Maria J.

Table of Contents of the Chart Notes of Maria J.

Intake Note: Mrs. J. is concerned that she now functions at computer school in the same problematic way she functioned as a child in grammar school.

Session Two: Much improved after two weeks on Ritalin.

Session Three: ADD symptoms became worse again after she was transferred to a more demanding job. Daily dose of Ritalin increased.

Session Four: No change in job but a great improvement in symptoms after the increase in her dose of Ritalin.

Intake Note

Present Illness:
This 45 year old married mother of two has been a machine operator for many years but hurt her back recently and feels she must now change her line of work. So a few months ago she started a computer class. Her poor level of functioning immediately reminded her of the terrible days she had in grammar school. She was kept back in the seventh grade because she could not study or test well. (Note: ADD symptoms often get better or worse depending on the kind and amount of demand being put on a person. Under certain circumstances, individuals with ADD may have few or no apparent problems.) However, she excelled in hands-on, practical work and courses.

She quit high school in her freshman year because she couldn't do the work. She finally got her GED with some private tutoring after her daughter was born 22 years ago.

Her daughter was diagnosed with ADD when she was a freshman in high school. She was put on Ritalin and, while on the medication, did very well. Like Maria, she has succeeded in a hands-on career, VCR repair.

Years ago, the patient tried her daughter's Ritalin and found herself focused for a few hours after she took it. She felt the way she thought she should feel all the time. She could hardly believe a pill could make her feel so different. However, for reasons that are not clear, she never took it again. (Note: This is a common and very important finding in adults with ADD. Patients who report a successful one time experience with a stimulant are generally much more likely to respond positively to them when taken regularly.)

After smoking up to two and a half packs a day for most of her adult life, she stopped two months ago. Smoking had helped her relax and focus. When she stopped, she found herself more forgetful, more restless and fidgety. (Note: There is little evidence that smoking nicotine affects ADD. Certain individuals find that it helps their concentration or helps them be more alert; others find the opposite.) The forgetfulness increased her desire to try Ritalin again. However, she is anxious that if she takes it she will get a fast heart beat. (Note: The stimulants may in fact increase the heart rate, and some people are disturbed at feeling their heart beat more strongly. For someone who already has a fast heart beat, this may pose a problem. Anyone who may have heart problems should be sure to consult their medical doctor before taking stimulants.) She is also concerned that taking it may adversely affect her marriage, since she may turn into different person, and her husband may not like that.

At the present time, she has a lot of trouble focusing on two things at the same time and remembering what she has learned. Her recognition memory is good, but her recall is poor. She is very energetic and needs to be active all the time.

Executive Function Questionnaire Results:
Patient's response to the questionnaire is clearly in the moderate to severe range with major problems in focus, recent memory, and distractibility. Also the symptoms have significantly adverse effect on her life.

Other Diagnostic Possibilities:
At age 13, the patient was knocked out for a while. An EEG done afterwards was normal. There is no other history of brain problems or trauma. The patient did not complain of anxiety or depression. There was no evidence of other psychological disorders.

Summary:
Given the absence of anxiety, depression, or other more serious emotional problems, the positive executive function questionnaire results, the effect of her symptoms on her life, and the fact that her daughter responded so well to Ritalin, it is very likely that she has ADD. Her positive response to her daughter's Ritalin is also a very good sign that this medication may be helpful to her. There are no medical problems present that contraindicate its use.

Diagnostic assessment:
Attention deficit hyperactivity disorder, inattentive type

Prescription written:
Ritalin 10 mg; start with one per day, then increase to twice a day.

Plans and instructions:
Patient told of usual effects of Ritalin and possible side effects.
Patient given information sheet on Ritalin and ADD
Appointment in two weeks for follow up on effect of medication.

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Session Number Two

Date: Two weeks after previous session

Medication taken during the past week:
Ritalin 10 mg twice a day

Content of contact:
Maria was apprehensive for a few days before she started taking the Ritalin, wondering whether it would help.

Since she felt she needed to focus more in the afternoon and evening than in the morning, she took one pill 11 AM and one at 3 PM. She noted an effect (felt more focused) about 20 minutes after taking the pill. An hour after taking it she felt "together". The maximal effect was from about 45 minutes to about three hours after taking it. (Note: This is how most people report the effects of Ritalin. Adderall and long acting Ritalin have a somewhat longer effect.)

She described the benefits as follows:
   Feels down to earth
   Is much better able to focus
   Fits in better socially, more a part of what is going on around her
   Is able to go to a movie and stay focused on it
   Is better able to plan the seating for her daughter's wedding
   Can remember class work, better able to work at the computer

She had no trouble with sleep. The Ritalin has had no effect on her appetite.

This week her mother told her that every time Maria talked about her daughter's problems, she was reminded of Maria when she was her age.

Maria feels like she has now become the person she could be but wasn't. She feels like she has a new life. She is sorry that she didn't accept sooner some people's suggestion that she probably had ADD. She thought that she couldn't have it because she is an adult. Her mother says she denied it because she won't admit that she has a problem over which she has no control.

Maria didn't realize that she could take the Ritalin three times a day. I suggested that she increase the daily dose to 10 mg three times a day so can get the effect in the morning as well.

Assessment:
Very dramatic change. It is not clear yet what part of her response is placebo response, but I believe this is a genuine response to the medication. (Note: The placebo response may last anywhere from a few days to a few weeks.) Continued assessment planned.

Medication being taken:
Ritalin increased to 10 mg three times a day.

Next appointment:
Three weeks

Session Number Three

Date: Three weeks after previous session

Medication taken during the past week:
Ritalin 10 mg three times a day: at 6:30, 2 PM (inconsistent about time), and between 5 - 7

Content of contact:
About two weeks ago, Maria was put to work at the front desk at the company where she is employed. She has been very busy at this new job, doing detailed work with which she was not familiar, had not been trained to do. This put a strain on her ability to keep focused.

About a week and a half ago, many of her ADD symptoms returned. She wants a cigarette all the time. When she gets home, she no longer keeps to a routine.

She came at the wrong time for her appointment today and forgot to bring her check book.

She reports that she has been sleeping better since she started taking the third dose late in the afternoon. (Note: Since Ritalin's effect wears off abruptly, it usually interferes with sleep less than does dexedrine or Adderall if taken late in the afternoon or early in the evening.)

Assessment:
I think that the reason Maria's symptoms have returned is that her executive function systems are overwhelmed by the amount of cognitive work she has to do in her new job. If she is unable to limit the demands on her, hopefully a higher dose of Ritalin will help.

Medication being taken:
Ritalin increased to 20 mg three times a day

Next appointment:
Two weeks

Session Number Four

Date: Two weeks after previous session

Medication taken during the past week:
Ritalin 20 mg three times a day

Content of contact:
On the higher dose of Ritalin, Maria is more organized, doing much better at work. She is amazed at the difference in her abilities. She starts work at 7 AM so taking the Ritalin at 6 AM since it works better than taking it, as she had been, at 6:30, giving it more of a chance to kick in before she leaves home. She was able to handle a crisis situation at work quite well. This week her supervisor put a sign on the wall making her the employee of the month.

She continuing to learn about computers and says she is having fun with them.

She notes that she is generally more aware of things. Friends and people around her have remarked on the difference. For example, she goes to church to play bingo with a friend, who was amazed last week that she no longer got distracted and missed numbers. In fact, Maria pointed it out when the friend missed a number.

Another unexpected benefit: with the greater self awareness that she has with the Ritalin, it occurred to her that she has been feeling a lot of pressure in her abdomen over the past few months when she bends over or does exercises. She consulted a doctor and discovered she has an ovarian cyst, which is now being worked up. She is sure that she would not have noticed or taken steps to have it looked at if she weren't taking the Ritalin.

She had been concerned that the Ritalin might induce a fast heart beat and criticism from her husband. Neither has occurred. Her blood pressure is also unchanged.

Assessment:
The changes in Maria are quite dramatic. It does not appear at all likely that they are placebo effects. However, there is a "honeymoon" quality to the striking breath of the changes. I will continue to follow her progress.

Medication being taken:
Ritalin 20 mg three times a day

Next appointment:
Two months

Follow-up: Maria continued to do well over the ensuing two years, after which I transferred her care to her primary care provider for on-going medication management.