Ep. 126 The Missing Diagnosis of John F. Kennedy's Life: Linking ADHD and Chronic Pain. Part 3

Ready for a journey into the unseen layers of JFK's life? Prepare yourself to rediscover the 35th President of the United States, not just as a charismatic leader but as a man grappling with chronic pain likely brought on by ADHD. His vibrant public image often overshadowed this personal battle. We'll unravel the evidence suggesting ADHD as a significant aspect of JFK's health struggles, shedding light on his symptoms like inattention, lack of diligence, and poor planning abilities that potentially contributed to his painful physical condition and even his tragic end.

Stimulating discussion doesn't stop at JFK, as we also illuminate the story of his sister, Rosemary Kennedy, and her fight with autism and ADHD. We'll explore how ADHD is potentially linked to chronic pain, how revolutionary ADHD treatments can alleviate pain symptoms, supported by compelling studies showing patients responding positively to these treatments. We delve into how Rosemary's tragic experience with a frontal lobotomy could have been an ill-informed attempt to manage her symptoms, further accentuating the importance of appropriate treatments. Brace yourself for an engrossing discourse that blends biography, medical history, and scientific advancements, offering you fresh perspectives and insights.

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Transcript

Dr Michael Lenz: 0:48

I've been discussing a paper published as a case report in October by a group from the University of Tokyo Medical Center Pain Clinic. John Fitzgerald Kennedy, jfk, the 35th president of the United States, had chronic low back pain deemed to be centralized pain. Stomach pain is often nonspecific, implying no pathology or tissue damage, or the limited amount of pathology or tissue damage is not severe enough to explain the full extent of the pain experience. The nonspecific nature accounts for non-cancer pain as well as post-cancer pain. For clinical purposes, central pain is an amplification of neural signaling with the central nervous system that elicits pain hypersensitivity. Another definition provided by the International Association for the Study of Pain is an increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input. The central nervous system dysfunctions contribute to increased responsiveness to various sensory inputs such as tactile stimuli, and also can lead to hypersensitivity to non-musculoskeletal stimuli such as chemical substances, light, sound, heat, cold, stress and electricity. Attention deficit hyperactivity disorder, known as ADHD, has been found to play an essential role in many with centralized pain. We have been looking at the biographies of John F Kennedy and trying to understand the role ADHD played in his life, looking at some of the positive aspects, but also the distress it caused. Based on his biographies, jfk likely had ADHD, a plausible contributor to the pain that afflicted him. Remember that while I am a doctor, I am not your doctor. All of your signs and symptoms, as always, should be discussed with your own individual physician. And now on to the episode. As discussed earlier, jfk's chronic low back pain started in 1937 and developed during football. However, a specific cause for pain was never identified. It was aggravated with stress and did not respond to several analgesics, including coding. Despite undergoing four lumbar spine surgeries, including an L4, l5 laminectomy, lumbosacral and sacroiliac fusion, JFK's low back pain was exacerbated rather than improved At the time of JFK's assassination in Dallas in 1963, when the first bullet struck him in the back of the neck, his back brace held him erect, allowing the second and fatal bullet to hit the back of his head. However, according to the final report of the House Select Committee on Assassinations, other factors contributed to Kennedy's assassination. Despite being aware of the danger of assassination and warnings from people around him, jfk chose not to attach a protective bubble top to the convertible, making it easier for the sniper to take aim. This kind of impulsive tendency was often observed during his childhood and contributed to his promiscuous behavior even within the White House. Research has demonstrated a strong connection between centralized pain syndromes and ADHD. Adhd is a developmental disorder associated with central nervous system dysfunction. We are both positive aspects of ADHD, but also struggles that many go through. John Fitzgerald Kennedy was depicted as a lively man full of energy. He forced himself to act this way. In reality, he suffered from poor health. The details of his ailments remained a secret until 2001. At the request of the Kennedy family, when the medical archives of the Kennedy Library were open for public scrutiny, kennedy's biographer, robert Dahlick, chose Dr Jeffrey Kelman, a specialist in internal medicine and physiology, to accompany him, along with Dr Park, a neurosurgeon and the author of the Impact of Illness on World Leaders, to examine all records from 1955 through 1963, reading medical reports and several documents. With the help of these records and documents, he constructed JFK's clinical history and his biographies. I paid special attention to his complex medical history using the biopsychosocial, spiritual model of care. Going through Dahlick's biography, james McGregor Burns was a Democratic nominee in Massachusetts first congressional district who published a biography of JFK in 1959 to determine whether JFK had the qualifications of a president. Burns's biography of JFK was written while he was alive and became the presidential candidate, under the condition that Burns would have complete and unrestricted access to his official and personal files. With JFK's consent and assistance from his office and aides, burns interviewed JFK's wife, parents, family members, teachers, assistants, political supporters and many others. Burns had full access to his files of correspondence, legislative records, family records and such from the past, as the bibliographical notes explain in greater detail. Burns's biography is based largely on these data and has the most detailed records of JFK's developmental and behavioral characteristics. Therefore, it has been cited as a vital source of developmental and medical research. In the past, critical factors indicate JFK experienced problems with attention, including inattention related to work-related activities, difficulty in sustaining attention to tasks, being dreamy or preoccupied, not following through on instructions in the workplace, having difficulty keeping belongings in order and poor time management, avoiding duties requiring sustained mental effort, often losing things and frequent forgetfulness. I will go through the DSM criteria, looking at several examples of inattention that can be quoted from the biographies, as follows and as listed in the paper, if you want to look at it as well JFK's thesis had many typographical errors and the English diction was defective. His lack of diligence in his studies, or let us say, lack of fight in trying to do well in those subjects that didn't happen to interest him. He was the intellectual's type of absent-mindedness. He breaks off of a conversation with a staff aide, perhaps in the middle of his own sentence, to reflect for long moments on a different subject. He did not feel that he had to live by the ordinary rules governing everyone else. He was always arriving late for meals and classes, setting his own pace, taking the less traveled path. John's sloppiness was symbolic of his disorderliness. In almost all of his organization projects he keeps appointments late and was not much for planning ahead. John studies at the last minute. He showed early a trait that baffles his office staff today an almost photographic memory for correspondence conversations and, historical fact, an almost total absent-mindedness about where he has mislaid speeches, books and clothing. He has even overflowed the bathtub, as was his boyhood custom. He forgets the little things around him because he is preoccupied with what appears to him as bigger ones. Other descriptions indicate that he also often had characteristics of hyperactivity and impulsivity, including fidgeting with his hands, leaving his place or seeking fast-paced activity, running about or feeling restless, always on the go, acting as if driven by a motor in difficulty, in waiting patiently, specifically as he talked with visitors in his office, kennedy would fidget with a pencil. Kennedy sat tapping his front teeth with his thumb and running his hand through his hair. Avril Herrmann thought Kennedy was less tense than when I saw him last, but his hands are still constantly in motion. He liked madcap drives to get to an airplane or dinner on time. He hated to waste time In the morning. He would read a magazine while taking a bath, at the same time shaved there, guiding his raider by glancing occasionally at a mirror set up on the bathtub tray. He was always too much in a hurry, that he was going too far, too fast and that he should pace himself better and should learn to take a breather. But the dynamo would not slow down. He was always in the process of going or coming. The congressman hated to be late. A stop for a train, an unnecessary delay, a button-holing admirer would tense Kennedy's face and send him into short tirades back in the car. Considering the above descriptions of JFK, which indicate these were mannerisms that were going on before the age of 12, he met several diagnostic criteria for ADHD outlined in the DSM-5, including 8 out of 9 items for the inattentive section and 5 out of 9 items for the hyperactivity-impulsive section. This could be considered ADHD of the combined type of inattention and hyperactive impulsivity symptoms. This study was the first report to investigate the possibility of JFK's diagnosis of ADHD in line with valid diagnostic criteria. However, adhd did not prevent JFK from achieving success because he could surround himself with competent, detailed-oriented principally his brother Robert, who had the exact opposite of JFK's personality he was willing to delegate to both responsibility and authority. It's common to have someone being a CEO or another in management who can solve big picture problems but skillfully delegate responsibilities to colleagues to handle the more tedious aspects necessary but not incredibly stimulating or challenging. Thus, adult ADHD is less likely to manifest functional impairment when occupational and social demands are met by internal resources, such as intellectual ability and self-control, an external resources such as support from family members. Furthermore, to others, an adult with ADHD is more likely to appear to function normally despite their psychological distress, because they invest significant time, energy and effort or engage in excessive activity to compensate for their functional impairment. Thus, adult ADHD is underdiagnosed in the vast majority of cases, even in psychiatric practice. A recent meta-analysis focusing on individuals with ADHD over 50 years old identified a prevalence of 0.23% diagnosed with ADHD, but only 0.09% being treated for ADHD. All things considered, this is when the actual prevalence of a DHT is likely close to 5 to 10%, depending on the studies, but woefully under-recognized All things considered. This raises the question of whether the prevalence of ADHD is indeed very low beyond age 50, indicating a decline across adulthood, or whether we recognize ADHD in old age. It has been shown that 90% or more of children with ADHD meet the criteria in adulthood. Many experienced clinicians feel that it never goes away, but instead the symptoms are masked through job choice, supporting overall lack of recognition by those living with ADHD, their family and loved ones and their physicians. Furthermore, since orthopedic surgeons, physiatrists, internists and family practice doctors who treat patients with chronic pain, such as low back pain, are unfamiliar with ADHD diagnosis and management, most people with comorbid ADHD with pain are underdiagnosed. As JFK was also called the dynamo, his overactivity, action-pronus and ergo-mania, which have been described as typical behavioral traits of patients with chronic pain in the previous literature, have been suggested to be underdiagnosed ADHD. Therefore, the pain clinic at the University of Tokyo and many others feel screening for ADHD in patients with chronic pain is considered necessary. Adhd screening instruments such as the adult ADHD self-report and Wendor-Utah rating scales should be used widely in clinical practice and research Studies have shown that many can still be missed with these screeners and a more in-depth assessment with the DIVA-5 or Connors adult ADHD rating scales, along with a careful, comprehensive history, are needed. These tests are more sensitive, with the DIVA-5 being much more affordable than the adult Connors rating scales and equally sensitive and specific for ADHD. One of the reasons ADHD is missed in adults with chronic pain is that they generally tend to deny their psychosocial problems and may underestimate the severity of their ADHD symptoms. Therefore, the Connors adult rating scale, which consists of two scales, one for parents and one for family members, should be used to screen for ADHD in patients with chronic pain more appropriately. The DIVA 2.0 is a free option. The DIVA 2.0 is a free option and there is an updated DIVA 5.0 which charges a small fee for use. It stands for the diagnostic interview for ADHD and is a valuable tool on par with the adult Connors rating scale. The presentation of chronic pain, including low back pain, in John F Kennedy was centralized and could be attributed to central nervous system dysfunction. Central nervous system dysfunctions that cause centralized pain are assumed to be a common basis for disorders such as myofascial pain, failed back syndrome, fibromyalgia, irritable bowel syndrome and chronic prostatitis, many of which could be identified in Kennedy's medical history Following the CNS dysfunctions in centralized pain. The focus of attention with ADHD is the dopaminergic nervous system and the prefrontal cortex. Dopamine plays a central role in pain perception and descending pain suppression pathways, and reduced dopamine levels may increase pain. Thus, patients with ADHD are assumed to have dopaminergic dysfunction and are considered vulnerable to chronic pain. The prefrontal cortex is also functionally connected to the descending pain inhibitory pathways and can act as a virtual filter to reduce unpleasant stimuli such as pain and itching. Prefrontal cortex performance allows an inverted U-shaped curve in relation to dopamine and noradrenaline activation. It is maximized when concentrations of both neurotransmitters are moderate. Stimuli evoking moderate brain arousal lead to well-functioning performance, whereas either too little or too much stimuli attenuate cognitive performance. Strong salient stimuli may easily disrupt attention. In contrast, an environment within poverous stimuli causes low arousal, which is typically compensated for by hyperactivity. However, because the pathophysiology of ADHD includes impaired dopamine and noradrenaline neurotransmission, this filter does not function adequately, and one with ADHD is considered vulnerable to pain. Moreover, the fact that centralized pain syndromes can be improved with ADHD. Medications support the correlation between chronic pain and ADHD. In addition to pain disorders, conditions such as fibromyalgia, ibs, celiac disease, insomnia, malabsorption, hypothyroidism and allergies, which were present in JFK, are all physical disorders associated with ADHD. Given this information, adhd appears to be a plausible cause of the numerous illnesses that affected JFK. Although the concept of ADHD did not exist during his lifetime, jfk preferred the central stimulant dextromethamine-originetic form of Adderall for pain management, which, unintentionally, may have also served as self-medication for his ADHD condition. This is an example of something used for the wrong reason but ends up helping. I've had some patients use venteramine for weight loss and had some success in losing weight with it, but also, on further reflection, recall being able to focus much better and concentrate, or maybe having less pain or less frequent headaches or migraines. But because the doctors at the time were not aware that they may have had coexisting ADHD, they would not have even been clueing the patient or themselves to look for those benefits. Recent patient of mine who had chronic pain and fatigue and had seen numerous doctors previously, was given prescription in the past for methylphenidate without the recognition and diagnosis of ADHD. Because he wasn't given a reason for using methylphenidate, he never started it. He also was not diagnosed with fibromyalgia, despite having symptoms that should have alerted his prior doctor to make a careful assessment. I used the widespread pain index symptoms severity score and DIVA 2.0, along with a thorough clinical history that supported the diagnosis of fibromyalgia and ADHD, along with suspected autism spectrum, with other careful instruments and careful history taking. Interestingly, there was also a family history supportive in both his father and his brother of being on the spectrum and having chronic pain issues, which is not uncommon. A study showed symptoms in patients with chronic pain, including persistent chronic low back pain, improved with ADHD medicines. It was found that the pain and ADHD symptoms of patients with chronic pain and co-morbid ADHD tend to improve with ADHD treatment. The results showed that 35 of the 110 patients, or about 32%, with chronic pain at various sites who referred to the psychiatrist at a pain clinic were finally diagnosed with ADHD. Of these 35 patients, 21 received adjusted ADHD medicines with methylphenidate or atomoxetine. 20 of the 21 medicated patients experienced an improvement in their ADHD symptoms and 67%, or two thirds, experienced a simultaneous improvement in their pain symptoms. As evaluated using the numerical rating scale, the numerical rating scale of the 14 patients decreased by 65%. Moreover, considering that there were only seven patients with chronic, persistent low back pain. Among the 21 patients with chronic pain at various sites who received adjusted medication, seven out of the seven experienced a reduction in pain symptoms as measured using the pain rating scale, with an average of 65% reduction. A different study looking at 153 consecutive patients with chronic pain at the University of Tokyo Pain Clinic 37% were men and 63% were women, which are similar to the ratios of fibromyalgia. 73% tested positive for ADHD through the adult Connors ADHD rating scales, with all of them also fulfilling the criteria using the Structure Diagnostic Interview for ADHD in Adults 2.0, also known as the DEVA 2.0,. As mentioned previously, none of them had previously been diagnosed with ADHD. 58% of the patients with ADHD received treatment with mentholphenidate or adomoxetine, of which 73% showed improvement in ADHD symptoms and the average pain reduction was 62%. Fibromyalgia and chronic fatigue syndrome can reportedly improve by central nervous system stimulants, and administration of adomoxetine and central nervous system stimulants has been considered an appropriate treatment strategy to alleviate executive dysfunction in fibromyalgia patients with ADHD. There has been speculation about the potential mechanisms underlying these changes. Patients with ADHD who exhibit inattention symptoms are highly sensitive to the environment and have difficulty filtering out unpleasant stimuli and showing intolerance to mild tactile stimuli. They are prone to overeating in stressful environments and to developing chronic pain because their cognitive impairments make it difficult for them to filter out physical stimuli, including pain and tinnitus, for example, throughout their bodies. Central nervous system stimulants are considered to effectively enhance the filtering function by increasing the signal to noise ratio, allowing patients to properly discriminate various irritating stimuli and improving pain symptoms. Given that most patients with chronic pain are evaluated by physicians unfamiliar with ADHD, diagnosis and treatment are too often overlooked. This illustrates the importance of assessing patients with chronic pain for ADHD. Additionally, kennedy's son was reportedly diagnosed with ADHD and numerous tragedies have been attributed to thrill-seeking behaviors in the Kennedy family, which are consistent with our understanding of the inheritability of ADHD. It has been suggested JFK's central pain would have improved if he had been able to sufficiently resolve conflicts by facilitating emotional processing. The limitation of this study is that ADHD diagnosis of JFK is a hypothetical diagnosis based on the description in the published literature, as the authors obviously did not directly examine John F Kennedy. The president's panel on mental retardation, organized by Kennedy as one of his frontier policies, contributed to the creation of the termed developmental disability, which now includes ADHD in the United States public law. After 60 years, the seeds of his ideals have budded and born findings of a link between ADHD and centralized pain and are about to pave the way for the treatment of central pain, a condition that he suffered from during his lifetime. I hope that you have found this three-part series on John F Kennedy's life insightful. I know that when you hear stories of other people going through challenges, it makes you feel like you're not alone, but there is even more validation when you can understand that a highly successful person like John F Kennedy, who is masking so much struggle with all of these fibromyalgia and related issues from pain, fatigue, brain fog, untreated ADHD or only partially treated ADHD symptoms and now, 60 years later, we can learn from this. Some of the biggest take-home messages, of course, are being more aware of ADHD and trying to recognize this, especially if you're having these chronic fibromyalgia, central pain, processing syndrome. And if you do have those, make sure that you seek help by someone who is trained in diagnosing and treating you and make a huge difference in your quality of life on so many different aspects that go well beyond just fibromyalgia symptoms to just general functioning. There is so much more that could be included. As a clinical epidemiologist and pediatrician who treats patients with heart disease and diabetes, there are studies that have tens of thousands of people in them that have been demonstrating small percentage differences in outcomes on top of other successful therapies. However, we don't have these massive studies of tens of thousands of people and we probably never will. Part of that is because of the medications for treating ADHD are now generic for the most part, with a few small exceptions, and those newer medications are just different delivery systems of currently existing medications. But there is robust data strongly supporting the benefits of treating ADHD and what we are learning is that many people with fibromyalgia and centralized pain syndromes also have ADHD and at minimum their ADHD symptoms should have a strong benefit, but they also often have benefits from a lot of these overlapping fibromyalgia symptoms. I also will be doing a series on Rosemary Kennedy. As I talked about on episode one, she had a lot of struggles of what we now would call autism and ADHD and unfortunately went through a frontal lobotomy last ditch attempt while she was going through what's likely an autistic burnout crisis. If you have any comments, please email me at doctormichaellenz@ gmail. com. Until next week, go, team Fibro.