Jerald Grobman, M.D.
Short-term use of psychotropic medication can be a useful adjunct to a psychiatric intervention when other methods have failed. Sadly, this type of intervention is rarely considered when psychological symptoms and dysfunctional behaviors are getting worse but only when they have reached crisis proportions
Evidence based recommendations for best practices indicate that these psychotropic medications achieve best results when administered in the context of a therapeutic relationship .Often this means medications need only be used on a short-term basis.
The clinician who understands the elements of a gifted endowment and a gifted personality can avoid the pitfall of mis-diagnosis and not mistake a gifted individual in crisis with a gifted individual who may have developed a genuine psychiatric syndrome or pathological personality disorder
Bringing symptoms and dysfunctional behavior back into safe control allows the psychiatric assessment to proceed . Uncovering a gifted individual’s unresolved emotional responses to all aspects of h/h giftedness helps formulate specific therapeutic interventions so gifted development can get back on track.
Introduction and background
Gifted individuals often have problems managing their family’s and friend’s reactions to their giftedness, finding a school that promotes it’s development, establishing relationships in which to share it and creating a career path that will allow it’s potential to be realized. Gifted individuals also have trouble controlling creative frenzies or reactions to success and failures. They also have trouble managing certain parts of their gifted personalities: passionate engagement over all else; the need for independence and overreactions and over-sensitivities. These of course are essential for high levels of creative work but they also need to be modified when engaging in social or intimate relationships. Gifted polymaths – individuals with multi-potential – can have difficulty choosing a particular domain in which to develop expertise.
For some gifted individuals, educational adjustments, coaching ,counseling, and various forms of cognitive/behavioral therapy can succeed in addressing the more straightforward aspects of these problems: circumstances can be improved; more appropriate relationships can be found ; family dynamics can be shifted and critical thinking can be used to make important decisions.
When and why standard assessments and interventions often fall short
However, when problems persist it can be a sign that a set of deeper psychological/emotional issues may be operating. Often, these dynamics exist at a subconscious or unconscious level making it hard to employ conscious cognitive and behavioral interventions. Without a more comprehensive assessment that uncovers and examines these issues and points the way to how to address them, serious psychological symptoms – anxiety, depression , mood swings and self-defeating behavior can develop alongside the more obvious areas of dysfunction.
The role of an early psychiatric consultation/assessment and use of psychotropic medication.
Before these symptoms reach crisis proportions, a psychiatric consultation and the short – term judicious use of psychotropic medication can stabilize the psychiatric symptoms and allow a more in-depth assessment to take place.
More often than not however, the emotional symptoms are thought to be simply secondary reactions to undiscovered complex cognitive and executive dysfunctions. As a result more sophisticated tests are requested. Although these tests are excellent in providing a microscopic view of specific cognitive and executive functions, their findings may not be easy to understand or to translate into practical recommendations for remediation.
Furthermore, because these tests are primarily focused on examining cognitive/executive strengths and weakness of gifted individuals, they rarely include ways to categorize and measure the non-cognitive (intuitive) aspects of giftedness as well as how unconscious conflicted emotional reactions to these may have compromised the cognitive/executive functions of gifted intellectual functioning. In this way these testing methods often miss the subtleties of the complex deeper emotional dynamics that are at the root of cognitive/executive and behavioral problems.
After modified interventions have not made an appreciable difference and problems and symptoms still persist, it becomes even clearer that it may be that complex non-cognitive emotional problems have remained undiscovered and unexamined.
The consequences of failed standard assessments and standard interventions
After new information from different assessments and new interventions fail to make a difference, a sense of pessimism sets in. This is often the beginning of a downward psychological spiral. Gifted individuals may slowly become convinced that their problems and symptoms are rooted in primary neurological/biological defects or deficits. Now the very qualities ( especially the non-cognitive intuitive ones) that were once thought to be the remarkable traits of being gifted are experienced as liabilities or disabilities. The capacity to see beyond the ordinary( clairvoyance ) the immediacy of intuitively arriving at answers to complex problems now actually seem irrelevant. Feeling more and more hopeless, all aspects of giftedness can be disavowed: precocious accomplishments that were once a source of pride and self-esteem, are now considered “flukes” and the whole idea of being gifted can be seen as a self- indulgent fantasy.
The psychiatric consultation and the use of psychotropic medication becomes an emergency
The tipping point – when a psychiatric consultation and the use of psychotropic medication become an urgent necessity – is reached when psychological symptoms of anxiety depression and mood swings, and self- destructive behavior become immobilizing. Suicidal ideation begins to creep into every day thinking and thought experiments about techniques for self- harm become preoccupations. Now gifted individuals and their friends and family worry that in addition to their other problems they have also developed a psychiatric syndrome or a pathological personality disorder.
Sadly, the psychiatric consultation and the issue of psychotropic medication become last-ditch efforts to for-stall a full- blown psychiatric crisis. Employed earlier, these interventions might well have stopped this downward destructive path avoiding a lot less suffering and wasted time.
The psychiatric consultation/assessment and the proper use of psychotropic medication
As the crisis deepens and dysfunction spreads out over all aspects of their life, some gifted individuals can accept that they are ,in fact ,out of control. Rational thinking allows them to set aside their fears of being misunderstood, misdiagnosed, over medicated and agree, for the time being, that their need for help is more important than their need for independence.
The most immediate goal of the psychiatric consultation/assessment is to make an accurate diagnosis of the symptoms, formulate how underlying psychological factors caused the symptoms, stabilize the symptoms and restore a basic level of cognitive/executive functioning. Judicious use of psychotropic medications often play an important role in this early stage of these processes.
The ultimate goal is to help a gifted individual reconnect with h/h giftedness in positive ways so they can reclaim their identity as a gifted individual and proceed on their unique developmental path.
The first step in the assessment process is to determine if the symptoms and dysfunctional behavior are caused by medical illnesses or the side effects of prescription medications and/or the use or abuse of recreational drugs.
Formulating the causes of symptoms and dysfunctional behavior and avoiding misdiagnosis:
Symptoms and behavior need to be evaluated in context in order to determine their origins
In order to determine the deeper psychological causes of a gifted individual’s symptoms and behavior the clinician must first understand the nature of the giftedness at the time it was discovered. How giftedness influenced ( possibly turbo-charged ) and was influenced ( possibly restricted ) by the forces of “normal” growth and development are also important features of the assessment. Whether giftedness did or did not unfold often depends on how it was effected by and effected life circumstances as well as reactions of family, friends and classmates. Identifying areas of precocious accomplishment , real or perceived failures , perfectionism and procrastination can also be important data points in formulating the pathway for how unresolved and conflicted emotional reactions to the experience of being gifted might have been transformed into psychological symptoms and dysfunctional behavior
The clinician’s interest in all these areas demonstrates h/h belief that giftedness is a real phenomenon and not simply and quirky personality feature of an otherwise smart person. This type of assessment – the process of making connections between past and current unconscious emotional factors and their symptoms and behavior -also appeals to a gifted individual’s belief in the complex multi-layered nature of things. It often has it’s own calming effect by providing hope that techniques and strategies for symptom and behavior control can be improved. By doing so the assessment process itself becomes the foundation of a trusting therapeutic alliance.
Familiarity with the elements of a gifted endowment and features of a gifted personality are essential in avoiding misdiagnosis
Particular sensitivities and re-activities; an affinity for aesthetic features in all activities; a protean imagination; and the capacity for immediate intuitive insight and uncanny abilities are all important endowed characteristics of gifted individuals.
Passionate engagement, a powerful sense of purpose , charisma, grand visions , mood swings and a strong sense of fairness and justice as well as a strong affinity for existential issues, conflicts and dilemmas are important features of a gifted personality.
The symptom picture of a gifted individual in crisis is a mixed one
Anxiety, depression, insomnia , mood swings and unexplained physical pains can co-exist and differentiating one from another can be challenging. Gifted individuals often have idiosyncratic ways of describing what’s wrong and how and when it went wrong. Careful listening and observing the nuances how a gifted individual expresses these can help avoid the most common pitfall of misdiagnosis: mistaking a gifted individual in crisis for a gifted individual with a genuine psychiatric syndrome or personality disorder.
A gifted individual in crisis may exhibit symptoms that seem to fit certain psychiatric syndromes such as bipolar disorder or borderline or histrionic personality disorders. However, it does not mean these gifted individuals have actually developed one. Charisma, a conviction of purpose, low frustration, impatience and volatile mood swings may reflect the exaggerated personality traits of a gifted individual in the grip of a creative frenzy and impending outsized success or a gifted individual compensating for a disappointment.
The grand visions of a gifted individual whose mentors have encouraged h/h to “think big” and one who has had real ,exceptional –often precocious – success is not the same as an individual with a narcissistic personality disorder whose grandiose fantasies developed as compensation for deficits of early parental neglect, abandonment and trauma
Careful listening and observing is also necessary in order to translate very personal descriptions into standard psychiatric terminology that leads to accurate diagnosis and selection of specific medications.
The same careful listening also helps differentiate primary symptoms from secondary ones. This avoids another consequence of the second type of misdiagnosis : polypharmacy- treating various symptoms as separate entities and needlessly using different psychotropic medications when instead an accurate determination of the true nature of the primary symptom and their appropriate treatment will often help resolve the secondary symptoms.
For example: the effective treatment of depressive symptoms with the correct anti-depressant often reduces the accompanying anxiety and insomnia or hypersomnia. The same is true in reverse: successful treatment of primary anxiety can help alleviate secondary depression and insomnia.
Respectful attention to a gifted individual’s concerns about how psychotropic medication might affect the subtle aspects of their personalities helps them make a short term sacrifice for a long term gain: tolerating the downside effects of psychotropic medication on their sensitivities and exquisite reactions for the upside relief of bringing these qualities back into safe control.
The clinician’s sensitivity to these concerns is another step in enhancing the therapeutic alliance. This helps a gifted individual remain in place for the rest of the assessment process once early symptom relief is achieved: ending the assessment process abruptly may lead to long-term use of psychotropicmedication for symptom management because underlying causes have not been uncovered or addressed.
The assessment process after diagnosis and symptom control
Good symptom control provides the opportunity to complete the assessment and understand why improvements in circumstances and relationships were not enough to restore adequate cognitive and executive functioning. This usually means uncovering and addressing a gifted individual’s unresolved ambivalent emotional reactions to h/h giftedness (for example: worries about how to embrace appropriate positive self regard and distinguish it from destructive arrogance and narcissism), ambivalent reactions to how others responded and now respond to their giftedness as well as finding the proper form and venue for how giftedness should be used individually ,socially , ethically and morally.
As the assessment yields answers, the need for medication diminishes and it becomes clear how to formulate the deeper psychological and existential causes of the symptoms and dysfunctional behaviors as well how to address them.
The downside of refusing psychiatric consultation/assessment and the use of psychotropic medication
However, even in a crisis state of cognitive and executive dysfunction, some gifted individuals will flat out refuse a psychiatric consultation that could provide an accurate diagnosis or consider the use of medication that could stabilize symptoms and then allow for a comprehensive assessment that could enhance existing ones.
Instead, they can enter a mind- set of double – think. Driven by fears of misdiagnosis, mistreatment, and worries that the effects and side effects of psychotropic medication will wipe out the subtleties of their gifted personalities, they begin to experiment with various forms of self-medication. Despite the well known dangers of alcohol, marijuana, extra-caffeinated drinks, unregulated stimulants, dietary supplements and recreational drugs, they begin to counteract the effects of one group of substances with the actions of the other. They seem to be able to bypass their exceptional intelligence and instead use exceptionally poor judgement to continue this dangerous process even though they are quite aware of compelling evidence that these substances can disrupt brain function brain development and lead to serious forms of addiction. They will even ignore their own personal experience of how their razor sharp perceptions and the smooth operation of their cognitive, executive, and intuitive abilities have deteriorated.
As an outgrowth of this mind set, some gifted individuals will begin to “normalize” their symptoms and behavior by incorporating them into a new version of a gifted identity. In this process they will loose touch with the reality of how their existence has become a increasingly marginal one – one with limited productivity, limited relationships and limited possibilities. Slowly, the sparkle of what was once their real gifted personality traits, exceptional abilities and grand visions begin to fade away.