Richard Brown discusses symptoms that often get in the way of full recovery in ADHD, including dyslexia, and problems with working memory, processing speed, and executive function.
Published On: 08/15/2022
Duration: 13 minutes, 57 seconds
Referenced Article: “Complementary Therapy in ADHD,” The Carlat Psychiatry Report, August 2022
Chris Aiken, MD, Kellie Newsome, PMHNP, and Richard Brown, MD have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Stimulants are one of the most effective meds in psychiatry, but they don’t always bring ADHD to full recovery. Today, Dr. Richard Brown talks with us about how to address the symptoms that remain.
Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.
KELLIE NEWSOME: In this month’s issue we feature an interview with Dr. Richard Brown. Some of you may know Dr. Brown – he gives about 200 lectures a year and has written lots of books on natural and complimentary therapies in psychiatry. We asked Dr. Brown about the role of natural therapies in ADHD, and his answer was so informative that we’re just going to play it here in full.
Dr. Brown: So I feel like we can help patients with ADD better than any other diagnostic group in psychiatry. I mean stimulants work for many people. I mean I think you know you’ll see different things in the literature 60-80%, but of course there are side effects and I get to see the ones who don’t respond. Or you know the other thing is they only help certain aspects of ADHD and a lot of other stuff remains.
TCPR: What kind of symptoms tend to remain after stimulant use?
Dr. Brown: Well I think there’s still a lot of executive system dysfunction and higher level cognitive issues. And then, of course, there are comorbid conditions whether it’s dyslexia or processing things. Two things I try to ask all of my patients to get neuropsych testing one way or another. I mean it can be expensive privately, but like in New York I have them go to a graduate school of psychology and be tested by somebody who’s got a really good supervisor, for example. That’s one way of bringing the price down. And what I look for is processing deficits and which kind of processing problems they have as well as working memory. So two of the biggest comorbid problems I've seen are slow processing of certain kinds of material either visual or verbal or both, and that can be really tough in school or at work. And then dyslexia often relates to that because I see it as partly a processing problem and there are alternative things that can be helpful for that.
And then the other thing is decreased working memory. And decreased working memory correlates with poor performance in work or school.
TCPR: So for those of us who haven’t done the testing, can you tell us what would give you a hint in a patient that they had each of these three deficits from their everyday life?
Dr. Brown: Right. So it requires a tester who doesn’t just do what some testers do these days, which is kind of a battery of kind quick ratings of stuff like there’s trail making kind of testing; there’s the Tower of London testing of abstract thinking; there’s a number of tests they can do. And there are tests of how they’re processing and working memory. So when patients or parents often ask, “What is working memory?” I say, “On your computer there’s a clip board and your
own brain has a clip board and it can keep certain things in active play when you’re trying to solve a problem. And the average for most people is around three to seven things at one time. But you do better if you keep it toward the higher end of the range and not the lower end.” And so many of the people I see with ADHD or ADD (inattentive) have major problems you know. They may have a hard time keeping three things in mind. So, you know, and I ask for a history of dyslexia. I ask them do they have trouble taking notes in class. Do they do better if they see it? Do they do better if they hear it and those kinds of things.
TCPR: Better if they see it versus better if they hear it; which one would be more dyslexia?
Dr. Brown: I’d say the seeing is more likely to correlate with that. But in a sense, small children are dyslexic, and they are often seeing things in pictures, and they haven’t discriminated down to word levels. And you know I also explain to them that “This can help you be very creative and it’s a nice skill to have when you’re an adult, but instead of always having to look at things this way, we’d like for you to learn another way of processing things.”
And the other thing is often they don’t understand, “Well, I’m getting by,” especially if they’re intelligent if they have a pretty high I.Q. You know, “Why should I work on my processing?” And I’m like, “Well, it doesn’t just go into your work at school. Is there a sport you like to play whether it’s tennis or soccer, and you will be able to make a connection with the ball much better when you’re processing is better.”
TCPR: Now most people don’t learn dyslexia in residency so can you just define it like a general intro there?
Dr. Brown: Well, it’s where people reverse letters typically that’s how it will show up.
TCPR: And numbers too?
Dr. Brown: Numbers too yes. Kind of symbols get reversed.
TCPR: So it’s gonna show up in reading and math.
Dr. Brown: Right.
TCPR: So you said they’d do better at seeing things, but of course that’s not seeing the chalk writing on the board…
Dr. Brown: Right. They’re seeing at a different level in a sense.
TCPR: Why did you say they’re not as good at listening?
Dr. Brown: Sometimes they’re not. Sometimes they can’t follow a spoken lecture, but they can read it better.
TCPR: Can you explain that since it’s a problem of reading why that is?
Dr. Brown: Well it depends on the person. So people have different deficits of different kinds.
TCPR: Are you saying you can have dyslexia of the spoken word.
Dr. Brown: Yes, absolutely.
TCPR: I did not know that, okay.
Dr. Brown: And that can also make a difference in terms of career choices. I remember years ago a patient – it might have been a case example in the book under Treatments for ADHD – where the guy came to me; he was sent by a clinician for treatment-resistant depression. And I interviewed him and I felt like he’s not depressed, but he’s very unhappy with his life and his career. And this was a good bit of time ago, but he was a photographer and his parents had to keep giving him money to keep it going. And when I interviewed him I began to feel that there was something subtly wrong, and when I looked at his pictures it was like he wasn’t good at creating the picture for his clients. And I sent him for neuropsych testing and said, “I think there
is some brain damage her and let’s see how he actually compares to other people in terms of processing visual information.” And it was interesting that they found a spot in the cortex in the vertex where he was like zero ability at looking at and observing visual information, and if you’re trying to have a career as a photographer that would be the last deficit you’d want to have. And his parents somehow – I guess he liked taking pictures when he was a child - and they thought, oh, he’d be a good photographer, and they pushed him to do that. And it was just the wrong thing and he had to get some career counseling and change careers and then he was totally fine. It wasn’t a matter of giving him a more powerful set of antidepressants in other words.
TCPR: Fascinating. So how would slow processing speed show up in work or the classroom, what everyday examples?
Dr. Brown: Often they will have trouble completing an assignment or test on time. They are always late and they don’t have enough time to answer the questions. Now there can be other reasons for that.
CHRIS AIKEN: I was struggling with word recall in that interview – the word I was looking for was Sluggish Cognitive Tempo, not Slow Cognitive Tempo. This is a new diagnosis that often occurs with ADHD. These patients daydream a lot, they get easily bored, they feel “spacey” or lethargic, and they do not process information quickly or accurately. As Dr. Brown said, it’s been around for a long time, and it goes by different names, but a group led Russel Barkley at Harvard are arguing for it as a legitimate diagnosis. In this month’s issue we covered the first randomized controlled trial of a stimulant – Vyvanse – for sluggish cognitive tempo in ADHD. And like Dr. Brown suggested, it helped, but the results were mixed, and it certainly didn’t work all the way.
KELLIE NEWSOME: In the second half of our interview, we asked Dr. Brown how to help these associated symptoms. There aren’t many good medication trials for dyslexia or working memory, but he pointed us toward some complimentary and alternative treatments that have evidence. For dyslexia, he uses piracetam; for working memory, American ginseng. He also uses the alpha-agonists clonidine and guanfacine for working memory.
CHRIS AIKEN: I first met Dr. Brown 20 years ago when he gave a talk in Charleston South Carolina. After the conference he had magically switched from his suit and tie into appalachain hiking gear and was off to enjoy the outdoors. He’s a rare combination of researcher and clinician, a psychiatrist who is willing to think outside the box but also take a skeptical look at the evidence. So I was excited to ask him about all the new randomized controlled trials that are coming out for natural therapies in ADHD – vitamin D, iron, zinc, resveratrol, omega 3, saffron, Coenzyme Q10, or a proprietary plant extract called Pycnogenol … but Dr. Brown shook his head about all of these except that last one, Pycnogenol. They all have positive controlled trials in ADHD, but he just doesn’t see much benefit when he tries them in practice. It’s a problem I run into as well – few things that look good on paper really make a difference in my patients. I asked Dr. Brown why.
TCPR: That’s really interesting talking to you, Richard, because you know I just do bipolar so I’m always looking at the effect size in the study, and I gotta share it doesn’t always match up with what I see in practice. How does that work out for you? Do you have the same experience?
Dr. Brown: Yeah, yeah, totally. And I think part of the reason for that is I think when people start doing research, their enthusiasm - and often colleagues either in their specialty or related specialties - they’re enthusiastic and they send patients, and I think in the beginning sometimes you get skewed population who’s more likely to respond, or I also feel there’s a powerful Hawthorne effect.
TCPR: What’s that?
Dr. Brown: That means if you introduce a new program into the factory, the factory workers do better for a while.
TCPR: I remember that.
Dr. Brown: And there are so many factors that go on. I mean I did NIH and drug company research with mentors of mine for years, but I still remember years later I had a colleague call me up and he said, “I got to talk to you about something.” I said, “Why me?” And he said, “You’re the only one who might I think listen to me.” He said, “I’m doing research. I have a team of people who do the ratings and treat the patients and there’s one guy – it doesn’t matter if it’s the active drug or the placebo, his patients do worse than any of the other clinicians.” He said, “I don’t know what to do.” I said, “You get rid of him.” He says, “Well, he seems perfectly fine. He relates to me okay. He relates to his colleagues.” I said, “There’s something about him with his patients and he needs to be in a different part of the field, not taking care of patients directly without therapy or some other kind of treatment, and it’s unlikely at his stage of life that he is gonna go for that.”
TCPR: It sounds like what you do is read the research, the basic science, and the controlled trials. I imagine you look at the effect size, I mean something, but ultimately you then try this out on yourself and in your patients and do you see it with your eye; do you see a difference, is that right?
Dr. Brown: I’ve got to see a difference and my feeling is you can get fancy statistics that show stuff, but if you can’t see it more easily. Use things like that in a whole bunch of patients and if there’s an effect it’s a small one. I like going for bigger effects.
KELLIE NEWSOME: Dr. Richard Brown is associate clinical professor of psychiatry at the Columbia College of Physicians and Surgeons and has a practice in Kingston, New York. He has written over 80 articles and books on psychopharmacology including the 2012 book Non-Drug Treatments for ADHD.
CHRIS AIKEN: The first muscarinic receptor agonist for schizophrenia. A psychotherapy that treats social anxiety disorder in half the sessions. Psilocybin-induced mania. A personality trait that predicts response to SSRIs vs. mirtazapine. That’s just a few of the daily research updates we’ve shared in the past two weeks, and we’ll have more in the weeks to come. Join the fun and follow along – search for Chris Aiken, MD on LinkedIn or my twitter handle @ChrisAikenMD.
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