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Wednesday, April 1, 2015

Attention Deficit Disorder (ADD) / ADHD

Christopher L Bray MD PhD

Attention deficit disorder (ADD) / ADHD is a cluster of symptoms that has been defined as a psychiatric disorder. It is characterized by 1) Persistent short attention span, 2) Distractibility, 3) Disorganization, 4) Procrastination, 5) Forethought and judgment problems, 6) Impulse control problems (in some, but not all), and 7) Hyperactivity (in some, but not all). ADD (and the subtypes) have a genetic inheritance pattern.

Diagnosis usually depends on patient reported information as well as a structured psychological interview. The patient reported symptoms relate to functionality – at home, school, and work. Often a diagnosis also relies on outside supportive information such as what is reported by family, teachers, and co-workers. It is important to recognize that there are many different personality types, introversion/extroversion characteristics, activity interests, and focus abilities within the realm of “normal”. Under some circumstances, this normal variation can cause functional problems. So a person may be very productive and functional in one environment, but just not be able to succeed in another environment - like school, on standardized tests, or in "dry" boardroom meetings. True Attention Deficit Disorder tends to span multiple domains of life. Hyperactivity (the “H” of ADHD) is usually associated more with children and is less common in adults.  The traditional “cause” for ADD/ADHD relates to an under-functioning prefrontal cortex of the brain – the area of the brain needed to focus. The cause of this dysfunction is complex and not easy to define and in most cases unknown.

Dr. Daniel Amen classifies ADHD into 7 subtypes.
Type 1 – Classic ADD/ADHD: SYMPTOMS: Primary ADD symptoms (short attention span, distractibility, disorganization) plus hyperactivity, restlessness, and impulsivity.

Type 2 – Inattentive ADD: SYMPTOMS: Primary ADD symptoms plus low energy and motivation, spacey, and internally preoccupied. Type 2 tends to be diagnosed later that than Type 1, if at all. It is more common in girls. These are quiet kids and adults, often labeled as “lazy”, “unmotivated”, or “not all that smart”.

Type 3 – Over-focused ADD/ADHD: SYMPTOMS: Primary ADD symptoms plus cognitive inflexibility, trouble shifting attention, being stuck on negative thoughts or behaviors, worrying, holding grudges, argumentativeness, oppositional, and saddled with a need for routines. It is often seen in families with addiction problems or obsessive-compulsive tendencies.

Type 4 – Temporal Lobe ADD/ADHD: SYMPTOMS: Primary ADD symptoms plus a short fuse, misinterprets comments, periods of anxiety, headaches or abdominal pain, history of head injury, family history of rage, dark thoughts, memory problems, and struggles with reading. This subtype is often seen in families with learning or temper problems.

Type 5 – Limbic ADD/ADHD: SYMPTOMS: Primary ADD symptoms plus chronic mild sadness, negativity, low energy, low self-esteem, irritability, social isolation, poor appetite, and sleep patterns.
Stimulants by themselves usually cause problems with rebound or produce depressive symptoms.

Type 6 – Ring of Fire ADD/ADHD: SYMPTOMS: Primary ADD symptoms plus moodiness, anger outbursts, oppositional, inflexibility, fast thoughts, excessive talking, and very sensitive to sounds and lights. Dr. Amen named it “Ring of Fire” after the intense ring of over-activity he saw in the brains of those affected. This type is usually made much worse by stimulants.

Type 7 – Anxious ADD/ADHD: SYMPTOMS: Inattentiveness, distractibility, disorganization, anxiety, tension, nervousness, a tendency to predict the worst, freezing in test-taking situations, and a tendency toward social anxiety. People with this type are prone to experience the physical symptoms of stress, such as headaches and gastrointestinal problems.

Dr. Bray’s natural augmentation therapy for ADD/ADHD:

  1. Food quality has an important effect on how the body functions and feels. The nutritional building blocks should not be taken for granted and the reactivity of the body and mind to artificial substances should not be underestimated. Processed food, sugar, and artificial colors / flavors / preservatives all need to be reduced. You should eat plenty of whole organic vegetables, fruits, nuts and seeds along with sufficient “healthy” oils / essential fats and hormone / chemical free protein. Patients with attention problems should never skip breakfast and should focus on eating a high protein breakfast like eggs – not cereal and OJ.
  2. Over-focused ADD/ADHD (Type 3) may do better with healthy complex carbohydrates (Potatoes Not Prozac). Ancient versions of whole grains (not the same as whole grain bread or whole grain cereal) are very nutritious if they are tolerated. All other types tend to do better with higher protein, lower carbohydrates.
  3. Simple sugars should be reduced / avoided. (Bad breakfast: Pop-Tarts or pancakes/syrup and orange juice – all sugar; Bad after-school snack: Oreo cookies and soda – all sugar). Good fats are encouraged, bad fats are discouraged.
  4. Exercise helps to reduce stressful hormones, balances neurotransmitters, increases blood flow to the brain, and allows for heavy metals to be removed from the body (via sweating).
  5. Sleep is critical to attention and memory. 7 hours is ideal. There are a lot of things that impair sleep and the “fix” is not just to take a “sleep pill”. Sleep hygiene is very important. This should be discussed with a knowledgeable provider. Pain can interfere with quality sleep. Sleep apnea / snoring can impair sleep (and is often missed by the physician in thin adults and children). Anxiety and depression can also cause poor quality sleep. These should be addressed at the level of the root cause rather than a pill that just makes you sleepy.
  6. Stress should be managed. Resiliency should be practiced. Stress, anxiety, and depression impair the memory areas of the brain.
  7. Place a limit on intensely stimulating activities – these deplete dopamine and dopamine is already low in people with ADD/ADHD.
  8. Avoid activities where head injuries are a possibility – these cause more rapid decline in patients with ADD/ADHD.
  9. Avoid toxic substances – this includes heavy metals, pesticides/fungicides/herbicides, synthetic chemicals, alcohol, drugs, nicotine, and excess caffeine.

Supplements that have been helpful in my experience:

  • Magnesium L-Threonate (Jarrow MagMind for example) – 144 mg elemental magnesium daily – acts as a good mood stabilizer and helps with “calming” the mind (good for all types)
  • Omega-3 - 1000-2000 mg daily (not the same as fish oil) – helps with mood stability as well as focus (good for all types – including type 6)
  • L-tyrosine – 500 to 1500 mg three times daily – helpful for improving focus (good for types 1 through 5)
  • GABA – 100 to 400 mg two to three times daily - helpful for “calming” or “quieting” the mind during the day and night (particularly good for type 4)
  • St John’s Wort 300 mg three times daily or 5-HTP 100 mg three times daily (particularly good for type 3)
  • SAMe 200 to 800 mg twice daily – particularly helpful with ADD/ADHD with strong negative emotional features (particularly good for type 5)
  • Melatonin, valerian, tryptophan for sleep problems


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