Thursday, February 14, 2013

Two unusual therapeutic effects of Adderall - promotion of sleep and control of paranoia

One thinks of  Adderall (Dextroamhetamine), the prototypical psychostimulant, as something one would avoid to get restful sleep. Yet, two of my patients use Adderall as a sleep agent. Since this paradoxical effect throws some light on how dopamine activation helps in ameliorating symptoms of ADHD, I will give a brief account of these two cases, and then make some theoretical comments.

A single woman, in her early forties, never married and with no issues, attractive and shy, who lives a lonely life, a result of excessively fearful disposition, and whose temperamental sensitivity is so high that the slightest social or environmental threat during the day causes affective diisturbance for hours, and, at night, the slightest noise wakes her out of sleep, requested Adderall. Someone she knew had suggested it to her, and after reading about it on the Internet she claimed that she has many of the symptoms that Adderall is suppose to help with, and since none of other therapeutic efforts have made a dent in her condition I should give her what she was asking for.

But I was reluctant to prescribe her Adderall. None of the previous medications had produced lasting results. She came to me burdened with the label of schizoaffective disorder, probably tacked on her by biological psychiatrists to justify giving her all kinds of medications without having to know what was really wrong with her, and had been tried by them on numerous antipsychotics - dopamine neurotransmission blockers.  Except for Zyprexa all other neuroleptics had made her miserable. Even with Zyprexa her mood had not been quite right. When asked what she meant by "not quite right", she stated that Zyprexa made her feel that she was "part of a system", and it left her "high strung". Antidepressants had been equally useless. Only Prozac had helped, but for just a few months. Diazepam and Clonazepam had helped with agitation and anxiety but they did not ameliorate the fatigue, body aches and pains, and while they helped her with falling asleep their effectiveness had dulled over time. But my greatest concern was presence of what looked like a predisposition to develop paranoid psychosis. She showed phobic fear of people and going to places away from home, especially if she was likely to run into African-American men. These were clearly hysterical defenses and projection of her own hostility - rather ambivalence; unconscious attraction and consequent fear -  towards black men. But then she sometimes - pointing more to some genuine paranoid process - complained that neighbors talked and criticized her as a "free loader" living on welfare because they did not see her going to work and just hanging at the apartment complex. In reality her expenses were taken care of by her elderly parents who barely could make both ends meet and she felt very guilty about taking money from them.

When she would not take no for an answer I went ahead and prescribed her Adderall. Very low dose, just 10 mg., and reluctantly, for though she protested that my recall was wrong I had memory of her once complaining to me that she could actually hear the neighbors talking about her which sounded like frank auditory hallucination.  And amphetamines are known to exacerbate paranoia. In fact one of the most used animal model of psychosis in pharmaceutical research is to  give very high doses of intravenous amphetamine to rats and other lab animals.

But when she returned in a a month - she has no insurance and cannot afford to see me more often than that - my apprehension that Adderall will worsen her paranoia proved to be wrong. She had shown a good response to it across the board. The best proof of which, she claimed, was her restored ability to watch TV and read books by sitting down for a while instead of running from one place to another trying to calm herself down. When asked as to how the medicine achieved this she said because it stopped her mind from racing excessively.  What was even more surprising was that even her paranoia was better. Now she felt comfortable talking with neighbors, including a black couple, and added that they should reclassify Saphris and Latuda as not anti-paranoid drugs - both had failed to help her - and declare Adderall as the true anti-psychotic. In praise of Adderall she also added that it gives her a boost of energy and makes her more confident of herself. A further benefit she claimed was that since she is less fearful during the day she can interact better with people and as a consequence sleep better at night.

The second case is a little more complex for though superficially it appeared as a simple manic-depressive illness, it was highly complicated by a traumatic neurosis. She was subjected to a shocking, humiliating and painful rape that occurred when she was just twelve and half years old. She had been pulled inside a car near her house, by two 17 year old men, and after being driven for a short distance in to an alley, subjected to the rape. The psychological content of her manic-depressive illness was entirely about undoing this trauma and getting even with the perpetrators. During the upswings she would be suffused with energy to take revenge and would drive aimlessly for hours hoping to run into the two rapists and subjecting them to the exact same pain, humiliation and physical act through the agency of another man that was perpetrated upon her, despite the fact that the trauma had occurred more than 25 years ago and the prospect of meeting them was almost zero. The only thread she had to reach them was overhearing them while they were molesting her that one of them was going to have his 18th birthday next week and from their conversation she could also make out that they lived locally. She remembered their faces clearly, and assumed that if they were 17 years old then that year's high school yearbook would have their pictures and names and from there she could research further and finally trace them out. Despite driving around for endless number of hours for decades she could never take the final step of getting to the yearbook. These upswings would start with the search for those rapists but soon would change from euphoria into tense dysphoria and a great dread of going completely out of control like turning into a serial killer and then she would seek company of a trusted friend, counting upon her to keep tabs upon her and not enter into complete craziness. When asked if she would really turn into a serial killer she said that it happens only to those who do not receive their mother's love. In her case though her mother was not at all nurturing her grandmother was and the latter's memory would act as a barrier to her becoming totally evil.

The downswings would be filled with pessimism, suicidal thoughts, inability to get out of the house, sleeping through the day, inability to do house chores and go to work. Fortunately her boss was her friend, who accepted her mental limitations and expected her to come only if she was feeling up to it. The trauma had also generated in her fibromyalgia which required Tramadol a borderline narcotic. To make matters worse she had extensive obsessive-compulsive behaviors and rituals, including the tendency to hoard, the etiology of which owed heavily to the fact that after the rape her mother had taken no steps to take her to the police station and take action against the rapists, and in fact had cast doubts at  her story, suspecting her to have been compliant with it,  provoking a tremendous rage in her towards the mother, the flare up of which now was handled by turning the affect and the accompanying aggressive impulses into obsessive-compulsive rituals. The rage towards her mother however was present even before the trauma, a precipitate of an intense Oedipal conflict. The mood swings also existed before the sexual trauma, and were a reflection of her high intelligence and talents. She was on Topomax and Saphris to control her mood swings. Which as the case history shows were doing a very limited job, and she often felt completely out of control during the upswings.

What however is the real subject of this communication is the role Adderall played in her daily functioning. Without Adderall-XR she could neither motivate herself to go for work nor could she sleep. She took 15 mg. of Adderall-XR around noon to help her step out of the house and go to work. But additionally she took 15 mg. of Adderall-XR every morning at 7 am to get two hours of very intense sleep. She rarely slept at night, and after tossing and turning all night long would get up at 5 am to get her children ready for school. After sending them to school she would take the morning dose of Adderall and go into very deep sleep till 9 am.

When asked how does Adderall help her to sleep, she claimed it stopped her racing thoughts. Her brain stopped trying to be in 100 different places allowing her to concentrate upon sleep. Analysis revealed that her mind was racing to all these different places to prevent harm coming to herself and her children. Her mind would not shut off busy trying to put out fire everywhere.  But once she took Adderall she felt protected and did not worry as much. She added, "You know how I sleep with lights and TV on. The brightness of the light and the noise from the TV act as my companions." When asked why does she not take Adderall at night and sleep through the night she said that that Adderall does not work at night. To get into real deep sleep which requires that mental vigilance/ego tension be dropped she needed the additional protection of daylight. With the TV on and daylight there she did not feel alone and vulnerable. It may be mentioned here that she was abducted and raped while walking home  from a friend's house at dusk and blames her mother who ordered her to return before dark and wonders if that phone call had not come at that particular point of time would she have escaped running into those two boys.

Why does Adderall a dopaminergic agent which wakes her up and keeps her alert during the day and while at work, works in just the reverse fashion in early morning hours, enabling her to sleep?

In both my patients what Adderall appears to have been doing was to act as a barrier against fear. This surmounting of fear with the aid of dopamine - a sympathomimetic compound - made the first patient more social and less paranoid and by getting more satisfaction out of life during the day she did not have to take her conflicts to bed and dreams and thus sleep restlessly. In the second patient the daylight and the noisy TV  were protection against fear but were insufficient by themselves and only with the addition of Adderall the balance was tipped in favor of allowing her to fall asleep deeply, though for no more than two hours. Daylight may have signified that most of the world was awake now and could be summoned for help in case danger came her way.

 In both cases Adderall reduced the racing thoughts. Fear makes one want to run away, and if one cannot run on their feet they run in their imagination (daydreams) and racing thoughts. So at the root of racing thoughts lies the motive to run away from the situation in hand and when the conflict reemerges at the new locale to run from their to the next and so on, resulting in trying to be in 100 different places at the same time putting out fires everywhere. Children with ADHD cannot concentrate either because they are running away from their internal fears - in most cases unresolved Oedipal conflict where the  residual (unconscious) sexual attachment to the mother and corresponding fear of the father keeps generating fear/anxiety - and thus their mind is racing and unable to concentrate in what is happening in "here and now". Amphetamines by enforcing dopamine secretion and thus giving a sense of something positive happening raises the person's interest in the immediate surroundings. This sense of something positive happening gives the feeling that this situation is pleasure giving, therefore not dangerous, and where one should focus one's attention to get more of similar pleasure.

One must caution that these two cases are not typical and as a rule amphetamine prevents sleep and exacerbates paranoia.