. He prescribed Wellbutrin™. From that time to the present, I visit his office every three months. He asks, “How are you doing?” I say, “Fine.” I then pay his fee and he hands me a prescription. That’s it. Does he do any tests? Blood? Brain? Reflexes? I.Q.? Anything? No. He performs the “typical” diagnosis, makes an assessment within minutes and prescribes medication. The effectiveness of the medication is determined by my answer to the single question, “How are you doing?” This method of diagnosis may have made sense prior to the explosion of knowledge in brain functionality and neuroscience. However, it no longer makes much sense. It ignores too much and thereby misses too much. Charles Parker, neuroscientist and psychiatric consultant, wants to supplant this overly simplistic diagnostic methodology with one that integrates some of the latest work done in neuroscience, psychopharmacology, and brain studies (e.g., SPECT scans). In his book – ADHD Medication Rules: Paying Attention To The Med For Paying Attention – he shows how diagnosis and treatment can be based on precise measurements, how medications can be precisely targeted and how this will result in better results, providing what he has termed personalized, customized medicine.
Parker’s New Methodology
Note: The following description is a simplified version of Parker’s methodology and, therefore, it is important to read his book in order to fully understand the richness of the methods and diagnosis.
Once it is determined that the patient has ADHD, [note 1] the doctor uses a set of diagnostic categories that maps the observed behaviors to specific brain functions. This is a crucial point. Both the current and proposed new DSM categories take a broad-stroke view of ADHD. These categories do not correlate observed behaviors to specific brain functions. They point in a general direction but lack precision. Parker’s alternate set of categories makes up for this shortcoming. His three major categories and eleven subcategories make possible a finely tuned diagnosis and treatment because each subcategory corresponds to specific brain functions and specific medications that can affect these brain functions. Therefore prescribed medications based on this finely tuned diagnosis are much more effective than a broad-stroke approach. [note 2]
Parker’s Methodology In Action: Inattentive Type vs Thinking ADHD
The current Diagnostic & Statistical Manual has the category Inattentive Type [note 3] that is based on behaviors indicative of inattention and a lack of hyperactivity. But once a patient is diagnosed as Inattentive Type, what does that really mean? What deep neurological functions correspond to this category and, therefore, what medication should be prescribed? The problem is that we do not precisely know based on DSM categories. [note 4] Of course we know the locus of activity (or inactivity) is in the frontal lobe but there are many different neurological processes taking place that create different types of observable behavior. The DSM categories are not specific enough to correlate behavior with brain functions at the neurological level which is the level at which medications work. Consequently, treatment based on broad categories becomes a matter of let’s try this and see how it works.
For Parker, there is no inattentive type but, instead, a much richer category called Thinking ADHD, which is “thinking without subsequent action” and without evidence of hyperactivity. [note 5] This category is broken into four subsets: Physically restricted (“thinking, not doing”); Emotional overthinking (“worrying, fretting”); Cognitive overthinking (“mind-stuck, unable to decide”); Compulsively decisive (acts immediately in order to avoid thinking). These subsets, in turn, correspond to specific brain functions. Once a proper diagnosis has been made and the correct subset has been determined, we know which brain functions are involved and, therefore which medication to prescribe (see Figure 1 above). Subsequent visits with the doctor determine the effectiveness of the treatment and whether the initial diagnosis was correct. There could be other factors that only become evident later on and which require a change to the diagnosis. Therefore, these visits are not a simple “How are you doing?” The doctor engages the patient in detailed discussions to determine how the medication is metabolized, whether it works for the correct duration and effectively during that duration, and so on.
Brain Optometry & Personalized Medicine
Viewed as a whole, what Parker has accomplished with these new categories, the large number of subsets, the mapping of subsets to specific brain functions and medications, and the detailed follow up analysis, is what he calls brain optometry. It moves the practice of medicine away from cookie-cutter diagnosis and treatment (“What’s your height and weight? How do you feel?”) to personalized, customized medicine. In the same way that an optometrist tailors each prescription to the patient’s specific needs, Parker believes that doctors can provide a diagnosis and treatment that is as precise as the optometrist’s prescription. His book lays out the basic methodology required to make this a reality in the world of ADHD medications.
Additional Thoughts & Comments
Who Is This Book For?
Both doctors and patients will find something of value in this book. It is not written like a medical textbook so the layperson should have no problem understanding the concepts. Doctors will find that the later sections of the book provide methods and guidelines that may be integrated into their practice.
Misdiagnosis and Suicidal Thinking
In addition to laying out a new diagnostic methodology, Parker also examines the potential for misdiagnosis which can lead to suicidal thinking. This information is of vital importance to both patients and doctors. This information alone is reason enough to purchase this book.
A Sea of Metaphors
Parker has, to a large degree, moved into somewhat uncharted medical territory. In numerous sections of the book he strains to find the right metaphor to explain particular behaviors or diagnoses. The reader may find the frequent change in metaphors to be disconcerting. However, this should not be allowed to detract from his vital work. Parker is trying to describe the multidimensional nature of ADHD using three categories and eleven subsets. The metaphors go a long way in helping the reader understand the underlying concepts and the many ways in which ADHD can manifest itself.
A Note About The Diagrams in this Review
The diagrams were created by me and NOT by Dr. Parker. They are based on my understanding of the concepts.
Other Posts of Interest
- ADHD’s Genetic Basis Old News! Recent Research: “First Direct Genetic Link” (Maybe) (ADHD Roller Coaster: “Is It You, Me, or Adult A.D.D.?”)
- New Evidence of Genetic Basis for ADHD (psychcentral.com)
- Filling in the Gap: Some Thoughts on Dr. Parker’s “Psychiatric Diagnostic Labels: Functional or Static?” (Jeff’s ADD Mind)
- Does ADHD Medication Ruin Creativity? (Jeff’s ADD Mind) Be sure to read Dr. Parker’s comment
- It is possible that further tests and discussions point to a different diagnosis and Parker notes the issues of misdiagnosis.↩
- My post, Filling in the Gap, which was a reflection on one of Dr. Parker’s posts, examines the issue of mapping the observed to the neurological.↩
- “314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months” where Criterion A1 describes behaviors associated with inattention and Criterion A2 describes behaviors associated with hyperactivity. See: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=383#↩
- If one were to speak in Freudian terms, for example, what does Oedipus Complex mean? What part(s) of the brain are involved? What medications are there that would alleviate this condition?↩
- Interestingly, Parker notes that being smart is detrimental to those with Thinking ADHD since being smart means the ADHD patient can discern more variables that need to be dealt with which makes decision making that much more difficult.↩