The Unreal World: ‘In Treatment’

The Unreal World

The Premise

Dr. Paul Weston (Gabriel Byrne) is worried that his slowing movements mean he may have inherited his recently deceased father’s Parkinson’s disease. In this episode, Paul’s new 16-year-old gay patient, Jesse (Dane DeHaan), has been contacted by his birth mother and wonders if she may hold some genetic clues to his erratic behavior. He pushes people away, is prone to impulsive behavior (he wonders if this is a symptom of Tourette syndrome), has frequent bouts of unprovoked rage and is sexually promiscuous. He is being treated with Adderall for his attention deficit hyperactivity disorder. Paul encourages him to speak with his birth mother while at the same time working to improve his relationship with his adoptive mother, Marissa, whom he resents.

The medical questions

Can Parkinson’s disease be inherited? Are people who are adopted more prone to anxiety, depression or behavior problems? Do these problems worsen when the individual is confronted by birth parents, and should a therapist encourage such a reunion? Does ADHD have a genetic component? Can Adderall worsen anxiety? What is Tourette syndrome, and can it be inherited?

The reality


Parkinson’s disease is generally not thought to be inherited, but there may be exceptions, says psychiatrist Jess Shatkin, director of education and training at the New York University Child Study Center. Studies have shown a slightly greater risk of developing the disorder if a first-degree family member (parent or sibling) had it.

Most adopted children do well, Shatkin says, but some studies have found that they “have an increased risk of psychological maladjustment and behavior problems.” Shatkin points to a recent study of more than 1,000 children: It found that being adopted doubles the odds of having “a disruptive behavior disorder.”

“Every adopted person I have counseled harbors significant and often-unspoken feelings — often including or sparking anxiety and depression — about the circumstances of his or her birth and adoption,” says Boston psychiatrist Keith Ablow, author of a 2007 book about honesty, “Living the Truth.” The sudden appearance of one’s birth mother would be likely to trigger significant anxiety, Ablow adds, “a testament to how incredibly powerful our biologic bonds to our birth parents are — even if we have never met them.”

Most therapists would not advise for or against a reunion with the birth parents “unless the risks or benefits of such a reunion are resoundingly clear,” Shatkin says. Most therapeutic efforts are spent trying to help the child and adoptive family reconcile their differences, he states, rather than “encouraging a problem-solving fantasy of the ‘what if?’ family.” Ablow agrees and adds that the role of a therapist in this situation is to help a patient uncover his or her own reasons for having, or avoiding, a meeting with birth parents.

ADHD is highly inheritable, Shatkin says. The likelihood that a biologic parent is affected when a child has the condition is three to five times greater than the risk for this condition in the general population.

Adderall — in fact, all stimulants — can worsen anxiety, Shatkin says. Typically, the anxiety will diminish when the medication is stopped or the dose adjusted.

Finally, though Jesse’s symptoms of impulsivity and obsessive-compulsive behavior (such as his sexual acting-out and excessive worrying about his relationships) are commonly found in Tourette syndrome, he lacks the jerking movements and vocal tics (including snorting, barking or blurting words) that are often seen with the disease. Studies have shown that first-degree relatives are at increased risk, but Jesse is probably off base in thinking that either he or his birth mother may have the condition.

Siegel is an associate professor of medicine and medical director of Doctor Radio at NYU Langone Medical Center.

“In Treatment”

9:30 p.m. Nov. 2, HBO

Episode: “Jesse, Week Two”