This is a follow-up to my language-learning metaphor entry.
One comment was about the unlikelihood of mastering a "new language" (literally or metaphorically) if you only start learning beyond childhood or adolescence.
This seems to be a common view.
I always like to look for counterexamples (it's my mathematical way coming out in me):
1) the first one that leapt to my mind is Joseph Conrad, one of the greatest authors in the history of the Engish language. Conrad did not speak a word of English until he was 21. He began writing in English at age 32. His first published works came out when he was about 37. In order to learn English, he did not attend language classes or read grammar books, but chose to live and work in an English-speaking environment (immersion!).
2) I don't know much about rock musicians, but my research led me to a biography of Tom Scholz, from the group Boston. He started playing musical instruments at 21.
3) Here's a link to someone else's list:
http://creativejourneycafe.com/2008/04/09/10-creative-late-bloomers/
4) Here's another list, which is part of a review of a book called Defying Gravity: A Celebration of Late-Blooming Women:
http://www.bookpleasures.com/Lore2/idx/28/2190/Womens_Issues/article/Defying_Gravity.html
5) Another link with good examples:
http://en.wikipedia.org/wiki/Late_bloomer
(I'm the one who added Joseph Conrad to this list).
...I invite other suggestions to expand my list!
Monday, September 14, 2009
Friday, September 11, 2009
Making it through a difficult day or night
It can be hard to make it through the next hour, if you are feeling desperately unhappy, agitated, empty, worthless, or isolated, especially if you also feel disconnected from love, meaning, community, "belongingness," or relationships with others.
Such desperate places of mind can yet be familiar places, and a certain set of coping tactics may evolve. Sometimes social isolation or sleep can help the time pass; other times there can be addictive or compulsive behaviours of different sorts. These tactics may either be distractions from pain or distress, or may serve to anesthetize the symptoms in some way, to help the time pass.
Time can become an oppressive force to be battled continuously, one minute after the next.
I'd like to work on a set of ideas to help with situations like this. I realize a lot of these ideas may be things that are already very familiar, or that may seem trite or irrelevant. Maybe things that are much easier said than done. But I'd like to just sort of brainstorm here for a moment:
1) One of the most important things, I think, is to be able to hold onto something positive or good (large or small), in your mind, to focus on it, to rehearse it, to nurture its mental image, even if that good thing is not immediately present. The "good thing" could be anything -- a friend or loved one, a song, a place, a memory, a sensation, a dream, a goal, an idea. In the darkest of moments we are swept into the immediacy of suffering, and may lose touch with the internalized anchors which might help us to hold on, or to help us direct our behaviour safely through the next 24 hours.
In order to practice "holding on" I guess one would have to get over the skepticism many would have that such a tactic could actually help.
In order to address that, I would say that "covert imagery" is a well-established technique, with an evidence base in such areas as the treatment of phobias, learning new physical activities, practicing skills, even athletic training (imagining doing reps will actually strengthen muscles). The pianist Glenn Gould used covert imagery to practice the piano, and preferred to do much of his practice and rehearsal away from any keyboard; he preferred to learn new pieces entirely away from the piano. There is nothing mystical about the technique -- it is just a different way of exercising your brain, and therefore your body (which is an extension of your brain).
In order for covert imagery to work, it really does help to believe in it though (skepticism is highly demotivating).
Relationships can be "covertly imagined" as well -- and I think this is a great insight from the psychoanalysts. An internalized positive relationship can stay with us, consciously or unconsciously, even when we are physically alone. If you have not had many positive relationships, or your relationships have not been trustworthy, safe, or stable, then you may not have a positive internalized relationship to comfort you when you are in distress. You may feel comforted in the moment, if the situation is right, but when alone, you may be right back to a state of loneliness or torment.
The more trust and closeness that develops in your relationship life, the easier it will be to self-soothe, as you "internalize" these relationships.
Here are some ways to develop these ideas in practical ways:
-journaling, not just about distress, but about any healthy relationship or force in your life which helps soothe you and comfort you
-using healthy "transitional objects" which symbolize things which are soothing or comforting, without those things literally being present. These objects may serve to cue your memory, and help interrupt a cycle of depressive thinking or action.
-if there is a healthy, positive, or soothing relationship with someone in your life, imagine what that person might say to comfort or guide you in the present moment; and "save up" or "put aside" some of your immediate distress to discuss with that person when you next meet.
2) Healthy distraction.
e.g. music (listening or performing); reading (silently or aloud, or being read to); exercise (in healthy moderation); hobbies (e.g. crafts, knitting, art); baking
-consider starting a new hobby (e.g. photography)
3) Planning healthy structured activities
e.g. with community centres, organized hikes, volunteering, deliberately and consciously phoning friends
4) Creating healthy comforts
e.g. hot baths, aromatherapy, getting a massage, preparing or going out for a nice meal
5) Recognizing and blocking addictive behaviours
-there may be a lot of ambivalence about this, as the addictive behaviours may have a powerful or important role in your life; but freeing oneself from an addiction, or from recurrent harmful behaviour patterns, can be one of the most satisfying and liberating of therapeutic life changes.
An addictive process often "convinces" one that its presence is necessary and helpful, and that its absence would cause even worse distress.
6) Humour
-can anyone or anything make you laugh?
-can you make someone laugh?
7) Meditation
-takes a lot of practice, but can be a powerful tool for dealing safely with extreme pain
-could start with a few Kabat-Zinn books & tapes, or consider taking a class or seminar (might need to be patient to find a variety of meditation which suits you)
8) Being with animals (dogs, cats, horses, etc.). If you don't or can't have a pet, then volunteering with animals (e.g. at the SPCA) could be an option.
9) Caring for other living things (e.g. pets, plants, gardens)
10) Arranging for someone else to take care of you for a while (e.g. by friends, family, or in hospital if necessary)
11) Visiting psychiatry blogs
-(in moderation)
...I'm just writing this on the spur of the moment, I'll have to do some editing later, feel free to comment...
Such desperate places of mind can yet be familiar places, and a certain set of coping tactics may evolve. Sometimes social isolation or sleep can help the time pass; other times there can be addictive or compulsive behaviours of different sorts. These tactics may either be distractions from pain or distress, or may serve to anesthetize the symptoms in some way, to help the time pass.
Time can become an oppressive force to be battled continuously, one minute after the next.
I'd like to work on a set of ideas to help with situations like this. I realize a lot of these ideas may be things that are already very familiar, or that may seem trite or irrelevant. Maybe things that are much easier said than done. But I'd like to just sort of brainstorm here for a moment:
1) One of the most important things, I think, is to be able to hold onto something positive or good (large or small), in your mind, to focus on it, to rehearse it, to nurture its mental image, even if that good thing is not immediately present. The "good thing" could be anything -- a friend or loved one, a song, a place, a memory, a sensation, a dream, a goal, an idea. In the darkest of moments we are swept into the immediacy of suffering, and may lose touch with the internalized anchors which might help us to hold on, or to help us direct our behaviour safely through the next 24 hours.
In order to practice "holding on" I guess one would have to get over the skepticism many would have that such a tactic could actually help.
In order to address that, I would say that "covert imagery" is a well-established technique, with an evidence base in such areas as the treatment of phobias, learning new physical activities, practicing skills, even athletic training (imagining doing reps will actually strengthen muscles). The pianist Glenn Gould used covert imagery to practice the piano, and preferred to do much of his practice and rehearsal away from any keyboard; he preferred to learn new pieces entirely away from the piano. There is nothing mystical about the technique -- it is just a different way of exercising your brain, and therefore your body (which is an extension of your brain).
In order for covert imagery to work, it really does help to believe in it though (skepticism is highly demotivating).
Relationships can be "covertly imagined" as well -- and I think this is a great insight from the psychoanalysts. An internalized positive relationship can stay with us, consciously or unconsciously, even when we are physically alone. If you have not had many positive relationships, or your relationships have not been trustworthy, safe, or stable, then you may not have a positive internalized relationship to comfort you when you are in distress. You may feel comforted in the moment, if the situation is right, but when alone, you may be right back to a state of loneliness or torment.
The more trust and closeness that develops in your relationship life, the easier it will be to self-soothe, as you "internalize" these relationships.
Here are some ways to develop these ideas in practical ways:
-journaling, not just about distress, but about any healthy relationship or force in your life which helps soothe you and comfort you
-using healthy "transitional objects" which symbolize things which are soothing or comforting, without those things literally being present. These objects may serve to cue your memory, and help interrupt a cycle of depressive thinking or action.
-if there is a healthy, positive, or soothing relationship with someone in your life, imagine what that person might say to comfort or guide you in the present moment; and "save up" or "put aside" some of your immediate distress to discuss with that person when you next meet.
2) Healthy distraction.
e.g. music (listening or performing); reading (silently or aloud, or being read to); exercise (in healthy moderation); hobbies (e.g. crafts, knitting, art); baking
-consider starting a new hobby (e.g. photography)
3) Planning healthy structured activities
e.g. with community centres, organized hikes, volunteering, deliberately and consciously phoning friends
4) Creating healthy comforts
e.g. hot baths, aromatherapy, getting a massage, preparing or going out for a nice meal
5) Recognizing and blocking addictive behaviours
-there may be a lot of ambivalence about this, as the addictive behaviours may have a powerful or important role in your life; but freeing oneself from an addiction, or from recurrent harmful behaviour patterns, can be one of the most satisfying and liberating of therapeutic life changes.
An addictive process often "convinces" one that its presence is necessary and helpful, and that its absence would cause even worse distress.
6) Humour
-can anyone or anything make you laugh?
-can you make someone laugh?
7) Meditation
-takes a lot of practice, but can be a powerful tool for dealing safely with extreme pain
-could start with a few Kabat-Zinn books & tapes, or consider taking a class or seminar (might need to be patient to find a variety of meditation which suits you)
8) Being with animals (dogs, cats, horses, etc.). If you don't or can't have a pet, then volunteering with animals (e.g. at the SPCA) could be an option.
9) Caring for other living things (e.g. pets, plants, gardens)
10) Arranging for someone else to take care of you for a while (e.g. by friends, family, or in hospital if necessary)
11) Visiting psychiatry blogs
-(in moderation)
...I'm just writing this on the spur of the moment, I'll have to do some editing later, feel free to comment...
Tuesday, September 8, 2009
When your therapist makes a mistake
Sometimes your therapist will make a mistake:
- an insensitive or clumsy comment
- an intrusive line of questioning
- a failure to notice, attend to, or take seriously, something important in the session
- unwelcome or way-off-base advice.
If such problems are recurrent and severe, it may be a sign that you don't have a very good therapist, and that it is important to seek a referral to someone else.
Some problems could be forms of malpractice (e.g. being given dangerous medications inappropriately), and could be pursued through legal channels.
I think that a healthy therapy frame is one in which the therapist will be open to discussing any problems or mistakes.
The therapist should sincerely apologize for all mistakes, and be open to making a plan to prevent similar mistakes from happening again.
You deserve to feel safe, respected and cared for in therapy.
There are other types of conflicts that can arise in therapy, when one person or the other feels hurt, frustrated, or misunderstood. I can think of situations over the past ten years in which there have been tense conflicts, and in which my patient chose not to continue seeing me. In some of these cases, I have felt that there was a conflict--a problem in the relationship--which needed to be resolved. Sometimes these conflicts were made more likely by my own character style or behavioral quirks; other times I think these conflicts were at least partly "transferential," in that my actions triggered memories associated with conflicts from previous relationships (such as with parents growing up). In a few cases, I think the conflict was influenced by active mood symptoms (e.g. severe irritability). I think many conflicts have a mixture of different causes, and are not necessarily caused by just one thing.
In any case, I do strongly believe that resolving conflict in therapy is very important. And I believe a therapist must gently and empathically invite a dialog about conflicts, in a manner which is open, non-defensive, and "non-pushy." Such a moment of conflict-resolution, if it occurs, could be one of the most valuable parts of a therapy experience, a source of peace and freedom.
- an insensitive or clumsy comment
- an intrusive line of questioning
- a failure to notice, attend to, or take seriously, something important in the session
- unwelcome or way-off-base advice.
If such problems are recurrent and severe, it may be a sign that you don't have a very good therapist, and that it is important to seek a referral to someone else.
Some problems could be forms of malpractice (e.g. being given dangerous medications inappropriately), and could be pursued through legal channels.
I think that a healthy therapy frame is one in which the therapist will be open to discussing any problems or mistakes.
The therapist should sincerely apologize for all mistakes, and be open to making a plan to prevent similar mistakes from happening again.
You deserve to feel safe, respected and cared for in therapy.
There are other types of conflicts that can arise in therapy, when one person or the other feels hurt, frustrated, or misunderstood. I can think of situations over the past ten years in which there have been tense conflicts, and in which my patient chose not to continue seeing me. In some of these cases, I have felt that there was a conflict--a problem in the relationship--which needed to be resolved. Sometimes these conflicts were made more likely by my own character style or behavioral quirks; other times I think these conflicts were at least partly "transferential," in that my actions triggered memories associated with conflicts from previous relationships (such as with parents growing up). In a few cases, I think the conflict was influenced by active mood symptoms (e.g. severe irritability). I think many conflicts have a mixture of different causes, and are not necessarily caused by just one thing.
In any case, I do strongly believe that resolving conflict in therapy is very important. And I believe a therapist must gently and empathically invite a dialog about conflicts, in a manner which is open, non-defensive, and "non-pushy." Such a moment of conflict-resolution, if it occurs, could be one of the most valuable parts of a therapy experience, a source of peace and freedom.
Monday, August 31, 2009
Language Learning Metaphor
I have often compared psychological change to language learning.
This could be appreciated on a metaphorical level, but I think that neurologically the processes are similar.
Many people approach psychological change as they would approach something like learning Spanish. Reasons for learning Spanish could be very practical (e.g. benefits at work, moving to a Spanish-speaking country, etc.), or could be more whimsical or esthetic (e.g. always enjoying Spanish music or movies). There is a curiosity and desire to learn and change, and steps are taken to begin changing. A Spanish language book would be acquired. An initial vigorous burst of energy would be spent learning some Spanish vocabulary.
This process often might last a few weeks or months. There might be a familiarity with certain phrases, an intellectual appreciation of the grammatical structure, and perhaps the ability to ask for something in a coffee shop.
Then the Spanish book would sit on the shelf, and never be opened again.
Another pathway could be like the French classes I remember during elementary school. We must have had some French lessons every week for eight years. I did well academically, and had high grades in French.
But I never learned to speak French.
And most people don't learn to speak Spanish either, despite their acquisition of instructional books.
So, there is a problem here: motivation exists to change or learn something new. There is a reasonable plan for change. Effort is invested into changing. But change doesn't really happen. Or the change only happens in a very superficial way.
Here is what I think is required to really learn a language:
1) Immersion is the optimal process. That is, you have to use only the new language, constantly, for weeks, months, or years at a time. This constrains one's mind to function in the new language. Without such a constraint, the mind shifts back automatically to the old language most of the time, and the process of change is much slower, or doesn't happen at all.
2) Even without immersion, there must be daily participation in the learning task, for long periods of time.
3) The process must include active participation. It is helpful to listen quietly, to read, to understand grammar intellectually -- but the most powerful acts of language learning require you to participate actively in conversation using the new language.
4) Perhaps 1000 hours of active practice are required for fluency. 100 hours of practice will help you to get by on a very basic level. 6-10 hours of work per week is a reasonable minimum.
5) Along the way, you have to be willing to function at what you believe is an infantile level of communication, and stumble through, making lots of mistakes, possibly being willing to embarrass yourself. It will feel awkward and slow at first.
6) It is probably necessary to have fellow speakers of the new language around you, to converse with during your "immersion" experience.
7) Part of the good news is that once you get started, even with a few hours' practice, there will be others around you to help you along enthusiastically.
I think that psychological change requires a similar approach. The brain is likely to change in a similar way. I am reminded of Taub's descriptions of constraint-induced rehabilitation from strokes: recovery of function, and neuroplastic brain change, can take place much more effectively if the person is in a state of physiologic "immersion."
Many people acquire books about psychological change (e.g. self-help books, CBT manuals, etc.) in the same way one might acquire a book about learning Spanish. People might read them through, learn a few things, then the books would sit unopened for the next five years.
Or many people might participate in psychotherapy similar to a weekly language lesson: it might be familiar, educational--if there was an exam to write, people might get high grades--but often the "new language" fluency never really develops.
So I encourage the idea of finding ways to create an "immersion" experience, with respect to psychological change. This requires daily work, preferably in an environment where you can set the "old language" aside completely. This work may feel artificial, slow, contrived, or superficial. But this is just like practicing phrases in a new language for the first time. Eventually, the work will feel more natural, spontaneous, and easy.
I think the greatest strength of cognitive-behavioural therapy is its emphasis on "homework," which calls upon people to focus every day on constructive psychological change. And the different columns of a CBT-style homework page remind me of the "columns" one might use to translate phrases from one language into another. In both cases, in order for this homework to work, it has to be practiced, not just on paper, but spoken out loud, or spoken inside your mind, with sincerity and repetition, and preferably also with other people in dialogs.
There's some interesting academic work out there on language acquisition--but for a start, here's a reference from a language-learning website (particularly the summary on the bottom half of this webpage):
http://www.200words-a-day.com/language-learning-reviews.html
Monday, August 17, 2009
ADHD questions
Here are some great questions about ADHD, submitted by a reader:
I don't know the answers to a lot of these, but I am interested to keep trying to learn more. Here's my best response I can come up with for now:
1) First of all, the bottom line of whether something is helpful or not may not be some specific thing, like academic performance. Perhaps "well-being" in a broad, general sense is a more reasonable goal. Yet, things like academic performance are important in life. Perhaps stimulants or other treatments for ADHD are "necessary but not sufficient" to help with ADHD-related academic problems over the longer term. It appears to me from the data that stimulants are actually helpful for academic problems, it's just that the size of the effect is much smaller than what most people would hope for.
2) I wrote a post about zinc supplementation before. Also adequate iron stores are probably important. A generally healthy diet is probably important. I've encountered some people with ADHD who have reduced tolerance for irritation or frustration, and may be particularly bothered or distracted by hunger; yet they may not be organized to have meals prepared regularly through the day. So it can help them manage their ADHD to make sure they always have snacks with them, so that they are never in a hungry state. Other than that, I think there are a lot of nutritional claims out there which have a poor evidence base. The link between sugar intake and hyperactivity is poorly substantiated--I've written a post about that.
Food additives or dyes could play a role in exacerbating ADHD symptoms. Based on this evidence, it makes sense to me to limit food dyes and sodium benzoate in the diet, since such changes do not compromise quality of life in any way, and may lead to improved symptoms. Here are a few references:
http://www.ncbi.nlm.nih.gov/pubmed/17825405
(this is the best of the references: it is from Lancet in 2007)
http://www.ncbi.nlm.nih.gov/pubmed/15613992
http://www.ncbi.nlm.nih.gov/pubmed/15155391
I once attended a presentation on EEG biofeedback. I think it is a promising modality. Harmless to give it a try, but probably expensive. It will be interesting once the technology is available to use EEG biofeedback in front of your own home computer, at low cost.
A few of the self-help books about ADHD are worth reading. There are a lot of practical suggestions about managing symptoms. Some of the books may contain a strongly biased agenda for or against things like stimulants or dietary changes, so you need to be prepared for that possibility.
3)The ADHD label is an artificial, semantic creation, a representation of symptoms or traits which exist on a continuum. Even for those who do not officially satisfy symptom checklist criteria for ADHD, they could benefit substantially from ADHD treatments if there is some component of these symptoms at play neurologically. Many people with apparent disorders of mood, personality, learning, conduct, etc. may have some component of ADHD as well: in some cases ADHD treatments are remarkably helpful for the other problems. So I think careful trials of stimulants could be helpful diagnostically for some people, provided there are no significant contraindications.
4) I've always thought about the ADHD label as just a semantic updating of the previous ADD label. Subtypes of ADHD which are predominantly inattentive rather than hyperactive may differ in terms of comorbidities and prognosis.
5) Hard to say. Many people think of bupropion as a "dopaminergic" drug, whereas bupropion and its relevant metabolites probably act mainly on the norepinephrine system in humans (its dopaminergic activity is more significant in dogs). But perhaps bupropion response could correlate with stimulant response. I haven't seen a good study to show this, nor do I have a case series myself to comment one way or the other based on personal experience.
6) I don't know about that. Comorbidities (e.g. substance use, relationship, or conduct problems) may have accumulated in adults who have not had help during childhood. Yet I have often found it to be the case that the core symptoms of most anything can improve with treatment, at any age.
7) Patients with psychotic disorders (i.e. having a history of hallucinations, delusions, or severely disorganized thinking) often seem to do poorly on stimulants. Patients who are using stimulants primarily to increase energy or motivation often are disappointed with stimulants after a few months, since tolerance develops for effects on energy. Patients with eating disorders could do poorly, since stimulant use may become yet another dysfunctional eating behaviour used to control appetite. And individuals who are trying to use stimulants as part of thrill-seeking behaviour, who are using more than prescribed doses, or who are selling their medication, are worse off for receiving stimulant prescriptions.
1) You write here that long-term use of stimulants has NOT been shown to improve long-term academic outcomes. Why do you think this is, given that symptoms of ADHD improve on medication? (It actually really depresses me to think that individual symptoms can improve, yet no real change takes place...though I know that this might not apply to all patients.
2) What are some effective non-drug treatments for ADHD? I am particularly interested in dietary measures, and also EEG biofeedback.
3) I have read about prescribing psychostimulants as a way of basically diagnosing ADHD...i.e., the diagnosis is based on your response to the medication. I am just wondering how precise this would be, given that stimulants would probably (?) impove most people's concentration, etc. Or is there any role for neuropsychological testing in trying to establish a diagnosis? Is there any way of definitively establishing this kind of diagnosis?
4) I have read that there are many differences between ADD and ADHD, i.e. not just in symptom presentation but in the underlying brain pathology. Is that true? I'm not sure how to phrase it, it seemed like the suggestion was that ADD was more "organic", although maybe that doesn't make sense. Does that have implications for prognosis or treatment strategies?
5) I have read that one red flag that suggests ADD in the context of MDD treatment is a good response to bupropion. If a patient did not have a really good response to bupropion-- or if the response was only partial-- does this usually mean that treatments with psychostimulants like Ritalin, Adderall, etc. will be ineffective (or only partially effective) also?
6) If ADD is not diagnosed/treated until adulthood, is it usually more difficult to treat than if it is diagnosed/ treated in early childhood? Is the response to stimulant treatment just as good? I guess I am wondering if there are certain structural changes that occur in the brain that result from untreated ADD-- kind of like long-term depression and hippocampal atrophy?
7) Is there a certain type of patient who usually does poorly on psychostimulants, or who experiences severe side effects on psychostimulants?
I don't know the answers to a lot of these, but I am interested to keep trying to learn more. Here's my best response I can come up with for now:
1) First of all, the bottom line of whether something is helpful or not may not be some specific thing, like academic performance. Perhaps "well-being" in a broad, general sense is a more reasonable goal. Yet, things like academic performance are important in life. Perhaps stimulants or other treatments for ADHD are "necessary but not sufficient" to help with ADHD-related academic problems over the longer term. It appears to me from the data that stimulants are actually helpful for academic problems, it's just that the size of the effect is much smaller than what most people would hope for.
2) I wrote a post about zinc supplementation before. Also adequate iron stores are probably important. A generally healthy diet is probably important. I've encountered some people with ADHD who have reduced tolerance for irritation or frustration, and may be particularly bothered or distracted by hunger; yet they may not be organized to have meals prepared regularly through the day. So it can help them manage their ADHD to make sure they always have snacks with them, so that they are never in a hungry state. Other than that, I think there are a lot of nutritional claims out there which have a poor evidence base. The link between sugar intake and hyperactivity is poorly substantiated--I've written a post about that.
Food additives or dyes could play a role in exacerbating ADHD symptoms. Based on this evidence, it makes sense to me to limit food dyes and sodium benzoate in the diet, since such changes do not compromise quality of life in any way, and may lead to improved symptoms. Here are a few references:
http://www.ncbi.nlm.nih.gov/pubmed/17825405
(this is the best of the references: it is from Lancet in 2007)
http://www.ncbi.nlm.nih.gov/pubmed/15613992
http://www.ncbi.nlm.nih.gov/pubmed/15155391
I once attended a presentation on EEG biofeedback. I think it is a promising modality. Harmless to give it a try, but probably expensive. It will be interesting once the technology is available to use EEG biofeedback in front of your own home computer, at low cost.
A few of the self-help books about ADHD are worth reading. There are a lot of practical suggestions about managing symptoms. Some of the books may contain a strongly biased agenda for or against things like stimulants or dietary changes, so you need to be prepared for that possibility.
3)The ADHD label is an artificial, semantic creation, a representation of symptoms or traits which exist on a continuum. Even for those who do not officially satisfy symptom checklist criteria for ADHD, they could benefit substantially from ADHD treatments if there is some component of these symptoms at play neurologically. Many people with apparent disorders of mood, personality, learning, conduct, etc. may have some component of ADHD as well: in some cases ADHD treatments are remarkably helpful for the other problems. So I think careful trials of stimulants could be helpful diagnostically for some people, provided there are no significant contraindications.
4) I've always thought about the ADHD label as just a semantic updating of the previous ADD label. Subtypes of ADHD which are predominantly inattentive rather than hyperactive may differ in terms of comorbidities and prognosis.
5) Hard to say. Many people think of bupropion as a "dopaminergic" drug, whereas bupropion and its relevant metabolites probably act mainly on the norepinephrine system in humans (its dopaminergic activity is more significant in dogs). But perhaps bupropion response could correlate with stimulant response. I haven't seen a good study to show this, nor do I have a case series myself to comment one way or the other based on personal experience.
6) I don't know about that. Comorbidities (e.g. substance use, relationship, or conduct problems) may have accumulated in adults who have not had help during childhood. Yet I have often found it to be the case that the core symptoms of most anything can improve with treatment, at any age.
7) Patients with psychotic disorders (i.e. having a history of hallucinations, delusions, or severely disorganized thinking) often seem to do poorly on stimulants. Patients who are using stimulants primarily to increase energy or motivation often are disappointed with stimulants after a few months, since tolerance develops for effects on energy. Patients with eating disorders could do poorly, since stimulant use may become yet another dysfunctional eating behaviour used to control appetite. And individuals who are trying to use stimulants as part of thrill-seeking behaviour, who are using more than prescribed doses, or who are selling their medication, are worse off for receiving stimulant prescriptions.
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