CHAPTER 8
Type 3: Overfocused ADD
In my experience Overfocused ADD is the third most common type of ADD. Overfocused ADD patients have all of the core ADD symptoms plus tremendous trouble shifting attention and a tendency to get stuck or locked into negative thought patterns or behaviors. This type of ADD can have devastating effects on families. It is frequently found in substance abusers and in children and grandchildren of alcoholics.
I discovered Overfocused ADD early in my brain-imaging work because it was the one I lived with at home.
My first wife grew up in an abusive alcoholic home. We were teen sweethearts. She was my first love—beautiful, smart, funny, and caring. I had met her when I was fifteen years old working in my father’s grocery store. We dated for three years and then, due to having a low draft number, I had to serve in the U.S. Army during the Vietnam War. While I was away, stationed in Germany, Robbin impulsively married someone else, in large part to get away from an abusive household. I was devastated and felt that I lost a part of myself. Her marriage only lasted a few years. She married someone who turned out to be an abusive alcoholic (not uncommon in adult children of alcoholics). When I was discharged from the service I finished college and was accepted into medical school. Shortly after opening my acceptance letter to medical school I called Robbin’s mother to tell her the good news. When I was a teen, her mother had been very supportive and spent long hours talking with me about my dreams and goals. She was thrilled for me and, by the way, she said, Robbin had left her first husband and was living in Southern California. I nearly lost my breath. I had never loved anyone like Robbin, my first love. I called her. We dated for several months before I went to Oklahoma for medical school and then we talked every day on the telephone until we were married a year later.
Shortly after our marriage I knew that something was very wrong. Robbin had terrible mood swings. She worried, focused on the negative, had periods of depression, and she had to have things a certain way or she would get very upset. Certain areas of her life were very organized and other areas were very disorganized. I had her see the chief of the department of psychiatry at my medical school—a very kind man who helped her a lot. Unfortunately, when we moved to Washington, DC, for my internship and residency things were not much different. She saw counselors in Washington, but it really didn’t help much. Then, while I was studying drug and alcohol treatment at the National Naval Medical Center in Bethesda, Maryland, I attended a lecture on adult children of alcoholics (ACOAs). The lecture brought tears to my eyes. Robbin was suffering with many symptoms attributed to growing up in an alcoholic home: she had trouble trusting others, she often blocked out her feelings, and she had trouble talking about her feelings.
It was only by accompanying Robbin to therapy that I learned about the abusive alcoholic environment she grew up in. While we were dating she never told me about the alcoholism, physical fights, yelling, and abuse going on at home. There was too much shame. When I came home that night I told her about the ACOA lecture. To my amazement, she told me that she felt guilty labeling her father as an alcoholic, but she agreed to go the ACOA meetings. The meetings and new understanding about ACOA issues seemed to help, but many of the problems remained. We then went to Hawaii for my child psychiatry fellowship at Tripler Army Medical Center in Honolulu. I did my research on children and grandchildren of alcoholics (I was married to a child of an alcoholic and at the time I had two children who were grandchildren of alcoholics). I found a very high incidence of ADD, obsessiveness, and oppositional behavior. This set the stage for my brain imaging work with these patients a number of years later.
Shortly after we left Hawaii Kaitlyn was born. She was my little hyperactive one. She was diagnosed with ADD at the age of four, even though I had suspicions about it from the time she was eighteen months old. Kaitlyn also had a strong oppositional streak. It seemed that she argued with everything and opposed everything Robbin or I asked her to do. She is the child who taught me a lot about oppositional defiant disorder. She taught me to ask parents this question in diagnosing oppositional defiant disorder: How many times out of ten when you ask your child to do something will he or she do it the first time without arguing or fighting? Kaitlyn got a goose egg—it seemed as though she would never comply the first time.
To find out what was normal I sent a questionnaire home to the parents of four hundred children at a school where I was the consultant, asking them that question. Seven times out of ten children from a general population comply the first time without giving their parents grief.
With Kaitlyn, I found that I used reverse psychology a lot. If you asked her to do the opposite of what you wanted her to do you were guaranteed a positive response nearly every time. When Kaitlyn was three years old I had just begun my brain SPECT work.
After seeing how helpful it had been for a number of my patients I decided to scan people I knew to get a good sense of the technology. I scanned my mother, Robbin, all three of my children, including Kaitlyn, and several friends of mine who I thought needed scans. It was so instructive to scan people I knew. Both Robbin and Kaitlyn had excessive activity in the anterior cingulate gyrus and decreased activity in the prefrontal cortex. I was just learning about the anterior cingulate gyrus at the time. It was never even mentioned during my psychiatric training programs. There were brain-imaging studies that suggested there was overactivity in the anterior cingulate gyrus in patients who had obsessive compulsive disorder (OCD). There was a SPECT study in 1991 reporting that Prozac decreased activity in the anterior cingulate gyrus in OCD patients. I saw hyperactivity in the anterior cingulate gyrus in many patients who did not have OCD. But I noticed a common thread with OCD. Patients had trouble shifting attention. Researcher Alan Mirsky wrote a book chapter highlighting the anterior cingulate area of the brain as being involved with shifting attention. In Robbin, Kaitlyn, and many of my patients who had too much activity in the anterior cingulate gyrus I saw this problem of shifting attention: there was a certain cognitive inflexibility that was evident in many of their symptoms. Could it be possible that oppositional children had a similar underlying brain mechanism found in OCD? I was intrigued. Over time the finding proved to be true.
When there is increased activity in the anterior cingulate gyrus a certain cognitive inflexibility is present. This can present as many different symptoms, but the underlying mechanism, trouble shifting attention, remains. The symptom list at the beginning of the chapter is a compilation of what we have seen in these patients. The anterior cingulate area of the brain is heavily innervated with serotonin neurons. We have also found that serotonergic medications seem to be the most helpful in this disorder.
The Anterior Cingulate Gyrus
Cingulate gyrus
Left side active view
Tammy
Tammy was in fourth grade when she first came to our clinic. Tammy was a stubborn child. If she did not get her way, she would throw mammoth tantrums that could go on for hours. In addition, Tammy was shy around other people, worried a lot, and was having problems in school. She would stare at her work for long periods of time. She craved perfection in her schoolwork, and as a result her papers showed evidence of many erasures. Tammy was distracted easily and had trouble sitting still. While Tammy’s attention could easily be diverted from some things, she held on to hurts. If a friend said something she didn’t like, her parents would hear about it for weeks. Another child psychiatrist diagnosed Tammy with ADD and put her on Ritalin. But the Ritalin aggravated her, making her moody, irritable, and even more anxious. Tammy’s brain scan showed that her anterior cingulate gyrus was very overactive. It was clear from a brain biology perspective that she had trouble shifting her attention.
Tammy’s Concentration SPECT Study (Top Down Active View)
She needed a calmer cingulate if she was going to improve. Given her poor prior response to medication, the parents and I initially decided to try an herbal approach to treatment. I placed her on St. John’s Wort (a serotonin booster) and had her engage in a daily exercise program. In addition, her parents had to learn to be very firm and prevent her from arguing or opposing them. It took two months for all of the interventions to work together, but they had a significant positive impact on her behavior and academic ability.
Mark
Mark, fourteen years old, was evaluated for anger outbursts and defiant behavior. Psychotherapy and parent training were ineffective, as were many different classes of medication, including stimulants and antidepressants. Prozac made him more aggressive. Mark’s parents were ready to send him away to a residential treatment center. The stress on their family was just too much. I ordered a SPECT study. His SPECT study revealed marked hyperfrontality (his anterior cingulate gyrus and lateral prefrontal cortices were very overactive). Mark was unable to shift his attention. He was unable not to be difficult. I placed him on Risperdal, a novel antipsychotic medication, that I have seen calm this part of the brain. He was clearly not psychotic—he wasn’t delusional or hallucinating—but we have found this class of medications helpful for this severe hyperfrontality. He had a dramatic response. He was more compliant, happier, and no longer aggressive. One week after I started Mark on Risperdal, his mother came to my clinic, even though she didn’t have an appointment. As I walked into the waiting room to greet a patient, I saw her. I wondered why she was there. I smiled at her and she immediately came over to me, grabbed me, and gave me a big hug. She said, “Thank you so much. I have my son back. Mark is doing so much better!” I felt pretty good that day. As the improvement held, and I also added natural treatments, I did two follow-up studies; one study was done a month later, the next one was six months later. There was a progressive calming of the hyperfrontality.
Brandon
Sixteen-year-old Brandon was one of the more difficult children I have treated in my practice. He was negative, surly, argumentative, and oppositional, and would throw long tantrums when he did not get his way. He did poorly in school. He would not cooperate with teachers, and he did not get along with other students. The parents were at their wits’ end when they brought Brandon to see me. Brandon was very opposed to seeing a psychiatrist. “I’m not crazy,” he announced to his parents, “and I’m not going to talk to any shrink, so don’t waste your money.” From the clinical history it was obvious to me that Brandon had anterior cingulate problems. He held true to his word that he wouldn’t talk to me, so for a number of months I spent most of my time with Brandon’s parents. Brandon refused to take medication and he was threatening to run away from home. The parents and I felt that Brandon might need a residential treatment center where he could get intensive treatment over nine months to a year.
Before I recommended sending Brandon to treatment, however, I ordered a scan to evaluate his brain function and partly to help convince him of the biological need for treatment. Surprisingly, Brandon agreed to the scan without his usual fuss. He was curious and had seen the brain images around our clinic. Brandon’s SPECT scan was one of the most abnormal studies that I had ever seen. His anterior cingulate gyrus was on fire. His frontal lobes were completely overactive as well.
Brandon’s Concentration SPECT Study (Top Down Active View)
Severe hyperfrontal pattern
As I explained the SPECT results to Brandon, he actually seemed to listen to me for the first time. He asked questions, seemed interested, and asked to see both healthy and dysfunctional brains. By the end of our appointment he had agreed to try some medication. He also agreed to exercise on a regular basis.
The scan seemed to help him shift to a more open emotional place. I placed him on 20 milligrams of Prozac. Three weeks later I had a follow-up appointment with Brandon. I walked to my waiting room, wondering what I would see. I was used to having bad interactions with Brandon. To my surprise Brandon stood up when he saw me, shook my hand, and said, “It’s nice to see you again, Dr. Amen. How are you?” My mouth dropped open. I thought to myself, Where is Brandon? Who is occupying his body? Someone must have performed a brain transplant on him. Brandon and his parents came back to my office and told me that about a week after taking the Prozac, Brandon’s whole demeanor started to change. He woke up in a pleasant mood. He was more cooperative and even asked if he could help around the house. The tantrums were gone and he was a joy to live with. Over the next several months Brandon’s improvement held firm, but he was still having trouble focusing in school. At that point I added a very small dose of Adderall, a psychostimulant medication, to help him focus, as well as some simple supplements and lifestyle interventions. Together, they were the missing pieces of the puzzle and Brandon’s schoolwork improved as well.
The first time I saw Brandon’s improvement, I wondered, “Who is he really?” What was Brandon’s character? What was his soul really like? Over time I learned that Brandon really was a charming, sweet young man who had been trapped inside the circular hell of his brain’s inflamed anterior cingulate gyrus. When his anterior cingulate gyrus and his brain worked right, Brandon was able to work right as well.
Sarah
Sarah, twenty-eight, was referred by her therapist because she had failed the bar exam six times. Even though Sarah had graduated from law school, the therapist felt that Sarah had attention deficit disorder because she had trouble with attention span, was distractible, and had poor impulse control.
Sarah had grown up in an alcoholic home. She struggled with periods of depression and obsessive thinking. Many of the people who knew her thought she was selfish, because if things did not go Sarah’s way she would get angry. She was rigid, frequently argumentative (while she was growing up her parents told her that she would make a good lawyer because of her tendency to argue), held grudges, and often worried about insignificant matters. Just before the evaluation, Sarah was nearly arrested for an incident on the freeway in which she chased down another driver who had accidentally cut her off. Whenever she took traditional ADD medications, however, she got worse. She overfocused on trivia and became more irritable. To my eye, Sarah had symptoms consistent with Overfocused ADD.
I placed Sarah on Effexor, which is a stimulating antidepressant that increases serotonin, norepinephrine, and dopamine neurotransmitters. Sarah began to feel better within three weeks. She felt more focused, less worried, and more relaxed. Her friends noticed that she was more flexible and didn’t always have to have things her way. Today I would have tried her first on supplements to boost both serotonin and dopamine, then evaluated her response before giving her medication. I have often seen that natural treatments can be effective with lower costs and few side effects, which is why I try them first.
Phil
At the age of sixty-seven, Phil was an unhappy, lonely man. He had been divorced three times and his children did not talk to him. Even though he had been somewhat successful in business, he didn’t enjoy his life. He was argumentative and negative and worried excessively. He hated to be alone but tended to be rigid, oppositional, and unpleasant whenever he was around others. Anything that did not go his way caused fierce outbursts. He came to see me after his grandson had been helped in my clinic. I ordered two SPECT studies on Phil as part of a family study we were doing. He had significant decreased activity in his prefrontal cortex during concentration and marked increased cingulate activity on both studies. After seeing his scans and listening to his family history, it was clear to me that Phil suffered from Type 3 ADD. He had a deficiency in serotonin and dopamine, causing the brain abnormalities in his prefrontal cortex and cingulate gyrus, which also caused his difficult behavior.
I treated Phil with a combination of medication, dietary interventions, and exercise. It was wonderful to see the difference. Phil became more relaxed, more positive, less argumentative, and more able to love. His children noticed the difference within several weeks and started to enjoy being around him.
GILLES DE LA TOURETTE’S SYNDROME (TS)
TS is a tic disorder that is frequently associated with Type 3 (Overfocused) ADD. Characterized by both motor and vocal tics lasting more than a year, TS provides the bridge between the basal ganglia and two seemingly opposite disorders: ADD and obsessive-compulsive disorder (OCD). Motor tics are involuntary physical movements such as eye blinking, head jerking, shoulder shrugging, and arm or leg jerking. Vocal tics typically involve making involuntary noises such as coughing, puffing, blowing, barking, and sometimes swearing (corprolalia). TS runs in families and there have been several genetic abnormalities found in the dopamine family of genes. SPECT studies, by my clinic and others, have found abnormalities in the basal ganglia of the brains of TS patients. There is a high association between TS and both ADD and OCD. It is estimated that 60 percent of people with TS have ADD and 50 percent of people with TS have OCD. On the surface it would appear that these are opposite disorders: People with ADD have trouble paying attention, while people with OCD pay too much attention to their negative thoughts (obsessions) or behaviors (compulsions). In looking further at both ADD and OCD patients clinically, I have found a high association of these diseases in the two groups’ family histories. The medications clonidine and guanfacine can be helpful for the tics, as can the supplements magnesium, zinc, and taurine.
DIFFERENTIATING TYPE 3 (OVERFOCUSED) ADD FROM OCD AND OCPD
I am frequently asked how I differentiate people with this type of ADD from people who have obsessive compulsive disorder (OCD) or obsessive compulsive personality disorder (OCPD). That is easy. All three groups have overfocused tendencies (anterior cingulate issues), but people with Type 3 (Overfocused) ADD also have long-standing core ADD symptoms: short attention span, distractibility, spotty organization, poor follow-through, and poor internal supervision. People with OCD have clear obsessive thoughts and/or compulsive behaviors, such as repetitively checking locks or hand washing. People with OCPD have difficult personality traits—such as emotional rigidity, an “anal” need for sameness, the need to have their way, and compulsive cleanliness—but generally do not have core ADD symptoms. In fact, they usually have the opposite of ADD symptoms: They are overorganized, always on time, never say something impulsively, and must follow through with every task.