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Adult ADHD from the board-certified PMHNP behind the YouTube channel Focus Path and the book The Process. Clinical perspective on medication, frameworks, and the conversations the internet hasn't been having.
Welcome back to Actually ADHD.
I am your host, Jonathan Murphy,
psychiatric nurse practitioner.
This podcast is brought to you by
the Focus Path YouTube channel.
To visit.
You can head over to @FocusPathSystems
There's now 102 videos there, whether you
want information about ADHD medication
behavioral modification or
Survival modality series,
among other things.
As I approach one solid year , , of
YouTube I have some reflections
And teaching the things that I
do in my office, ADHD medication,
et cetera, and looking at the
internet prior to making content.
I never understood or knew the,
quote-unquote, "ADHD internet."
I just knew a lot of my patients were
turning to it, and I always thought
in the back of my head, "Oh, man."
10 months ago I planted a flag
and said, "This is why I'm here."
What I'll talk about today is guanfacine,
but I'll, I'll make a larger rant about
what I've seen and how I've reacted
to stuff just through my own eyes,
'cause it's a unique perspective.
But the guanfacine is, it's useful
for children with ADHD, and there's
also lots of uses for adults,
and it's safe, and it's low risk.
And for a prescriber,
you're like, "Guanfacine?
Yeah."
However, There are issues with it.
There are side effects But guanfacine
finds its place within the pantheon of
medications or a prescriber toolkit.
However, it's never ever
gonna be the main medication.
nonetheless, the, the people
that come out of the woodwork.
But I was built for this, so here I am.
And that was leading into the second
piece, which is parasocial relationships
and all that, which has been fascinating.
So I have been talking about
media because that's so important
for people to understand.
Media literacy is the most, , is the
probably the biggest problem right now
It's more of a perception
problem rather than anything.
So, the internet and its tribal
nature there's groups on the internet,
people that share the same views.
"Oh, everyone on the internet says this."
No, people that share that view or are
part of that community share that, but
everyone else is just the silent majority.
So the mental health internet is really
troubling, and the misinformation
comes from a lack of media literacy.
When you have a community online like
Reddit, this platform, you're allowing
anybody to start a group if you're good
at that, if you are able to be like
this type of person that's like, "Hi,
everyone, I'm gonna start this community."
I mean it, it's a
tremendous amount of work.
However, you can develop this mob, and
these mobs are run by these petty tyrants.
I had this mindset.
I was thinking, "Oh, wow, it's like the
Wild West out here with the YouTube."
It's like the city with all the
infrastructure, like the medical system,
but then on the internet, it's like
the Wild West, and YouTube's out here
as like the saloon, and these like
medicine shows and grifters are out
here, and I'm just trying to make a
humble practice, just put my shingle up.
But meanwhile, there's this, these
medicine shows out front blocking the
way, blocking the door, and the mayor is,
you know, giving them all the attention.
But every day, the practitioner shows up.
Man, some people come in And
it's like this is the boom town.
, But what am I gonna do?
, I created this book, and then I look
out in the wilderness, and there it is.
I see the fires in the distance, and those
are those, those tribes, that's Reddit.
And I realized it's just like I
have to go out in the wilderness.
So I went out, and in my
mind I'm approaching this
large tribe, and it's huge.
Imagine like Burning Man at night.
So I'm going up and there's like
chiefs and I'm like on the side, and
you have to follow all these rules.
So I was following them to a T.
Listen to this.
People ask for medication
advice on a platform of peers,
and this is highly trafficked.
And I was just dipping in there and
responding and dropping knowledge.
And right away I was accumulating
like eyeballs and karma.
Sit down and answer a few comments
and the habit formation stuff
was actually doing the best.
People talk about this day in and
day out, and whoever these people
are, and if you're one of them,
this, I'm not hating on you, but
it's, this is about the masses.
The biggest thing is for people that
are interested in ADHD and like talking
about this online, like enjoy it
and do it for fun or whatever, It's
good to understand my point of view.
You're gonna, have a much better
comprehensive understanding when
you understand someone that's been
prescribing the medication to adults for
so long and what you see the outcomes.
The biggest issue is stimulant medication
and the access to it and the narrative
around it practice and the history,
all this stuff is the biggest issue.
Where we are in the old - world
of psychiatry and the new
world of the internet right now
The biggest issue is access to
stimulants, and no one really
knows about the stimulants.
People don't understand them.
So I wrote my book, and hopefully
people get that out there.
But I'm passionate about it, and I'm an
advocate because ADHD exists for a reason.
I've talked about it on my channel, the
narrative surrounding it, the shame.
I know that I see it every day
in my practice, things I see in
my office is clear guanfacine.
So going back to guanfacine.
Yep, ADHD storytelling, we're going
right back to guanfacine Because this
medication was first promoted through
the Reddit ADHD by someone named Dr.
Dodson from Attitude Magazine.
So Dr.
Dodson, he wrote an article, and
the article got spread in Reddit.
At this time, How to ADHD's
channel started right when I
was starting my practice and
That was a frustration.
I was like, I knew I wasn't ready.
Wasn't ready yet.
I think what happened is she
paired up with Attitude Magazine,
and she did a video about
rejection sensitivity dysphoria.
Now, that's Dr.
Dodson's article of rejection sensitivity
dysphoria, and hopefully we've learned
from this collectively because Reddit got
ahold of it, and the internet got ahold
of it, if I was talking about it like, "I
believe there's this condition calledâ¦"
Doesn't replace the diagnostic
system that we have.
We have a diagnostic system.
You don't just get to be like,
"Oh, you know, there's this
thing that's not in there."
So silly.
Nonetheless, the internet loved it
because rejection sensitivity just
basically means you have strong emotions.
So since everyone has strong emotions,
they're gonna attach to this because the
defensiveness that happens when you're
talking about your emotions, it's hard to
talk about, so it's easier to talk about
something that's associated with ADHD.
It gives a name for it, and I think
that's the good thing, but we have
to reframe what it actually means.
But Dr.
Dodson recommended guanfacine for it.
There it is.
And it's all about having ADHD because
on Reddit, there's just a tribe of
people talking, and you can't see their
faces, and it's just this whole thing.
It's a tribal community.
So I've talked about this
on the YouTube channel.
Gustave Le Bon, "Group Psychology."
All groups, they have three components:
sentiment, ideas, and custom.
The sentiment is it's not
fair that nobody noticed.
The idea is the world
needs to accommodate them.
And the custom is people don't change,
and they're still on the internet.
So
In order to have a tribal identity to
exist in the tribe, there's no individual.
You need to have the markings,
and guanfacine provides a very
interesting way to validate ADHD.
If none of the medications work, but then
guanfacine, maybe there's a relief in your
anxiety if it's a differential diagnosis.
I incorrectly believe
that's a treatment for ADHD.
What's the problem with that?
Uh, the problem is it becomes an ADHD
medication, not because it's approved
for adults, not because it's helpful, not
'cause it works, but because the internet
grabs a hold of it, and on the internet,
it's not an individual psychiatric
diagnosis, it's a tribal identity.
So the guanfacine is the
access to the tribal identity.
Now let's flip it and say,
what does the prescriber think?
Well, most prescribers don't
wanna prescribe stimulants.
You know, they're nervous about it.
There's bias about it.
They don't have the
experience or the training.
So guanfacine, the new fancy medication
, it's a non-control that You know,
helps with peripheral anxiety and since
it's an antihypertensive, basically
helps your body feel a bit calmer.
It might alleviate some nervous
system dysregulation, but
it doesn't increase focus.
It doesn't act in the dopamine center.
All ADHD medications are dopaminergic
in some way, and the stimulants are
gonna be the ones that work ninety-five
percent of the time, the non-stimulants
maybe five percent of the time.
And guanfacine can work, but you
really wanna think about the ways
in which it's working and how it's
working because people get an ADHD
diagnosis, and what are they prescribed?
Guanfacine.
"Hey, uh, how are you?
Nice to meet you.
You-- Okay, so what
medication are you on?"
" Guanfacine."
"Y- excuse me?"
Like, "Yeah, I went to the
doctor, I got the diagnosis."
I heard things like testing, multiple,
uh, appointments, and then you get
guanfacine, and it doesn't work
because it's not an ADHD medication.
You do this to get a stimulant,
so it's a dirty trick, I tell you.
And the Japanese government has
put out a study that people latch
onto, but the Japanese government
is more restrictive than the United
States on controlled substances.
So we have to understand
there's a societal risk.
You can't have stimulants
for out there on the shelves.
That already happened.
So how do we control the supply?
It's already happening, but if you're
the individual with ADHD, then you need
to understand what you're navigating.
You need to access the actual medication.
And guanfacine is not approved for
adults, and it's not helpful for ADHD.
It's a stimulant ninety-five percent
of the time and a non-stimulant
five percent of the time.
These aren't small numbers.
It's a huge difference,
a massive difference.
And I always laugh about guanfacine,
and people get frustrated.
But as I voiced it, I
made a video about this.
I thought it was not gonna be a big deal,
and wow, the comment section was lit up.
People are like, "No, that's my medicine,"
and it's because it's a tribal identity.
And so if guanfacine is a medicine
that works for you, it works for you.
Just understand that guanfacine being a
medication it's not first line for ADHD.
It's not a replacement for a stimulant.
If stimulants don't work and the
non-stimulants don't work and y- and
you use the ADHD medication optimization
process, you don't then land on guanfacine
and go, "Oh, great, ADHD is fixed."
You figure out the underlying pathology.
It's more than a pill.
Pill is just part of the equation.
Pill is helping you move
through a psychiatric diagnosis
So guanfacine, what's the big deal?
It's a big deal because anti-ADHD
bias, the providers don't believe
in ADHD, they have the pressure of
having to prescribe the medication.
This-- the funny thing is, though, when
you prescribe it, it works so well.
It's all about understanding the pattern.
And then I think about the people
that have guanfacine, and I get
comments, and they say, " But
I have ADHD, and guanfacine was
the only thing that helped."
And it's like, "That's really
great that you feel better.
Um, but what is your issue?"
ADHD is a chronic issue.
It's throughout the entire lifespan,
and there's a fluctuation in symptoms
from inattentive to hyperactivity,
but it's chronic And that's
what ADHD actually looks like.
And I hope you enjoyed
another little rant today.
My name is Jonathan Murphy,
psychiatric nurse practitioner.
Talk to you later.