Wednesday, July 23, 2014

Normal ≠ Perfect

I wanted to address a common problem in treatment, especially any treatment that involves a medication and that is the issue of setting a goal for treatment and when to know when that goal has been reached.  This seems like a very basic proposition that should be easy to do.  The reality is that it is not and a lot of that comes down to the subjectivity associated with the human conscious experience.  I am already on record here that I think subjectivity is a very good thing.  I am glad that everyone in the world has a unique conscious experience.  In many ways we communicate in broad brush strokes, but the reality is that all 7.2 billion of us have a unique conscious experience of basic phenomenon.  From the consciousness literature one of the basic examples is the unique experience of the color red.  My experience of the color red is not your experience of the color red.

What happens when a person discusses  their unique conscious experience with their friends and family?  The first threshold is whether there is any interest in the discussion.  People have varying levels of empathy, patience, and psychological mindedness and it is entirely possible that there are people who cannot have that conversation.  The people who can have that conversation make common mistakes.  The first is that they are some sort of diagnostician and can diagnose problems based on what they hear.  This can happen even though most people do not want a diagnosis - just someone to listen to their problems.  Over the years I have seen a lot of people who come in for an evaluation based on these conversations with friends and family.  The identified patient is often in a quandary because they either disagree or are confused about the amateur diagnosis from their friends or family.  Their presenting statement often is:  "I am here because my spouse thinks I am depressed."  Today the presenting complaints may seem more sophisticated: "My wife thinks I have adult ADHD because she saw a checklist on a doctor's show on TV and told me that I have all of the symptoms."   Clearly the wife has an expectation that there is a problem, a treatment, and expected improvement over the current situation.

All of these events can happen independent of other observers.  People are inundated with various sources of information and are concerned about whether they have developed certain problems.  They are concerned about whether they have a problems that can be easily fixed by medicine.  The cognitive enhancement field and its supporters are one example.  The idea that medical marijuana is somehow going to work much better than the usual medications is another.  There are many biases that occur in that scenario and play out in the relationship between the patient and the physician and two examples are instructive:

1.  The chronic pain patient and opioid analgesics:  The operative bias here is a very common one and that is:  "If this doctor would raise the dose of this medication enough - my pain would be gone."  The reality is that there really is no opioid dose that will do that and non-opioid medications offer the magnitude of pain relief.  There is no known perfect degree of pain relief for chronic forms of pain.

2.  The case outlined above of the adult with possible ADHD:  Let's say that an evaluation confirms the diagnosis of ADHD - combined type and medical treatment is recommended.  Whether the treatment is stimulant medication or atomoxetine, how the patient assesses the adequacy of treatment is critical.  There is often a discussion about "expectations" of treatment in terms of the outcome.  The patient in this case, may not have a good idea of their capabilities.  The physician treating the patient has hopefully identified target symptoms that seem to be the most important or urgent that allows the patient to be followed.

In both examples, there is a problem at the upper boundary of treatment.  As the dose of medication is increased, will the symptomatic changes as assessed by the patient get to the point that they are satisfied with the result?   In order for that to happen, the patient has to have a conscious and unconscious idea about what they want the result to be so they can compare what has actually happened to the idealized result.  The idealized result often incorporates the wishes of friends and family.  That is the extreme positive end of the Likert scale, depending on how the questions are phrased.  A common example that I use in teaching is the 10 point pain scale where 10 usually indicates the worst possible pain.  In every seminar that I give medical professionals I ask if anyone has said that their pain was a "14" on that ten point scale.  Members of every seminar have gotten that response.

In the case of ADHD, doing a similar assessment of the target symptoms is similarly problematic.  Many physicians find themselves in the position of prescribing the maximum dose of Adderall, seeing clear improvement, and the patient expecting even more improvement when that result is really uncertain.  The common correlate of this problem is higher than recommended doses and irrational polypharmacy.  I was discussing this issue with a colleague who is a board certified child and adolescent psychiatrist and he said something I had never heard before, but it seems very accurate:

"The goal is to get them functional and not to perfect their functioning."

One of the many errors in the philosophical approach to modern psychopharmacology is the idea that we can tune up the human brain by adjusting various medications.  The patients involved certainly expect this and some of the physicians involved go along.  There is often an implicit goal that the patient will be restored to their "normal" or "baseline self" - whatever that is.  Measurement based care seems to assume this when they suggest that the mood extremes of 7.2 billion unique conscious states can be characterized by a 21 or 27 point scale.  A further assumption is that the numbers on this scale mean the same thing across the population, as though this scale is really a quantitative measure when it is not.  Certainly there are very problematic symptoms that should require a best effort approach to get rid of by whatever means necessary.  But there are many others that are resistant to treatment, transient or for which we have no clear treatment approaches.  There are many symptoms that have meaning in the context of the persons life or their interpersonal relationships.  In many cases, a symptom is not a symptom at all but a response to overwhelming stress or a problem with no obvious solution.  In that scenario, a discussion of expectations from the outset, a discussion of what constitutes meaningful change for the person, and a discussion of possible non-medical approaches to the problem seems like the minimum for developing realistic ideas about outcome.

George Dawson, MD, DFAPA        

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