A real case emphasized the way problem drinking compounds ADHD and the importance it is to consider all co-existing issues when planning a solution.
My assistant walked into my office. She looked a bit nervous. She whispered: “You have to get that lady out of the waiting room – now!”
I asked: “Berry what happened, what’s going on.”
Berry replied: “She’s drunk! This gray haired old lady, she’s totally drunk. The whole waiting room smells of alcohol and the little kids and the parents look worried.”
I thought: “It’s Monday morning – what a start of the week.” So I got up and walked to the waiting room. There I welcomed Mrs. Jones and her husband.
Mrs. Jones has been referred to us by her primary care physician. The referral was by her own request because she thought she was suffering from attention deficit disorder. She had been seen by one of my favorite psychologists, who, after careful examination and psychological testing, had come to the conclusion that indeed the symptoms of this friendly 50-year-old lady fitted in with the diagnosis attention deficit disorder.
Mrs. Jones and her husband sat down behind my desk. She smiled shyly. The room quickly filled up with a strong scent of alcohol. I opened the window for a bit of fresh air and welcomed her and her husband. After a couple of pleasantries, I said: “My sincere apologies to start on this subject – but somebody in this room has been drinking, and it wasn’t me.”
She tried to look annoyed and puzzled, maybe even a bit angry. She then replied: “It wasn’t me either, at least not today. Maybe I had a glass of wine last night, but nothing more than that”. She then spoke about her life. She was a troublemaker at school. She never finished high school with a diploma. She had had a gazillion odd jobs that never lasted long. The couple had two daughters who were both in their twenties. The daughters did really well. They had college degrees and good jobs. The couple had a bit of trouble to get through the month on Mr. Jones’s wage. They self-confessed their housekeeping was at least slightly chaotic. Mrs. Jones was in charge of the household checkbook but had trouble keeping it balanced. While she was the household’s primary cook, she did have a tendency to forget to prepare dinner which led to frustration when Mr. Jones came back after a long, tiring day of work.
One of their daughters had a young son who had recently been diagnosed with attention deficit disorder, and the daughter had suggested to Mrs. Jones that she might be carrying the genes that led to her grandson’s ADHD.
I recognized my brain telling myself: “Come on, this is a 50-year-old drunk lady who wants you to prescribe amphetamines.” That was when I took a step back. I discussed the results of the psychological test with the couple and then also explained that I was a bit wary of prescribing her amphetamines because the alcoholic smell around her suggested a bit more than just a glass of wine in the evening. Apparently, I had done something right, because she didn’t get angry with me, and we agreed on a two-week trial of methylphenidate (a.k.a. Ritalin). After the required physical and lab evaluation I wrote a prescription for her and explained how to use the medication. We also agreed on her taking cognitive behavioral therapy with our psychologist to teach her to better deal with her ADHD through modification of her skills, emotions and thought processes.
I must confess I was a bit frustrated with myself, having given in to the prescription request by a pleasant 50-year-old alcoholic woman with ADHD. Two weeks went by, and there she was again. This time Mr. Jones wasn’t there because he was working that day. This was a different Mrs. Jones. She looks very smart in her clean, ironed clothes. She had just been to the hairdresser. She looked really happy. And most importantly: no trace of alcohol. She told me: “I don’t know what you’ve done, this was a miracle. It is as if the fog in my head has cleared for the first time after fifty years!” The combination of medication and the first sessions of cognitive behavioral therapy had evidently been hugely successful. She explained she had cleaned up her house, cooked dinner every day and enjoyed the rest in her head. She also told me that “while I have never been drinking much, I have given up on alcohol all together now.”
My take-home message is that:
- 50-Year-old women can have undiagnosed ADHD.
- They can self-medicate using alcohol to get control over the chaos in their head.
- And, yes, sometimes medication does create miracles.
Three months later, the miracle was still alive and kicking. A late diagnosis of ADHD had given Mrs. Jones back her life, and she enjoyed it to the fullest. It is miracles such as these that make my day to day work as a psychiatrist so rewarding.
Michiel Bosman is a psychiatrist based in the Netherlands. He is Editor of Open Forest, the online mental health self-help site.