You Mean I'm Not Lazy, Stupid or Crazy?!: The Classic Self-Help Book for Adults With Attention Deficit Disorder (34 page)

Why, though, would a woman with ADD think everything is her fault? Well, perhaps not
everything
, but we have heard a lot of clients express exactly that on “bad brain days.” In the study comparing women with and without ADD, a couple of the examples given were car accidents and the boss yelling at you. The women without ADD would express that the car accident
was due to weather, with poor visibility
the major culprit. The boss yelled because he was having a bad day. The women with ADD, however, blamed only themselves for the car wreck and thought that the boss was yelling because they did something wrong. These women did not seem to consider the possibility that something outside themselves might at least be partly responsible for the outcome.

Women with ADD, then, get a double whammy. They
think that the negative events in their life are their own fault, and then take their frustration out on themselves. It is not hard to imagine how women with ADD come to believe that they are always the guilty party. They already have a more negative self-image than men with ADD. Owners of an unpredictable brain that is prone to “oopses,” they learn to mistrust their actions and perceptions. The
self-talk starts with “I have made mistakes,” expands to “I make a lot of mistakes” and then, finally, “I always make mistakes.”

Estrogen—the Missing Piece

Hormones Again …?

Hormones have a powerful effect on both mood and cognitive functioning. In an earlier section we mentioned the impact of the male hormone testosterone on aggression. We humans all have the same hormones in our bodies, but the mix is quite different in males and females. More estrogen and progesterone for women, for example, and more testosterone
for men. Women, however, have a hormonal challenge that men simply do not. Creatures of the moon, we follow roughly lunar cycles as our hormonal balance ebbs and flows each month. This cyclic pattern starts at puberty and continues until menopause is complete.

We all have some familiarity with the impact of hormonal fluctuations on women’s mental/emotional state and behavior. It is no accident
that PMS jokes are stock in trade at the comedy clubs. Better that we laugh than tear our hair out … or we tear our hair out and then laugh when we feel somewhat better. In addition to the monthly roller-coaster ride, women also have to contend with the hormonal storms of puberty, the childbearing cycle and perimenopause/menopause. The temporary imbalances of hormones that happen during these times
of fluctuation cause the unpleasant “symptoms.” Some of these symptoms are a lot like the ones we contend with as ADDers, such as fluctuating moods, irritability, short fuses, forgetfulness and difficulty concentrating.

Years ago, when we were promoting the original version of this book, we showed up for a radio interview and were greeted by the same woman who had had us on her show the previous
year (let’s call her Susan). Susan was effusive in her welcome—acted like we were long-lost best friends, as a matter of fact. She revealed that she really didn’t “get it” about ADD the first time around. In the past year she had entered perimenopause and had her first experiences ever with lack of control over her functioning. Susan, who had always been organized, articulate and calm, was now
having difficulty locating her keys, finding the right words to say and keeping her cool on a day-to-day basis.

Well, if hormones wreak that kind of havoc on women without ADD, just imagine what they are doing to us. Dr. Pat Quinn, who has done groundbreaking work on the issues of ADD women, has found in the course of her clinical work that hormones have a significant impact on the symptoms of
women with ADD. Falling estrogen levels turn out to be the biggest problem for ADDult women. Unfortunately, it is not a simple matter of taking a blood test to determine if you have the correct level of estrogen in your body. It is possible to have an estrogen level that falls in the normal range but is low for you as an individual. Low estrogen states occur in the phase before menstruation and
during postpartum and perimenopause/menopause.

What Does This Mean for ADD Women?

First, it is important to recognize that a fixed dose of stimulant medication may not do the trick for you. The hormonal factor needs to be taken into consideration. Essentially, if there is not enough estrogen in your system, stimulant medication will not be as effective. For some women, low-dose birth control
pills have been used to keep estrogen levels steady for a longer time during the menstrual cycle. In other cases, estrogen replacement therapy has been used
before
perimenopause to increase the effectiveness of stimulant medication. Dr. Pat Quinn has studied eighty-five women with ADD, several of whom are postmenopausal. These women reported a worsening of ADD symptoms in menopause and an improvement
when treated with estrogen replacement therapy.

What Can You Do to Be Proactive
in Your Own Treatment, Given This
Information on Hormones and ADD?

First, keep a record of your cyclic changes and share it with your doctor. Dr. Pat Quinn has her patients keep a two-month record, rating their symptoms of attention, concentration, focus and organization on a scale of 0 (good) to 4 (poor) during the
first four weeks of their menstrual cycle. After two months, if it is determined
that ADD symptoms worsen during the third and fourth weeks, the dose of stimulant medication is increased.

Second, share information about ADD and the hormone connection with your prescribing physician. You can refer him or her to the chapter on hormonal fluctuations in
Gender Issues and AD/HD
, by Drs. Pat Quinn
and Kathleen Nadeau.

What About Pregnancy—What Can You
Expect as an Expecting ADD Woman?

Well, the bad news is that taking your stimulant medicine is not recommended during pregnancy. It is possible to continue with antidepressants, however, as the safety of tricyclics and SSRIs in pregnancy has been established. The good news is that pregnant women with ADD report that their functioning improves,
sometimes dramatically. This makes sense, given that pregnancy is a high-estrogen state, as is the breastfeeding period. Be aware, however, that you may experience a crash when the hormones shift, either postpartum or during the weaning process. Make an appointment with the person prescribing your stimulant medication before delivery if you plan to bottle-feed so that you can be ready to take
your medicine immediately after childbirth. If you are breastfeeding, have your supply of medication on hand before you begin the weaning process. Since stimulant medication is not approved for breastfeeding mothers, you are advised to wait until the baby is weaned before starting medication. But at least you will be prepared. Being a new mother is disorganizing enough, even when ADD is not a factor.
We are sure that you have had some experience with how long it can take to get an appointment. A little advance planning on this one is well worth it.

Do Men with ADD Have More Issues
with Anger Management?

The answer to this question is a qualified “yes.” Men in general are more likely to express anger than women, and ADDers in
general have more difficulty managing anger in an appropriate way.

One big piece of this may involve the differences in how our society responds to men and women in identical situations. While men in many Western societies have been discouraged from showing emotion, one great exception is anger. In some instances, it is even seen as a sign of strong leadership for a man to demonstrate his anger. Women, however, operate under a different set of expectations. Some
of the first female executives to reach the higher rungs of the corporate ladder were called “bitchy” or “manipulative.” They were surprised to find that the same behavior displayed by a male colleague was called “persuasive” or “being a real go-getter.” In the same way, you may have heard someone defending an angry outburst by a male authority figure in terms of his being “passionate about that
subject.” He could be praised for “rallying the troops” behind a cause, while his female counterpart may find herself described as “scary,” or even “unstable.” While this type of attitude is definitely changing, it is often useful to recognize that years of cultural conditioning are difficult to undo in a short time.

Of course, there are exceptions to the standard male-female differences around
anger. We know a woman (one of our clients, actually) who just signed up for her
third
round of anger management. She loves it. In contrast to the other folks in the class, her attendance was not mandated by the court. They spend their time being pissed off about being forced to take the class, while she does the work. Despite this example, in most cases it is true that ADD men (and men in general)
have more difficulty controlling anger. One of the things we know about folks with ADD is that we often find it difficult to inhibit our words and actions. Also, as we mention in the chapter on meditation, the limbic system, which is the seat of the emotions, is often overly reactive in ADDers. When you add the hormone testosterone into the mix, the results can add up to a hard-to-manage cocktail
for men with ADD.

Sex and the ADDult

A number of years ago there was a psychopharmacology update floating around the Internet about a woman who experienced a, well, unusual reaction to taking an antidepressant. Actually, she was taking two antidepressants. One of them was Wellbutrin and the other was an SSRI, which stands for “selective seratonin reuptake inhibitor.” Whew! What a mouthful. We have changed the
meaning of those initials around to reflect our experience (and those of our clients) taking the darn things. We now think SSRI stands for “suppressed sexuality reduces intercourse.” Some of the SSRIs are better than others, but basically they have a dampening effect on sexual functioning for most people.

Wellbutrin (bupropion), on the other hand, can counteract the sexual dysfunction caused
by an SSRI. The woman in the Internet story reported that she had a spontaneous orgasm while shopping. This had never happened to her before. The report
did not mention what kind of shopping she was engaged in at the time, so that is one of those pesky unknown variables. Obviously, this is not a controlled scientific study, but it does make you wonder …

Spontaneous Orgasm Brought on by
Combination of Buproprion and Sertraline

… Female patient (35 years old) with recurrent depression was placed on sertraline (Zoloft) 100mg/d. After two weeks she complained of impaired sexual function, which prompted the addition of buproprion (75 mg/d) as adjunctive therapy for this condition. Her sexual condition improved considerably after one week and greatly after four weeks. At six weeks on this regimen,
she experienced a spontaneous orgasm while shopping. She found the experience pleasurable, but socially unacceptable, and so she stopped taking the buproprion …

A friend sent this little tidbit from cyberspace, and also added a few comments of her own:

This has been haunting me ever since I read it. What store do you think it happened in? Did she moan and pant over the sausage counter in her local grocery store? Was she mooning over the men’s jockey shorts when the experience “came” upon her? Just exactly what did she do? Perhaps she was in the women’s underwear department and enjoyed a moment of rubbing a silky negligee across her cheek? How about the tool section in Sears? Would the sight of a power tool set her off? I just might order the
Psychopharmacology Update
just so I can get more exciting articles like this one!

This is not a chapter on medication … that comes later. The point of including this little anecdote is to underscore the relationship between brain functioning and sexuality. In Chapter 2, How Are We Different, we talk about how brain chemicals
(neurotransmitters) are culprits in producing the symptoms of ADD. If you have had the delightful experience
of having your libido turned off (like a water faucet) via the wonders of modern pharmacology, we don’t have to tell you that tinkering around with those neurotransmitters affects your personal plumbing too.