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Mindful Practice case is ADHD.

I read with interest the Mindful Practice column ("Chamomile for Anxiety," Internal Medicine News, June 15, 2010, p. 27). In my opinion, your patient most likely suffers from adult attention-deficit/hyperactivity disorder (ADHD). Many practitioners, including me, think that obsessive compulsive disorder (OCD) can represent a compensatory mechanism for ADHD. It is an attempt to find organization and structure amongst disarray.

Depression is under-recognized as a key component of ADHD, but patients routinely have difficulty concentrating, feel overwhelmed, and have poor self-esteem.

Bupropion is very beneficial, as it works on dopamine, which is a precursor of norepinephrine and a neurostimulant. It is noteworthy that the patient sought out another stimulant: caffeine. The four most abused substances in ADHD are caffeine, nicotine, alcohol, and opiates. In fact, when screening for adult ADHD, I ask if the patient consumes large amounts of caffeine, especially coffee. I ask whether it keeps them up at night. Routinely, my ADHD patients love their caffeine after dinner--especially the double espresso--because it helps them sleep. Psychostimulants calm ADHD patients by improving the catecholamine dysregulation in the prefrontal cortex.

I suspect a similar mechanism is involved in chamomile tea. When the ADHD is treated, depression, anxiety, self-esteem, and organizational skills all improve. The patient knew that the caffeine wasn't worsening his anxiety. We seldom engage in a behavior voluntarily if we don't get a benefit.

It must be remembered that bipolar disorder is the most significant comorbidity of ADHD. I would not have treated the patient with sertraline, but would have reevaluated his entire regimen.

John C. Sciales, M.D.

Flushing, N.Y.

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Title Annotation:LETTERS
Author:Sciales, John C.
Publication:Internal Medicine News
Article Type:Letter to the editor
Geographic Code:1USA
Date:Aug 1, 2010
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