Sunday, November 6, 2011

Fun Facts About ADHD Medication

To start with, I'd like to explain why I keep alternating between the acronyms "ADD" and "ADHD".  This is because the DSM keeps changing them on us.  When I was diagnosed, it was ADD -- attention deficit disorder.  Shortly thereafter it was changed to ADHD -- attention deficit hyperactivity disorder.  There's some talk of changing it back to ADD in the next iteration of the DSM.  Since both acronyms are used, I'd like to make it easier for people to find my post, regardless of which acronym they're using.

A few weeks ago, Mo over at Millgrams Blog asked me to do a post on ADHD.  In his comment to the post, he raised several interesting issues.  So many issues, in fact, that responding to them requires a series of posts.  In this post I'm going to cover the general facts about ADD meds and how they work.  In following posts I'll talk about the legal issues surrounding ADHD meds.  The final post will deal with the social issues that come with medicating ADD.

Since this post is pretty long, I've put the topic sentences in bold.

ADHD meds generally fall into one of two categories: amphetamines and methylphenidates.  Both of these meds are psychostimulants, but they actually stimulate activity throughout the central and peripheral nervous system.  This means that they increase production of several neurochemicals, including dopamine.  Dopamine plays a critical role in allowing the brain to focus and follow through on tasks.  One theory regarding ADD is that it's basically a "dopamine shortage" -- medication increases dopamine, which increases focus.

Dopamine is also the brain's reward chemical.  When you're enjoying a pleasurable activity like sex or a good meal, your brain releases dopamine to "reward" you.  Dopamine feels good.  If sex and food bring about good feelings, you're more likely to survive and pass on your genes.  Humans being what they are, we also get a dopamine hit from things like finishing a task, achieving a goal, and even learning.

Since dopamine feels so good, humans have developed plenty of recreational drugs that stimulate its production.  Every drug, from caffeine to cannabis to cocaine, releases dopamine.  The same is true of psychostimulants.  Taking stimulants in high enough amounts produces a "high" in most people -- and this is why people abuse them.  They're also highly addictive, and tolerance can be built up quickly.  Addicts meed more and more of the drug in order to get that initial high.  Needless to say, this leads to addiction and all kinds of negative consequences.

So why doesn't ADHD medication quickly lead to addiction?

The first reason is dosage.  Though it's less dramatic than lamictal titration, ADD meds are also prescribed at small dosages at first, and then adjusted up until the ADDer feels that her symptoms are being controlled.  Generally, pdocs like to prescribe the smallest dosage that will alleviate the ADHD symptoms.  This helps to prevent the drug tolerance that can lead to addiction.  Many folks with ADHD take their meds for years without ever experiencing any tolerance whatsoever.  If tolerance does become a problem, the doctor may suggest a medication break, or switch to another med for awhile.

In most people, stimulants often produce feelings of anxiety and nervousness.  For most people with ADD, they produce a feeling of calm.  There may be a chemical reason for this, or it may simply be that our brains are suddenly not being bombarded by several things screaming for our attention.  We can focus on one thing (OK, maybe a few things) without being pulled away by another urgent matter, and then another, only to find by the end of the day that nothing has been accomplished.

But do people with ADHD *really* have different brains? Neuroimaging of the brains of ADD patients has shown that certain parts of our brains are actually smaller than in "normal" people.  This is notable in the frontal cortex area of the brain.  What does the frontal cortex do?  Glad you asked.  The frontal cortex is responsible for executive functions -- planning, working memory, attention, problem solving, verbal reasoning, inhibition, mental flexibility, multi-tasking, initiation and monitoring of actions (list copied from wikipedia.)

Medications for ADD are not a crutch!  After scanning the brains of people with ADD, and comparing them to controls, the reserachers mentioned above continued their experiment.  They followed the ADHD patients after they'd been treated with methyphenidate (Ritalin) -- and their brain volume had actually increased.  

This is real, folks.


  1. Thanks for writing this and making it a series. There's high drama in this topic for me now -- in two days I see my pdoc and bring up the subject. I don't know why I'm nervous. Why should I be. Weird, huh? Afraid he won't listen to me, I guess.

    I've been reading about ADD, and marveling at how each web pub said it must be present from childhood. I can't remember being especially ADD as a kid, but I seem to have caught it now, like a bad cold, out of nowhere. Is that even possible?

  2. Let me know how the conversation with your pdoc goes!

    You can't develop ADD as an adult; however, there may be underlying issues that can cause similar symptoms, or the symptoms may be due to your meds. SSRI's in particular are very sedating to me (not sure if that's part of your cocktail or not) and can have dramatic effects on my cognition and motivation.

    The good news, depending on how your shrink sees it, is that stimulants can be prescribed for things other than ADD. Narcolepsy, for instance, or to improve treatment for depression. If you're still having some depressive syptoms (like lack of motivation) he may be willing to give it a shot. Good luck!

  3. Wednesday was a weird day. My pdoc just happens to also be an addiction specialist. He goes through phases with it, though, sometimes grilling me on alcohol and pot use, and sometimes going many sessions without bringing up the subject. It's weird. He's very parent-like for me, which is annoying. But he's great with meds, except for this time. This time he wants me to go to a several-hours long neuropsychologist examination. I asked him what the hell that is, and he said they run all kinds of tests, you know them. I kinda fucking didn't know what he was talking about, but it was clear that he wouldn't move forward on this topic until I'd gone. So I get in touch with them right away, and they similarly get back right away telling me my insurance doesn't cover it. Then, the doctor (shrink?) told me she'd get in touch with a psychologist at my insurance company (!) and try to plead my case. She knows nothing about me, unless my regular pdoc contacted them and downloaded me to their brains.

    So, five weird things:
    my pdoc is putting me to a test
    Neuropsychologists are a new mystery
    Neuropsychologists are either really nice, or are strapped for business
    All this shit just makes me want ADHD meds all the more, because they're hard to get (?)
    And ... My insurance company has a psychologist. How much does that person know about me?

  4. Wow.

    I imagine the psychologist at your insurance company doesn't know that much about you. I'm pretty sure that insurance companies only get billing information, not the details about your sessions.

    Sometimes pdocs are willing to give an ADD diagnosis by asking the patient a bunch of questions. Other times they try to talk to parents to establish that the attention problems are persistent and long lasting, or they look at old report cards for the same reason -- comments like "fails to pay attention in class" can provide important clues.

    Psych batteries are not a common way of diagnosing ADHD, but they're not completely unknown. I did one of these tests myself, in part because I was also getting tested for a specific learning disability (in math). It cost $1000 (in 1995, in rural Iowa). My insurance company didn't pay for it either. My parents couldn't or wouldn't help me out. I went into debt to pay for it.

    Again, your comment brings up a bunch of stuff worthy of it's own post. I'll get to that later this week :)

  5. First of all, thanks for sharing all this information!

    Are you referring to increased or decreased size of ACTIVITY rather than the brain parts themselves.

    I have had a SPECT scan a year ago and have researched this stuff a lot. The picture from the scan refers to activity, so it can show that a part of your brain is small while it only has decreased activity.

    This decreased or increased activity is not necessarily genetic at all. For example depression is associated with decreased PFC activity. So a depressed person will possibly have all the symptoms of ADHD but this might be completely a product of depression.


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