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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.
This is Actually ADHD, sponsored
by the Focus Path YouTube channel.
I am your host, Jonathan Murphy,
psychiatric nurse practitioner.
Today, I'm going to be covering more
content from my latest book, The Process:
An Adult's Guide to ADHD Medication.
At this point in time, I'm going to
answer a question that I get all the time.
How does someone know they're on the
right or correct dose of ADHD medication?
The first part comes with understanding
that there is no right dose for everybody.
There is no best medication for everybody.
The diagnosis points to the right group
of medications, but the right dose and the
right medication will be individualized.
Most adults with ADHD are going to
find that their symptoms are optimally
treated with a one-a-day extended-release
capsule of either a methylphenidate
or amphetamine formulation.
I'm gonna cover
the optimization of these medications
first, and then on another episode, I'm
gonna do the non-stimulant medications
Do you remember the story Goldilocks?
It's just like that with ADHD medication.
Not too little, not too much, just right.
The right dose of medication
for your ADHD brain.
Too low, you're just tired.
Too high, you're tweaking out, you're
geeking out, you're freaking out.
But Just right, that's gonna be
calm, able to actually function
There's also the duration.
It should last throughout the day.
If it's not lasting long enough, then
you'll get a crash, tiredness, fatigue.
Overall, the myth that ADHD medication
just comes with the territory of
side effects and poor toleration.
Many people live with side
effects and poor toleration
even though they don't have to.
It's a testament to the fact that
medication is hard to access even
though it is a controlled substance.
Many people, when they finally get a
good effect from the medication, they
don't want to rock the boat, and they
just manage and deal with what they have.
And my hope is with this podcast,
I'm gonna encourage adults to
advocate for themselves and be a
participant in their own treatment.
Understand what first line is, what
best practices are, because the
provider's goal should be the same goal
as the patient, to improve functional
impairment and target symptoms of ADHD.
On the amphetamine-based side,
Vyvanse and Adderall XR, feeling
overstimulated, like agitated, tweaking
out, freaking out, staying up two
night, the jitters, that's a sign that
you're probably going to do better
on a methylphenidate-based medication
like Ritalin long-acting, Concerta, or
Focalin, which is dexmethylphenidate On
the dexmethylphenidate, methylphenidate
side, poor toleration looks more like
zombification, as I call it, a muted
affect, simply don't feel like yourself
the toleration should be consistent.
It's rare for people to suddenly
discontinue methylphenidate.
Someone can still feel overstimulated
with methylphenidate, but if that's
the case, they're probably gonna
do better on a non-stimulant.
And of course, we're gonna go with
an extended-release medication
because the technology is what
allows optimization to occur.
The slowing of the absorption allows
for the nervous system to take in the
medication, and the firing on the dopamine
receptors are tonic as opposed to phasic.
Phasic are fast.
We're looking for tonic, consistent.
So there's no downregulation, so you
take it like a vitamin, works all day.
Then the next day you wake up
and take it again, and it works
again and again and again.
There should be no diminished response.
There's a myth of toleration.
There can be a perception that the
medication decreases in effectiveness,
and that's normal beyond the first month.
Let's say there's an initial response.
Your just right is Adderall
XR twenty milligrams.
And then after a month, maybe week
three, week four, minor decrease
in effectiveness and maybe shorter
duration in the presence of a crash.
That would be a sign to go up to
twenty-five milligrams or thirty.
It's a common increase from the
initial responsive dose, and that
would be the maintenance dose.
Whenever you follow up after a
month and the effects are sustained,
toleration is good, and response is
good after a month, it's a very good
sign that those benefits will continue
month to month to year to year.
And that's why I speak so confidently
about this because it's so
predictable when you have the method
and the process that I describe
in my book, An Adult's Guide to
ADHD, and now available on Amazon.
In the book and in other episodes, I've
broken down what it looks like in the
big picture, the optimization blueprint,
how to work through the medications
and collect data along the way.
The data is telling you about what
the nature of the pathology is.
Ultimately, ADHD is not confirmed
or nor is any psychiatric diagnosis
confirmed until symptoms are resolved.
When you're reaching for a certain
group of medications, they should
work if your diagnosis is accurate.
This is especially true for ADHD since
the ADHD diagnostic criteria came after
the medication -- many people complain
the diagnostic criteria isn't good enough.
I disagree.
I think it's great because it does a
great job of capturing the individuals
that are gonna respond therapeutically to
ADHD medication, which is not most people
The results are predictable, and
finding the medication through
the process I describe is simple.
So the goal isn't to nail
it right out of the gate.
If someone has to try one or
two medications, that's normal.
And it's also normal for someone
to trial several medications
and then not notice a response.
If that happens, I would say you
wanna look at the diagnostic criteria
and make sure you're actually
reaching for the tool for the job.
If the medication isn't working, then
it's important to consider that fact
openly and honestly since it is so
predictive of a positive response.
The reason I'm gonna say it's common
is because I don't think most people
have the experience I do treating ADHD.
And I know in the beginning it takes a
few times of prescribing the medication
and seeing what happens when someone
without ADHD gets put on the medication.
It's the normal part of prescribing.
That's why prescribing is
set up in the way it is.
There's a process, there's
regulations, there's informed
consent, there's an initial starting
dose, there's an FDA maximum dose.
And Someone getting prescribed
a medication and having
it not work is normal.
Unfortunately, the Controlled Substance
Act has created a system where
patients and providers are scared to
do something when in fact, having a
license means you've been vetted to
identify and prescribe these medications.
And if you're a patient that's been
prescribed these medications, that means
you've been legally granted access.
However, unfortunately, providers
get mixed up in their own personal
bias and sense of justice, and
then when they go to prescribe the
medications, they feel like they're
cop instead of a provider.
And then the patient goes to the
pharmacy to pick up the medication,
they feel shame, and they can't
ask a simple question like, "How do
I know if I'm on the right dose?"
The dose you'll know is right
when you look at the symptoms.
You gotta go to the ADHD symptom
criteria and identify the
symptoms that affect you daily.
Most of the time it's difficulty
sustaining attention or
starting tasks, but not always.
There is a certain percentage of busy
bodies that start tasks all the time,
they just fail to complete them and are
constantly distracted It is important
to individually understand the symptoms
of ADHD because the resolution of
these symptoms is not all primary.
Secondarily, due to consistent
application of the ADHD medication
essentially creates the conditions
where problem-solving can occur.
So something like forgetfulness or
difficulty prioritizing and organizing,
that's gonna occur secondarily to the
consistent medication administration.
The brain is online more consistently.
Someone doesn't do something
when they thought they should
or were going to, planned on it.
Instead of just going, "Oh, look, a
butterfly," they're gonna say, "Hey,
what can I do differently next time?"
Or they're gonna notice.
And that's why it's so important to
stick with the medication for one month.
You don't wanna keep
shooting a moving target.
And before I do get into those
non-stimulant medications next
episode, I should probably talk
about the side effects in more
detail because stimulants are so
predictive, and they are so effective,
extendibly stimulant medication,
that I have a lot of The frameworks,
including side effects, titration,
optimization, are related to that.
So the exceptions to the rule
are worth talking about, but they
are the exceptions to the rule.
I suppose I can take a moment to talk
about another interesting phenomenon.
Being online, I see a
different side of ADHD.
It's filtered through the internet.
On the internet, we consist
of anonymous, faceless users.
We go from individual to a tribe.
You can see this on
Reddit, tribal group think.
Being able to be a part of a tribe
is important for anybody, and when
ADHD becomes an identity suddenly
this individual psychiatric diagnosis
that's supposed to resolve individual
functioning becomes a identity label.
When it becomes an identity label, the
medication just becomes a part of it,
and that's where guanfacine comes in.
There's a medication, guanfacine, an
alpha-2 agonist, and I'll talk about it in
more detail in the non-stimulant episode.
But if that's the only medication that
you are taking, the only medication
that's ever worked for ADHD, and
you've tried the other medications
for ADHD, including methylphenidate
and amphetamine-based extended-release
stimulants, you've tried the other
medications, nothing works except for
guanfacine, then rethink your diagnosis.
Because online, ADHD as a
diagnosis is a identity.
It's a tribal identity.
No one is going to conduct a differential
diagnosis when you enter r/ADHD.
They're just gonna say, "Come on
in and don't break the rules."
But guanfacine does do something,
it reduces peripheral anxiety.
So ultimately, it's rare that diagnosis
is going to rule out ADHD completely,
but there are many comorbid diagnoses
that you need to treat first before
adequate ADHD treatment can really
start That's probably it for today.
Just wanted to make sure that I'm
getting the basics out of the way
so I can get into some new and
interesting topics that I haven't
covered in my book that's it.
Until next time, this is Actually ADHD.
Jonathan Murphy, psychiatric
nurse practitioner.
We'll see you later