Sunday, May 25, 2008

Back Roads: Lost or Distracted?


A few days ago, I posted on The Journey Versus The Destination and I've still been thinking about the comments that came in. Warning: This is going to turn into one more post on illness versus the spectrum of normal, one of our favorite Shrink Rap themes.

First off, there's no such thing as Journey people or Destination people. I made the whole thing up, so there's not really any arguments about definition because...well, it doesn't exist.

A lot of the comments that came in reflected the idea of 'stopping to smell the roses'....the idea that if one is reaching for a goal, there is no time to appreciate or enjoy the process of getting there. This isn't what I meant at all, I just didn't do the best job of describing what I did mean. Mostly what I meant was that there are people who have the ability to set goals, and know how to go about reaching them. Those are Destination people. If, on the way, a destination person changes her mind and sets a new and different goal (I don't want to be President, I want to bake cookies), they are still a Destination person, they have simply changed the destination. Cookies, I assure you, are a good destination, but a Destination person looks at the recipe first, buys the ingredients, and if the cookies burn, they either try again to bake them, or they get a new goal (e.g. buy cookies at bakery).

So MWAK asked how I knew she was a Destination person. Pretty much by definition (remember, I wrote the definition), the number of years, courses, planning ahead, it takes to go to medical school makes physicians Destination people. You can't do this on impulse, you have to sign up for specific courses, many of them boring and hard, do well in them, initiate applications to medical school, get to the interviews at your own expense, arrange housing, take a zillion courses, dissect bodies, go to clinical rotations at the right place and time, pass tests, remember to register for those exams and show up with your number 2 pencils, apply for residency training. Interview at your own expense. Get to the interviews (arranging the transportation and place to stay), survive residency, and it's good to remember which days you're on call. If you can do this while growing and smelling flowers, raising children, playing in a rock band, then more power to you! So MWAK, I read your blog and you have tons of goals-- currently you're on vacation, someone planned it and arranged for your coverage. See, you're at a destination (looks like Seattle), you're a destination person!

I think Mrs. Cake did a good job of capturing what I meant by Journey People. She wrote:

I think I am a journey person (think Drunkard's Walk) who always tried and failed to be a destination person. The number of endeavors I have embarked on, and rapidly failed at or lost interest in, could fill quite a crowded book. Currently I'm convinced it's the not-yet-diagnosed ADHD that kicked my feet out from under me in such a predictable pattern. I am in my 50s and mourn the books I could have written not because I couldn't write them, but because I have the skill and the ideas but not the persistence. dx on the horizon, I hope, but how many of us journey people are members of the 4 to 5% of ADHD adults, 90% of whom are not diagnosed? Mrs Cake

Yes, this is what I meant! People who set goals, sometimes extremely modest goals (I will clean out a closet) and can't negotiate to follow through on them. Time goes by and nothing gets done in a forward moving way towards accomplishing them. Often, these patients are diagnosed with ADHD, and that provides them with an explanation. I haven't found this to be all that helpful. I tell them to read books on ADHD and try the behavioral suggestions: get a Palm Pilot, (or a Franklin Planner), get back-up alarms, make lists, fall into a routine. While some patients find stimulants helpful, for unknown reasons, they haven't been my patients: my patients have had trouble tolerating stimulants and they've been surprisingly unhelpful at getting people to move towards their goals. Often people are equivocal about whether they helped at all and they forget to take them.

So there are two issues here: one is that some people are Destination people and don't know it: they can't meet some goals, but they meet others fine: can't get the house cleaned, can't finish a major paper, can't finish they're degree, but they do fine at getting a job, planning a vacation, getting to social events, whatever. These are Journey people because they are locked into Destinations they feel they
should have, not the ones they want. They would simply do better to redefine their goals to things they Want them to be, not what society says they should be. They need to reframe life, and this is often a hard sell.

I said this in the comment section of the last post, but I'll repeat it here:
Journey people choose goals (sometimes unrealistic ones) and they swerve, take the long road, somehow don't make or take a much longer time than they'd planned, they don't know what the next step is or how to get there, but often they get an interesting ride, see somethings that those of us in the library (or on the treadmill or changing the diapers) didn't get to see, smell, feel, or experience. It's good stuff and it's bad stuff. It's often unexpected, often painful.

The second issue is whether ADHD is an illness that captures this phenomena or whether we haven't simply redefined a spectrum of people who don't meet society's rigid expectations into being ill. I guess you can say that about lots of disorders (shy vs. social phobia pops into my brain). One set of alarmists will talk about the gross under-diagnosis of the illness, another set of alarmists will talk about the gross over-medication of school children, especially boys, and how stimulants are the most abused drugs out there among high school students.

Just to think about. Thanks for joining us Mrs. Cake. And Roy, just to clarify, you're a Destination Person (there's no doubt), you just keep changing the destination.

6 comments:

Dr. Pink Freud said...

That the DSM has limited utility is a given. Without laboratory tests for diagnosis, we're forced to rely on the use of a nosological classification system. This "Chinese menu" approach to diagnosis (three from column A, two from column B), leads to varying degrees of inter-rater reliability (from the low 40% range for schizoaffective D/O to higher for other D/Os), and makes Dx. difficult. You could easily take different elements of depression, anxiety and an impulse control disorder and end up with a category that would roughly approximate ADHD. Add the socio-political influences on the evoluation of the DSM (take the inclusion of homosexuality as a D/O until 1974, or so), and the Dx. waters are further muddied.

A good place to start would be to examine the socio-political context in which the Dx. of ADHD developed. First, factor in the tremendous political influence of pharmaceutical companies (who will capitalize on any opportunity to medicate a perceived D/O). Next, throw in the subjectivity of distress (usually the parent's perception of the child’s distress, or in some cases, the distress of the parents?), and unqualified clinicians making Dx, and you've got overdiagnosis and overmedication of a D/O that didn’t exist thirty years ago. Were we more tolerant of the symptoms that comprise this D/O, were we blind, or did we just not care to see it in the first place? Clinicians will Dx. A dog (and do) nowadays. Actually, my wife thinks I’m a bit ADHD, but I’m pretty sure she’s V62.89 (just kidding, honey!)

Therapy Patient said...

Decreased exercise and increased junk-food eating combined with exposure to hours per day of rapid image changes via technology such as computers, computer games, fast-cut TV editing are factors that might lead to the increase of ADHD in the current crop of kids.

I wonder what would happen with ADHD diagnosed kids if instead of a drug they went on a program of eating home-prepared natural foods (no packaged foods) plus daily morning vigorous aerobic exercise and reduced exposure to computer/TV?

Mrs Cake said...

...or whether we haven't simply redefined a spectrum of people who don't meet society's rigid expectations into being ill.

If that was the case I would be right with you. But for me, the problem is not social expectations, which I happily ignore. Instead, being able to accomplish things I want to accomplish consistently evades me, and it has made me sad for 50 years. The skill is there, just not enough gas in the tank, or maybe something wrong with the transmission. But thanks for this.

Evadne Cake

Psychiatry101 said...

How about journey person reaching different destination( still a good one) while going for the planned destination!
For example I have a specific plan,in two months I am giving a major exam but instead I blog and create a terrific design( my standards) blog!
I even got hits on my goole adsense and made some money!
I changed the blog header to red color, got some cute red buttons on right!and it just looks so cute!!
yay!
i reached a destination!
an unplanned destination!!!!!

Gerbil said...

First off, there's no such thing as Journey people or Destination people. I made the whole thing up, so there's not really any arguments about definition because...well, it doesn't exist.

Dinah, you have every right to make up a concept and then write about it, even if you're not working on a novel. (Heck, isn't that how we got the DSM? tee hee)

Midwife with a Knife said...

Ah... I don't think I understood the original classification system. ;)