Progress in Self Psychology, V. 12

Basic Ideas Reconsidered

Arnold I. Goldberg

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9781138376588
• eBook ISBN: 9781134894253
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

Volume 12 of the Progress in Self Psychology series begins with reassessments of frustration and responsiveness, optimal and otherwise, by MacIsaac, Bacal and Thomson, the Shanes, and Doctors. The philosophical dimension of self psychology is addressed by Riker, who looks at Kohut's bipolar theory of the self, and Kriegman, who examines the subjectivism-objectivism dialectic in self psychology from the standpoint of evolutionary biology. Clinical studies focus on self- and mutual regulation in relation to therapeutic action, countertransference and the curative process, and the consequences of the negative selfobject in early character formation. A separate section of child studies includes a case study exemplifying a self-psychological approach to child therapy and an examination of pathological adaptation to childhood parent loss. With a concluding section of richly varied studies in applied self psychology, Basic Ideas Reconsidered promises to be basic reading for all students of contemporary self psychology.

V
	Applied

Chapter 13
	A Self-Psychological Approach to Attention Deficit/Hyperactivity Disorder in Adults: A Paradigm to Integrate the Biopsychosocial Model of Psychiatric Illness
	Howard S. Baker Margaret N. Baker

Attention deficit/hyperactivity disorder (AD/HD) is a serious illness that probably afflicts at least 2% of adults (Wender, 1995). It often goes unrecognized. When it is not properly treated, it creates great suffering, and it may account for a significant number of psychotherapeutic treatment failures.

The purpose of this discussion is twofold. We will present clinical material about AD/HD, particularly as it involves adult patients. We also intend to show how the principles of self psychology can integrate the elements of the biopsychosocial model (Engel, 1977) of psychiatry. AD/HD offers a clear example of how biological, intrapsychic, and social factors can be synthesized into a coherent etiologic explanation and comprehensive treatment plan.

We will have only minimal comments regarding the diagnosis, etiology, and pharmacological treatment of AD/HD, since they are readily discussed elsewhere (Barkley, 1990; Silver, 1992; Weiss and Hechtman, 1993; Wender, 1995). Instead, using clinical examples, we will concentrate on the ways that the attentional symptoms disrupt the efforts of AD/HD patients to find sufficient selfobject experiences throughout the life cycle. Because of this, there often are intrapsychic deficits and intensified conflicts that yield a weakened self-structure. This in turn leaves these people in particular need of selfobject experiences, and the symptoms continue to interfere with their ability to generate these experiences or process them when they are present.

Most leaders in the behavioral sciences pay consistent lip service to the importance of the biopsychosocial model. In reality, it has been neglected every bit as regularly as it has been acknowledged. One reason for this is that, without a self psychological perspective, the model is difficult to consolidate. This creates a major impediment to pragmatic clinical application. In the present medical and economic climate, with its pressure for cheap, quick-fix treatments, the biopsychosocial perspective is especially likely to be disregarded. We believe, therefore, that it is particularly crucial to find a way to clarify this model.

We hope, then, to describe an important diagnostic entity from the perspective of self psychology and offer a comprehensible way to integrate and use the biopsychosocial model of etiology and treatment.

A HISTORICAL PERSPECTIVE ON AD/HD

Attention-deficit hyperactivity disorder is a pervasive developmental disorder that afflicts between 6% and 10% of children (Wender, 1995), although some popular literature places the incidence as high as 25%. AD/HD was recognized as a diagnosable illness 50 years ago; it has had an interesting history, being called “minimal brain damage,” “hyperactive child syndrome,” and attention deficit hyperactivity disorder in DSM-III-R. The DSM IV terminology is attention deficit/hyperactivity disorder, the slash added to recognize three subtypes: Combined, Predominantly Inattentive, and Predominantly Hyperactive-Impulsive.

Initially, it was assumed that AD/HD was more common in boys and usually was outgrown by the end of adolescence. It seemed clear that there was a biologically based difficulty sustaining attention. Ritalin and other stimulants improved attention and, “paradoxically,” diminished hyperactivity. Stimulant use was discontinued in adolescence when it was believed that the medication would no longer provide the paradoxical calming, and when the stimulants supposedly would create a potential for addiction. Use of the medication caught the attention of the Church of Scientology and others, and they led a campaign to discredit its use. Although their claims were unfounded, the Church of Scientology did succeed in seriously stigmatizing the diagnosis and its medical treatment.

Published follow-up of children diagnosed as having AD/HD date back to a 1976 effort by Menkes, Rowe, and Menkes (1967). This was followed by the improved work of Weiss and her colleagues, who began to publish their data in 1971. Papers by her group and by others began to show that there were significant long-term sequelae, including reduced academic and job success, increased contact with the law, higher levels of substance abuse, and troubled interpersonal relationships. Initially, it was assumed that any long-term problems were a secondary result of the now-outgrown biological elements of the illness. This belief persisted until the last decade, when a series of publications (Cantwell, 1985; Wender et al., 1985; Thorley, 1988) finally began to alter professional opinion.

Recent work by Zametkin et al. (1992) provides compelling evidence that supports Cantwell, Wender, and Thorley's hypotheses that there are biological differences between adults with AD/HD and normal controls. Using PET scans, they found that the AD/HD sample had reduced global glucose metabolism and that there were larger reductions in the premotor and superior prefrontal cortex. Those areas have been “shown to be involved in the control of attention and motor activity” (p. 1361). The specific neurochemical explanation for these findings is not established conclusively, but the catacholamine neurotransmitters dopamine and norepinephrine (Silver, 1992) and serotonin (Desch, 1991) have been implicated.

Although psychological testing is often used in establishing a diagnosis of AD/HD, there are no definitive diagnostic tests that robustly establish the diagnosis. Although Holdnack et al. (in press) have shown significant problems in memory processing in a controlled sample of AD/HD adults, standard neuropsychological testing scores are not abnormal in as many as half of patients who appropriately carry the diagnosis (Golinkoff, personal communication).

A series of clinical interviews (which may include the patient's family members, close friends, and even work peers) is the most valid and reliable way to make the diagnosis. The diagnostic criteria are summarized in the DSM IV (1994). It is necessary to show a childhood history consistent with the diagnosis. This may be difficult, especially when the symptoms were primarily attentional. Particularly if the patient is bright, they may have done passable work that merely was not up to their potential; they may have avoided teacher criticism because they developed ingratiating defenses pleasing to teachers. Still, they often will recall clearly how they always were concentrating on several things simultaneously or that their minds were “out the window more than in the classroom.” Over the course of several appointments, a characteristic cognitive pattern usually emerges. In general, AD/HD patients hop from one subject to another in an apparently unrelated fashion. Unlike people who use this primarily as a defensive maneuver, these patients eventually and happily return to the original subject, surprised that they have been confusing and able to make their circuitous thinking clear. The typical response engendered in others by this cognitive scatter is for the listener to want to control and organize. People often feel frustrated that these patients are not getting to or sticking to the point, or that they are not developing a coherent emotional theme. This clinical picture is described more fully in the following section.

There is thus an emerging professional consensus that AD/HD's biological elements persist and cause continuing impulsivity and barriers to sustaining attention. As a result, adults have been treated effectively with stimulants. Nevertheless, The American Medical Association's Drug Evaluations Annual 1994 only minimally addresses the use of medication in adult patients. Clear recognition of AD/HD's biological elements persisting into adulthood has yet to be achieved.

We believe that about half of children diagnosed with AD/HD will not have entirely normal brain function in adulthood. This results in difficulty sustaining appropriate levels of and direction to attention. In addition, either because of the altered brain function itself or as a secondary consequence of the attentional difficulties, these patients show varying degrees of impulsiveness and hyperactivity. Moreover, there are frequent secondary problems with self-esteem and affect regulation.

PHENOMENOLOGY OF ADULT AD/HD

The literature on children with AD/HD focuses on three basic difficulties: impulsiveness, hyperactivity, and attentional problems. We think that the difficulty establishing and sustaining appropriate levels of attention may be the most fundamental element in adults, and we suspect that this may create or at least intensify hyperactivity (which in adults may be expressed as hyperverbalization) and impulsiveness.

There are two opposite difficulties with attention: (1) sudden shifts of focus dart to all sorts of relevant or entirely irrelevant subjects, and (2) attention hyperfocuses so completely that the person is almost inaccessible. Since the onset of the illness is during childhood, the symptoms pervade and shape most areas of development. It also contrasts with many psychiatric disorders since there is no symptom-free reference state, as there would be in episodic depression. The “blinks” (Reisinger, 1993) in attention may seem normal.

The shifts in attention occur on the basis of independent, essentially random, biological events; they are not motivated in the usual sense of the word. Clinicians and patients have consistently noted that physical exhaustion, illness, and the boredom or affective turmoil that accompanies loss of self-cohesion will increase the intensity, duration, and frequency of the symptoms. Patients may discover that “tuning out” can be used to meet defensive ends. Failure to distinguish “blinks” from defenses will result in empathic failures that will increase symptom intensity. Neither those around them nor the patients themselves know where their thoughts and feelings will be next—and the reasons for these disruptive and aggravating shifts often are obscure and misunderstood by both the patient and other people.

Clinicians, let alone family members, find it difficult to explain “blinks.” For example, a patient we'll call Tom was literally in the process of particularly enjoyable sexual foreplay when he began unfolding his fingers one by one. His surprised wife asked, “What are you doing?” “Counting how many hours of sleep I had last night,” he replied. Startled, her organization of the event was narcissistic injury; she became furious and stopped the sexual interaction. From his perspective, the thought entered his mind and he became as captured by it as with sex. For him his irrelevant thought and sex could coexist. For his wife it signaled emotional withdrawl. He hoped to find comfort and self-restoration in sex. His wife's rage not only deprived him of a needed selfobject experience, it was a self-disruptive interaction, particularly since he was feeling loving toward her—not the insult she rather naturally experienced. It is this irrelevant, biological, inattentive event that must be distinguished from similar behavior that actually is motivated and intended to protect the self or hurt the other.

The “blinks" that disrupt attention break up normal thought processes and interfere with the integration of cognitions and affects. At times, they create almost continuous background noise, so that the person may be humming a tune mentally while talking seriously to a friend or thinking about a problem. In Tom's case, his sexual enjoyment was accompanied by something unnecessary and irrelevant; this led to an interaction that diminished his capacity to use sex for appropriate self-consolidation and self-enhancement. It is not only sexuality that becomes muddled. All cognitive and affective organizing, reorganizing, and processing can be disrupted by these disjointed cognitive patterns.

AD/HD patients usually do not know when they will be out of contact with their internal or external environment. They randomly respond to any variety of irrelevant internal or external cues. They also get locked into their own thoughts in a way that makes them completely unaware of what others are saying or doing. People will speak to them and get no answer. Repeating the comment may not help, and family members often resort to comments like, “Earth to Mars.” They may try to cover for lapsed attention during a conversation; having missed crucial details, however, their responses may appear inappropriate.

Popper (1988) has compared the internal affective and cognitive experiences of the AD/HD child to life “under a light strobe. Sudden attentional shifts and brief flashes of experience lead to a constantly changing view of the world: disconnected appearances impair the ability to form complex cognitions, respond emotionally, and leam social norms. The attention-shifting complicates learning about human emotions and complex thinking” (p. 653).

This combination of scattered and overfocusing often results in communication patterns that seem extremely convoluted or impulsive. Both factors increase the likelihood that they will interject ideas into conversations that are related to their unique attentional patterns rather than to the flow of the conversation. For example, during an initial evaluation, a man we'll call Mario was asked, “What did your father do for a living?” He replied, “He's retired. Well actually, he and a partner have a parttime business in which they install valves in sewage systems for industry. If the sewage comes back into the plant, this can mess up the manufacturing process. You would be amazed at the problems that it can create, and these companies really need Dad's product. But before he retired, he was an engineer for Kodak. He worked on their instant camera. You know, there really wasn't a patent infringement with Polaroid. The processes are really different, but Polaroid sued anyway, and they got a big judgment.”

Scattered or overfocused attention can lead to behaviors and communications that most people find confusing, impulsive, and often aggravating. Tom's w...

Table of contents

• Cover
• Half Title
• Progress in Self Psychology
• Full Title
• Copyright
• Dedication
• Acknowledgment
• Contents
• Contributors
• Introduction: Notes on the Integration, Reformulation, and Development of Kohut's Contributions
• I FRUSTRATION AND RESPONSIVENESS
• II PHILOSOPHICAL ISSUES
• III CLINICAL
• IV CHILD STUDIES
• V APPLIED
• Author Index
• Subject Index