KELLIE NEWSOME: When a child grows up with untreated mental illness, there's a good chance it'll affect their identity. We'll look at how to work with that in the psychotherapy of ADHD. Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. And this is a Throwback Thursday episode, where we're going to update this 2019 classic with new research and CME credits at the end.

CHRIS AIKEN: Today we'll continue our talk with psychiatrist Scott Shapiro about the therapy of adult ADHD. Dr. Shapiro practices chemo-focus therapy, which is a branch of cognitive behavior therapy that was developed in the mid-1980s by Dr. Jeffrey Young. Dr. Young had become dissatisfied with the effects of traditional CBT on patients with chronic problems like personality disorders.  
       

He hypothesized that these patients had deep-seated beliefs about themselves. He called these schemas, which he defined as a life trap or pattern of negative behavior that a person repeats over and over again throughout their life. Drawing from attachment theory, he theorized that these schemas developed at an early age when basic childhood needs failed to be met by early caregivers.                

Schema focused therapy is best studied in borderline personality disorder, but it's now being applied to ADHD and other chronic mental health conditions as well. Some of the schemas or enduring beliefs that are common in ADHD include failure, the belief that one will fail in virtually all endeavors. Defectiveness and shame, the idea that one is unwanted or insignificant to others. And unrelenting standards, the idea that one must meet unreachable goals in order to avoid criticism from others. Outcomes in ADHD are much better when treatment is started early, particularly before puberty. So, it seems to me that this schema-focused therapy would be most useful in people whose ADHD was not recognized and treated until adulthood. Because of the effects the illness would have on their identity and development throughout their life.

So, let's start with that, Dr. Shapiro, and tell us how you see ADHD play out differently in those who are diagnosed early compared to those who are first treated in adulthood.

SCOTT SHAPIRO: When someone has been treated, the person does grow up to realize their potential and what they're capable of doing and have a sense of hope. And for the people who have gone undiagnosed, it can be very frustrating. Often even creating symptoms of panic, depression, increased use of substance use, feeling like a failure, and receiving a lot of feedback, both from peers and potentially bullying. A lot of disappointment from teachers who are saying, you know, I live living up to your potential. And then a lot of feedback from parents often, rather than guidance and tutoring and getting accurate diagnosis and treatment, often punishment. Many people that are seeing me in their 30s and 40s, and even in their 20s, they were not diagnosed. And so, they do develop a lot of core beliefs of failure and of defectiveness. And that's why I think that therapy, whether it's cognitive behavioral therapy, or something that's a branch of cognitive therapy that's called schema therapy, where you're really addressing some of these lifelong patterns of disappointment, of underperformance, of feeling less than or feeling defective. That is one of the top five things to really remember when treating someone, especially when they haven't been diagnosed early on in life to address the shame.

CHRIS AIKEN: Tell us how schema focused therapy differs from cognitive behavior therapy. I would say that they both are under the same umbrella, of cognitive therapy, and that in CBT, you often are focusing on automatic thoughts and assumptions and rules and core beliefs, and that the focus may just be a little bit different, whereas cognitive therapy may focus more on the thoughts and behaviors. Schema therapy would incorporate that as well as addressing the core schemas on an emotional level, how they may get triggered at this point in time, and how they may be driving some of the avoidant behavior or repeating some of the same patterns, whether it's in terms of selecting a job, where may be, for example, the same critical experience that they experienced as a child. Or getting into a relationship where it may be with a very critical person or make them feel defective, or less than, or like a failure.

CHRIS AIKEN: Now I understand that CBT focuses on core beliefs like, I'm an idiot, I'll never accomplish anything, and schemas sound like... views about yourself that influence how you act in the world. Am I getting this right? Are these really very similar concepts?

SCOTT SHAPIRO: Absolutely. So, the schema or the core belief is a view of yourself and of the world.                    

So, growing up with, for example, an illness like cystic fibrosis. Or growing up with ADHD that goes undiagnosed and struggling in school, combination of the temperament you're born with, as well as your experiences would influence how you see yourself and how you see your potential in the world. And so that really is, I think, a key for you to trust those core beliefs of I can't do this no matter how hard I work, it's not going to turn out, there must be something wrong with me, no one's going to want to be with me because I cause so many problems. Those sound-like schemas that would be pretty common in ADHD. What are some others that we'd expect to see in adults with ADHD?                    

Yeah, you know, I think another case scenario, just to briefly tell you about someone who came from an entrepreneurial family. And as I talk about patients today, I'm going to disguise, of course, all the information. She always thought of herself as very bright, however, once she got into the work world, got great feedback about her ideas, but ended up getting, uh, a lot of problems, uh, executing and therefore went, you know, from job to job, the job. And when she saw me had been on her fifth job at the age of 39, even though she knew she was smart, she had always had this belief that just something was going to get in the way. And so, some of the schemas would be the failure schema, the defectiveness schema, the unrelenting standards schema, so that even though people may feel like they can't do things, they also may develop this almost obsessive or perfectionistic unrelenting standards schema that often kicks in to cope with the defectiveness schema.

CHRIS AIKEN: So where does shame fit in there?

SCOTT SHAPIRO: Great question. So, it's defectiveness/shame. That I'm not lovable, that I'm not okay, that I'm broken, that no one would want me, that I wouldn't be of any benefit to any team or to any group or any effort. So absolutely, it triggers a lot of shame and avoidance. And really what I kind of call in some of my writings the double whammy    

CHRIS AIKEN: What's the double whammy?

SCOTT SHAPIRO: When someone comes to me and they haven't been diagnosed, they talk a lot about this avoidance that they get an assignment, like a business plan, needing to do a thesis, and not only do they have the struggles of their executive function, procrastination, and attention, and organization, and time management, but it also triggers this defectiveness, shame schema, just even when they think about kind of taking the first step or asking for help. And so that often leads to avoidance and reinforcing the schema of failure and of defectiveness. So, it's kind of this double whammy because of the schema and then also because of the symptoms that are still untreated. CHRIS AIKEN: Thank you, Dr. Shapiro.

CHRIS AIKEN: In addition to his work in private practice, Dr. Shapiro also hosts workshops for adults with ADHD in New York City. He is a graduate of Massachusetts General Hospital's Psychiatry Residency Program and a diplomate in Cognitive Behavior Therapy from the Academy of Cognitive Therapy.

KELLIE NEWSOME: You'll find more about adult ADHD in our November/December issue, along with these research updates. How to use light therapy in depression and bipolar, and reviews of two new FDA-approved medications. The first antipsychotic skin patch, Cequa, and we compare it head-to-head with the oral version, Asenapine(or Saphris), and find some surprising advantages and drawbacks with both.

                   

Also, Pitolisant, a medication for narcolepsy, which is the first histamine H3 blocker to be released. And finally. We have research updates on Olanzapine in anorexia and a meta-analytic ranking of two dozen medications for generalized anxiety disorder.

CHRIS AIKEN: We don't have any updates to Dr. Shapiro's good work on identity here, but we do have another lifestyle intervention to endorse for ADHD, a healthy Mediterranean-style diet. In 2021, the first randomized controlled trial of such a diet was conducted in 80 children with ADHD. For a healthy diet, they used the DASH die. A popular diet for hypertension that is similar to the Mediterranean-style diet developed for depression. For the control group, they used a sham diet with enough directives to look like a healthy diet, but that really wasn't. In the end, after three months, those on the DASH diet had a significant improvement in both parent-teacher as well as child-rated ADHD scales, so across the board.

                   

The DASH diet they use for ADHD emphasizes fruits, vegetables, fish, whole grains, nuts, and beans. It steers away from the hallmarks of the Western diet sugar, salt, saturated fats, cholesterol, and refined grains. It is low in two specific ingredients that have been linked to ADHD, food dyes and artificial additives.

                   

KELLIE NEWSOME: To learn more about dietary approaches to ADHD, check out our September 2022 online issue. Earn CME for this podcast through the link in the show notes. And here's a preview of the question.

                   

1. Which therapy focuses on long standing core beliefs about the self in people with ADHD?

A. Acceptance and Commitment Therapy
B. Interpersonal Psychotherapy
C. Cognitive Behavioral Therapy
D. Schema Focused Cognitive Behavioral Therapy