ADHD (A Comprehensive Guide)

In this episode we discuss ADHD in depth, including the common signs and symptoms, how ADHD is diagnosed, the common risk factors and how ADHD symptoms can be managed both with and without medication. We also discuss whether or not ADHD is over diagnosed, whether ADHD being induced by our lifestyles, and common signs of impairment due to ADHD. 

Useful links:
https://www.additudemag.com/
https://adhduk.co.uk/
https://aadduk.org/

Dr. Alex Curmi is a consultant general adult psychiatrist with a sub-speciality in addictions who completed his training in the South London and Maudsley NHS foundation trust. He is also a UKCP registered training psychotherapist, and has a special interest in mindfulness meditation. 

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Transcript

Welcome back to the podcast. My name is Alex. I'm a consultant psychiatrist. Today we're going to be talking all about ADHD, attention deficit hyperactivity disorder, a condition that's talked about so much on the internet nowadays. It sparks so much controversy. It really awakens a lot of the discussions that have been had about psychiatry and mental health for a long time. The value of a diagnosis, the limitations of a diagnosis, the value of medications, what's happening in our environment that could be increasing the risk of certain mental health conditions. So a lot of online conversation about ADHD. I'm intending this podcast today to be a primer about ADHD, meaning if you're new to it, if you don't know anything about ADHD, whether you're a patient, potentially a relative of someone who's getting assessed for ADHD, or someone who has a diagnosis of ADHD, a mental health professional who's about to start working with clients with ADHD. I'm intending that this podcast can give you a decent understanding of the condition, some of the risk factors and causative factors. Something about what's going on in the brain of individuals with ADHD. The recommended treatments including medication and non medication based treatment for ADHD, all of that stuff. I'll also cover some interesting miscellaneous points about the condition, like the differences between childhood and adulthood, diagnoses and prevalence. Can new environmental stimuli, like different forms of technology, induce ADHD? Concerns about overdiagnosis and over medication, and the relationship between ADHD and trauma, which is certainly a very complex one. Fortunately, I've had the benefit of getting much more experience of assessing and treating adults for ADHD. In the past year, I've done more than 100 assessments for adults with ADHD and have seen people along the treatment pathways as well. And that has allowed me to gain some knowledge, which hopefully I can share with you all to give you a better understanding of this condition and and good ways of thinking about it and how it can be managed. So there's a lot of information to get into. Firstly, a bit of an introduction. What is ADHD? The first thing that's really worth pointing out is that as far as the diagnosis goes, ADHD is an outcome. It doesn't necessarily imply a specific cause in any one individual has been diagnosed with ADHD. It's a set of problems, and it has to be that way. Because ADHD is not diagnosed based on things like blood tests, genetic tests, brain scans. The investigations don't look for causes. We diagnose ADHD by doing a clinical interview with the patient and by getting information from friends and relatives and partners, so it's based entirely on symptoms, problems, history. Therefore, ADHD, like many mental health conditions like bipolar depression, anxiety is an outcome. It's a set of problems. In this case, it's a set of problems with attention, hyperactivity and impulsivity. And we'll go into some depth a bit later and what that actually means and all the individual possible symptoms. But important to mention that ADHD is an outcome. It doesn't imply a cause. We know something about what is likely to be causing ADHD insofar as different risk factors. But in any one individual scene in an ADHD clinic, we can't pinpoint one specific cause. The science hasn't gotten there yet. It may get to that point one day, but it's not there yet. This is important to point out because it means a couple of things. One, it means there's an element of subjectivity to the diagnosis that needs to be acknowledged. What it means. There's an element of subjectivity to the diagnosis that needs to be acknowledged, and it also means someone can meet the criteria for a diagnosis of ADHD at one point in their lives and not at another point in their lives. And this happens a lot as people get older. So, for example, not all children diagnosed with ADHD will continue to meet the criteria as adults. Something like 50 to 70% of children diagnosed with ADHD will not continue to meet the criteria as adults. So that's important to point out. And that makes sense because as people get older and their brain develops often, the symptoms improve and they're much better able to handle those difficulties. So as I mentioned before, ADHD involves difficulties with three kinds of symptoms one attention to hyperactivity and three impulsivity. Essentially, there are three subtypes of ADHD There are those that present with a combined presentation that means symptoms of inattention, hyperactivity, and impulsivity. This comprises something like 80% of diagnoses and the vast majority of diagnoses. Then there's the primarily inattentive side of ADHD people who just present with the inattentive symptoms, which I'll discuss in more detail later. That's about 15% of diagnoses. And then there's patients who just present with a purely hyperactive, impulsive set of symptoms. And that's about 5% of diagnoses. It's really rare. Personally, I've never seen the purely hyperactive kind. So how common is ADHD in children? It's thought to be as common as 5 to 7% of children. I've heard statistics that it can be as prevalent as up to 10% of children in the United States specifically, and in adults, it's thought to be something between 2 to 5%. So it's pretty common if you compare it to other mental health conditions like schizophrenia, which is thought to affect something like 1% of people, bipolar disorder, which is thought to affect something like 1 to 2% of people, similarly, obsessive compulsive disorder, OCD, around 2% of people, and anxiety and depression, which is a bit higher, something like 4 to 5% of people. ADHD is definitely pretty common, pretty prevalent. There's a lot of discussion now about don't we all have ADHD because we're using a lot of high stimulation technology that's making us more distracted and less able to concentrate, and therefore rather than it being a mental health condition per se, are we just pathologizing this very normal response to technology? And if we just regulated our use of our technology and had healthier lifestyles, wouldn't this problem go away? And I would say, certainly that's not the case. We've been studying ADHD for a long time. There are a lot of interesting historical examples of individuals who likely had ADHD. And more recently, it's been well studied for between 30 and 50 years, something like that. But I would like to make the interesting distinction between ADHD and ADHD. Like, just like something can make you more paranoid without giving you something like paranoid schizophrenia, there are things that can make you a little bit more ADHD like without giving you ADHD per se. So for example, if you had 3 or 4 cups of coffee and you use TikTok all morning, that would probably make you a little bit more ADHD like, it would make your attention a bit more scattered and less able to focus. And maybe you'd be a bit restless and a bit hyperactive, so you'd be a bit more ADHD like, but it wouldn't give you ADHD, and that if you stopped drinking coffee and took away your phone, probably things would go back to normal. Whereas ADHD can certainly exist independently of things like caffeine and too much use of technology. So just because there are environmental stimuli that can give you symptoms resembling ADHD, it doesn't mean ADHD as a mental health condition doesn't exist as a valid entity onto its own. So I think that's an important distinction to make. Let's talk a little bit about the symptoms of ADHD. And I'd like to be really transparent about exactly how we diagnose it. So what are the criteria that us clinicians use to distinguish between ADHD and non ADHD. So to get a diagnosis of ADHD someone needs to meet the following criteria. And those criteria are. Firstly, a person needs to have at least five persistent problems with either attention or hyperactivity impulsivity. So in terms of inattention those symptoms tend to look like problems voluntarily using their attention to do things like watching a whole TV show or a film, or reading problems, using their attention to listen to someone one on one problems, finishing tasks problems, getting started with tasks, problems giving attention to fine detail, resulting in careless mistakes. Problems organizing time like being late, or problems estimating how long something is going to take, problems organizing objects and keeping their things neat, tidy, organized, frequently losing or misplacing things which are important. Forgetfulness, particularly problems with short term memory or working memory. Frequently, people with ADHD need to write things down, otherwise they'll definitely forget them. A general tendency towards distraction problems filtering out sensory information. So it's really common for people with ADHD to say if they're in a crowded environment, it's really hard for them to lock onto the conversation that they're having, and instead they tend to be really distracted by all the conversations happening around them and things along those lines. So it's going to extend the problems with organized thoughts, planning, thinking about the long term, even though it's called attention deficit disorder, many experts in ADHD feel that's a bit of a misconception, that it's not a deficit of a person's ability to pay attention. Exactly. It's more that a person doesn't really have voluntary control over their attention. Their attention is being drawn to different stimuli all of the time. A kid in school, for example, could be trying to pay attention in class, but they feel they're easily distracted by something outside the window, or another child talking or something along those lines. People with ADHD describe. They just don't feel like their attention is a tool that they can use. Often they feel that they can't concentrate on something at all, or they get totally sucked into something that they're really interested in, and that could be something like a hobby or very commonly something like a video game. And when they're so-called hyper focused on something, they can totally lose track of time. They can forget important things like eating or drinking. They can actually not hear. And being stimuli, for example, they can not hear people talking to them, and they can even forget important things like going to the bathroom. So funnily enough, hyper focus isn't one of the diagnostic criteria, but it is something that people with ADHD reports really commonly So that's an overview of the attention to the symptoms. So so a person would need to have at least five or more of those persistently, and or five or more persistent problems with hyperactivity or impulsivity. So in terms of impulsivity, that can look like something simple. As a child darting across the road without looking, or as an adult, it can look like spending too much money using drugs or alcohol, missing school, making important choices on the spur of the moment like booking holidays at the last minute, making big decisions on the spur of the moment like buying property things along those lines. It can also result in problems with gambling or a vulnerability to gambling addiction, impulsive choices around dating and relationships. People can start or end relationships impulsivity, but also a whole bunch of hyperactive symptoms. And sometimes it's the hyperactive symptoms which are the most obvious. And that can be things like general restlessness constant fidgeting, problems, sleeping, feeling that the body's never really calm or at peace. Often patients with ADHD reported their mind is really hyperactive, that they have a very loud inner monologue, or that they can hear music in their mind. Constantly. Having a hyperactive mind or body can mean that they have trouble sleeping. Often, people with ADHD will report they've had trouble sleeping their whole lives, that their sleep is interrupted easily, and if they get up, if they're woken up for some reason, then they can't go back to sleep. So that's something I hear really commonly in the diagnostic interview. Will also ask if they have a sense of being always on the go. A sense that they're driven by a motor, that they always need to be doing something, that it's difficult for them to have relaxing or quiet moments, that they feel a more consistent state of tension in their body, which isn't even relieved by things like exercise. Also, hyperactive symptoms can come up a lot socially, so people with ADHD often talk excessively. Often they talk more than they would like and they can also talk impulsively. They can easily say things they regret and that can look like, for example, oversharing, sharing too much personal details about themselves. But it can also look like someone losing their temper and saying things they don't mean, or things they regret. Things that are very emotionally driven. And that's also important to talk about with ADHD, that that seems to be a problem with emotional regulation. People with ADHD frequently have anxiety. They frequently have problems with low mood, and they frequently have problems with anger management. People with ADHD can also have trouble tolerating slowness, so waiting in queues can be very quickly distressing or frustrating. Also, being in traffic, unexpected delays and people with ADHD can also get angry or frustrated, not just at other people or at the situation, but also at themselves, at their seeming inability to do things that other people seem to be able to do quite easily. So that's often the first thing someone in an ADHD assessment will tell me is, I feel like things that come easy to other people seem to be a bit of a problem for me, or I feel like I don't get the results that's proportionate to the work I put in. I put a huge amount of work in, but I get really meagre results. So that's often pops up in things like exams and tests at school or work projects. Going back to social difficulties, people with ADHD often find they can't help but interrupt people and blurt things out, again, a sign of impulsivity. So going back to the diagnostic criteria, a person will need to have at least five persistent problems with attention, which we described, and or at least five persistent problems with impulsivity or hyperactivity. Those problems need to be present lifelong, typically from at least the age of 12. And that's why usually in an assessment will ask for an informant report from a parent or someone that knew the patient as a child. Those problems can't be better explained by a different mental health condition, because many mental health conditions can present with impaired thinking and concentration. So, for example, if someone's having a manic episode or a psychotic episode, severe depression or severe anxiety, those will all impair attention and they may cause impulsive behavior and other problems with behavior. But if those are present and they're a better explanation, that would obviously invalidate the ADHD diagnosis. What tends to distinguish ADHD is it tends to be present lifelong since childhood, as I mentioned, and it tends to be present persistently. So it's a problem that that person is always going to have in different contexts, like school, work at home, and the problems aren't episodic. So like a manic episode will typically last a few weeks up to a couple of months. It's an episode, and in between episodes they can function normally. And that's not the case with ADHD. It's a persistently lowered baseline of functioning when it comes to attention, hyperactivity, and impulsivity. Now lastly, the problems we described can't just be present. They also need to be demonstrated to be causing significant impairment and at least a couple of areas of life like school, work, relationships, home life, emotional life, etc. and this is important. I think a lot of diagnoses are often made or not made on the basis of the degree of impairment. It is likely that most individuals will have a few problems with attention or a few problems with hyperactivity impulsivity, but it doesn't mean that those problems are causing a significant degree of impairment in at least two areas of life. So I'd like to talk a little bit about what that impairment can look like, because that's super useful to understand whether you think you might have ADHD or someone you know, or if you're about to start working with clients with ADHD, it's really good to know these common signs of impairment. So I think there's probably two ways to think about impairment. One, and probably this is the most common is it's when the environment pushes back. So a person has a certain set of problems. And those problems meet a certain threshold where the environment pushes back. So in school this can look like getting in trouble, getting in detention, getting penalties for not doing homework, failing exams in work. This kind of look like disciplines, cautions, reprimands, getting fired, having to take an easier job, or an easier role in relationships. This can mean the end of a relationship, or simply that the symptoms are causing a significant amount of arguments or conflicts with their partner. In terms of emotional life, this could mean that their symptoms are severe enough that it's causing significant emotional impact. Like a lot of anxiety, persistent periods of low mood or depression, low self-esteem, and low self-confidence as a result of this feeling that they can't do the things that other people seem to be able to do. You can also see impact on financial life, for example, if the individual is doing a lot of impulsive spending, this can cause them to go into the overdraft or go into a lot of debt, that it may take quite a lot of time to pay back. So all of these things are important. So if I'm interviewing someone, I'm going to be asking all of these things, you know, how what was school like for you? Did you get in trouble at school? How did you perform in your exams? Did you perform in your exams in a way that was proportionate to the hard work that you put in? Have these problems impacted your relationships? Have you ever had a breakup as a result of these problems? Have you ever gotten into debt because of spending? Have these problems affected your self-esteem or your confidence? Does your partner support you with any particular tasks that you find it especially difficult to do, like paying bills or legal matters, or organizing your finances, or filling out forms? Things along those lines. Those are all really useful questions to screen for impairment. So those are the criteria for a diagnosis of ADHD in adulthood. At least five persistent problems with attention and or at least five persistent problems with hyperactivity. Impulsivity. They have to be they're lifelong. They can't be better explained by a different mental health condition. They have to be causing significant impairment and at least a couple of areas of life in children. It is slightly different. In children it has to be at least six or more problems with attention and or at least six or more problems with hyperactivity, impulsivity. And as I mentioned before, if the problems are both in the inattentive and hyperactive domains, then it's a combined type of ADHD, which is 80%. If it's just the inattentive symptoms, then it's about 15%. If it's just the hyperactive symptoms, it's about 5%. Again, the purely hyperactive type is really rare. I personally haven't seen it. So what are the causes and the risk factors for ADHD? Again, it's important to point out that what I'm going to list doesn't necessarily apply to any one individual with ADHD, because by its very nature, the diagnosis doesn't involve these factors, but these have been studied at a group level and looking at groups of people, these factors seem to be highly correlated with ADHD. So firstly genetic it does look like there is a strong genetic risk for ADHD. The heritability, according to some large high quality studies, is up to 80%. So what 80% heritability means is that 80% of the differences throughout the population of the level of ADHD symptoms is attributable to genetic differences rather than environmental differences. So clearly there's a strong genetic risk there. There are environmental factors. So for example, being born prematurely, being born at a low birth weight, but also maternal use of alcohol during pregnancy and cigarette smoking during pregnancy have all been linked with ADHD also after birth, early life adversity, chronic stress during early childhood and potentially trauma as well have been correlated with a higher prevalence of ADHD. And the relationship here is really complicated. But anecdotally, from the different patients I've seen, I would say that having higher levels of early life trauma does seem to predispose to to more severe, more persistent symptoms of ADHD. So what's going on at the level of the brain in individuals with ADHD? What seems to be happening, at least what studies have revealed is certain trends, like there seems to be decreased functioning of the prefrontal cortex, the front of the brain. So what the prefrontal cortex tends to do is it does tend to be responsible for thinking, planning, organization, so-called executive functioning. Really a huge job of the prefrontal cortex is to say no to our baser instincts and impulses. The prefrontal cortex is the part of our brain which figures out what we should do in a situation, often, rather than what we want to do. So it's no surprise that if that part of the brain isn't functioning as well, people are going to be more inclined to be impulsive and make poor decisions. There also seems to be decreased size and potentially decreased functioning of the basal ganglia. The basal ganglia people might know is also implicated in another condition called Parkinson's disease. So it's very important in motor functioning, the functioning of the movement of our body. Really, it's the job of the basal ganglia to stop our body moving when it shouldn't. So that makes sense in terms of ADHD, because it means if the basal ganglia aren't working as well, we're going to be moving when we shouldn't. So that might be responsible for symptoms like fidgeting, which we see commonly in ADHD, so that that decreased basal ganglia functioning might be responsible for the fidgeting that we see in ADHD, and the general sense of restlessness and the inability to stop moving, even though the situation demands it. And there's also thought to be increased functioning of something called the default mode network. So that's the part of your brain associated with daydreaming and being kind of lost in your thoughts. And so that also makes sense if that death. Part of the brain is functioning more than usual, than someone with ADHD is going to be more likely to be daydreaming, to be lost in their thoughts, etc.. Studies also suggest that in the prefrontal cortex of people with ADHD, there seem to be lower baseline levels of certain neurotransmitters, things like dopamine and norepinephrine. And that explains why when we give people with ADHD drugs like stimulants, which increase the amount of dopamine or norepinephrine released between nerve cells, then that seems to help a lot of the symptoms. Dopamine, in particular, is a neurotransmitter that in certain parts of the brain, like the prefrontal cortex, helps us plan, helps us organize, helps us seek future oriented goals which people with ADHD often have so much trouble with. Often, people with ADHD tend to default to goals very much in the present moment, and they tend to have problems planning for the future and working towards long term goals, which often requires like a delay in gratification. So what's the impact of something like ADHD? As you can imagine, the impact is huge. If you have problems voluntarily using your attention for things, if you're constantly swayed by different things in your environment, which call out to you if you have trouble concentrating on things which are mundane and you can only concentrate on something which you find hyper interesting. If you constantly make impulsive decisions, if you're restless, if you never feel like you can calm down or relax, can have a huge impact. But it is worth noting that just like any other mental health condition, there is a spectrum of severity. You do see cases which are a bit more mild, those which are a bit more moderate and more severe. But those different categories aren't formally recognized in the diagnostic framework. So as far as the DSM five diagnosis goes, you either have ADHD or you don't. But obviously in clinical work, you see the spectrum of severity from mild to moderate to severe. It's really worth pointing out just how much success in the modern environment really goes against a lot of the symptoms of ADHD. I've talked about this and other podcasts the ability to delay gratification, to not make decisions impulsively, to be able to think and plan, and then the ability to execute on those plans in a modern technological environment, especially one where many people are distracted anyway, is a kind of superpower. So if you do have ADHD, can definitely put you at a disadvantage, although these are problems that you can work on as I'll go into later, but it can cause a real impact. It can cause a lot of problems advancing at school. As we mentioned, problems advancing at work, particularly people with ADHD, often find abstract work to be quite hard. Things involving reading or writing, although they clearly can read and write, can be a lot harder and be a lot more time consuming. They may have to spend a lot longer checking their work for mistakes. Often people with ADHD really excel with hands on practical tasks. They excel in dynamic environments which are constantly changing and require your attention actually to constantly shift from one thing to the next thing. So people with ADHD will often tell me that their best work experiences are in fast paced environments, constantly doing different short tasks according to the needs of the moment, as opposed to a lot of jobs which really require a lot of long term planning. Things like report writing, for instance, often very difficult for people with ADHD. It's also important to point out the social impact of an at school. People with ADHD are more vulnerable to bullying if they also have comorbid autism and autism as a whole other subject. But people with ADHD are more likely to also have something like autism that can make them really vulnerable to problems with socializing and bullying in school, and more rarely, even bullying in the workplace. And as I mentioned before, there can be a real emotional impact ADHD. It can affect someone's self-esteem, their confidence, their belief in themselves that they can do things, that they can make their lives better, and they can lead to things like anxiety and depression. So important to address those things. When you're working with someone with ADHD or doing an assessment for someone with ADHD. I'd also like to point out that, of course, just because someone has ADHD, that doesn't mean there aren't a lot of other things about that individual which makes them unique, like their intelligence, their desire to work hard, the other aspects of their personality, and all those factors mean that ADHD can present quite differently from one individual to another. So, for instance, you often see people who have ADHD, but they are overachievers nonetheless, and they want to work really hard. They care about their jobs or they care about their school performance. They want to achieve things in their life. And in these individuals, often the impairment presents in a slightly different way. So often when people like this, what they'll say is they do well at work, but they have to work double the time everyone else has to work, or does stay late at work every shift. Or they did really well at university. They got a first, but they totally had to sacrifice their social lives in order to achieve that, or they do really well in their work life. But their family life, their personal life, their personal organization is a total shambles. So if you're assessing someone for ADHD, it's important to point out that just because they've achieved a lot in one area of their life, it doesn't mean they don't have ADHD. And what you want to look for is just making sure they're not overcompensating in one area of their life, but then totally suffering in other aspects of their life as a result. So important to point that out. So I'd now like to talk about the management of ADHD, different options, and the kind of mindset someone should think about when they're trying to recover from or manage the ADHD symptoms. As with any other mental health condition, I think it's important to think about this issue holistically. And by holistic, I simply mean taking into account all the different aspects of your life and how they could be influencing your symptoms and the different problems that you're facing. So roughly speaking, you can divide the management of ADHD into non medication strategies and medication. And generally I advise my patients to think about managing their ADHD symptoms foundationally with a range of non medication strategies and then thinking of medication as a really useful tool or bonus that can come on top of that. And the main reason I advise people to think about it that way is because non medication strategies are a lot more within that individual's control. There's way more non medication strategies than there are medications. And the non medication strategies are typically things which are good for a person's mind and body anyway. They're often things most people should be doing. Medication on the other hand although it can be really effective, isn't always within a person's control. There's only about 3 or 4 medications typically that people can use. They don't work for everyone, or they may have side effects which make the medication intolerable, or the person may develop a medical condition at some point in their life, which means they can't always take medication. So I usually find if a person bases their recovery on a foundation of non medication strategies, then they're in a much more stable position. And if medication also works, then they're in a really good position. But if they base their recovery just on medications then it's a bit of a fragile position. And if for some reason they can't take medication forever or the medication doesn't work or produces side effects, they're in a much more vulnerable position. So I think brain health and what it takes to look after your brain is an interesting and emerging area, and I think it's something that everyone should take into account, let alone if you have something like ADHD. I think it's important to look at the different aspects of your life and think, you know, is this good for my brain or not? In terms of the non medication strategies, there's a range. I usually encourage people to look online and find different strategies. But I will put some useful links in the description of the podcast. Often it's very simple things like altering your environment, for example to make your work environment less distracting, different behavioural techniques you can use. Like for example, people with ADHD often find work tasks overwhelming. So using different techniques to break down large, overwhelming tasks into smaller, more manageable tasks can be really used for psychological exercises like mindfulness. Meditation can be really useful because there are techniques which you can actually use to improve your attention your ability to pay attention to something without getting distracted. And although it can be hard if you have ADHD, I would encourage people with this condition to think of it like a muscle that they can train and improve upon, rather than something static which they can't fix or alter at all. I think nutrition is important to think about certainly foods that seem to cause huge swings in blood sugar, like a lot of junk food, probably bad for the brain, probably makes ADHD symptoms worse. And there's modest evidence that supplementing with certain nutrients, like omega three fatty acids, can show some good benefits for ADHD symptoms. Generally speaking, I would advise eating a very diet with good sources of protein, a wide variety of fruit and vegetables, and minimizing junk food, like I mentioned is probably a good idea. I would also strongly recommend exercise, probably as seriously as I would recommend medication. And it's also worth pointing out that physical exercise increases the levels of certain chemicals in the brain that are thought to be probably deficient in ADHD, like dopamine, like noradrenaline, and they're the very same chemicals. Which medication also increases. Exercise can also help with the restlessness, the hyperactivity. It can help people sleep better Exercise helps with anxiety with low mood. So really important, really useful intervention. And generally I would advise people to simply exercise in a way that they think they can do consistently. It doesn't have to be any one particular activity, but something they can do on a daily basis, even if it's just for 10 or 20 minutes. And generally I would advise the more vigorous that exercise is, the better. I think other lifestyle adjustments are probably important to think about as well. Often people with ADHD either smoke cigarettes or they vape. And that makes sense because nicotine at the end of the day is a stimulant. So if someone smokes or vapes temporarily, they're probably going to find that their ability to concentrate does improve. But unlike the stimulants we prescribe for ADHD, nicotine is a very short term stimulant, meaning it lasts for just a few minutes before it stops working. So if someone smokes or vapes, what they're going to find is they're going to be constantly in these highs and lows of their ability to pay attention. And in addition, they're making their brain dependent on yet another external substance in order to be able to pay attention properly. So you're really just making your brain even more vulnerable. And that's in addition to all the health risks of smoking or vaping. So generally, if my patients smoke or vape, I advise them to cut down or stop that if they can. Sure, it can help in the short term, like in the next few minutes, but in the medium to long term it's probably a bad idea. And similarly, I think the use of technology, particularly apps that provide a lot of intense short term stimulation like TikTok, Instagram Reels, YouTube shorts, although I don't think they necessarily cause ADHD, especially not in adults. It does mean adults with ADHD are more vulnerable to those kinds of technologies, and probably they use that all the time. They're just going to condition their brain more and more to play into the ADHD, meaning to be dependent on short, intense forms of stimulation. Whereas really, if you have ADHD, you want to be doing the opposite. You want to start conditioning yourself to more, longer form, slower burn forms of stimulation, like watching a long film, having a long conversation, reading a book, something along those lines. So really in terms of non medication interventions for ADHD, it's about realizing that you have this certain set of problems and vulnerabilities and starting to devise a set of tools and building a structure around you. And that structure can also involve people that you rely on to help support you and help support, basically, your ability to do the things that you have to do in order to get through life. I think what a lot of people without ADHD can probably take for granted is simply the ability to pay attention to something when it's not that interesting, but it is important. So, for example, doing your taxes or filling out a form to apply for something, these are things that we know we have to do. They're important. We don't get any particular excitement from doing them, but we can do them relatively straightforwardly. This is exactly the kind of mundane task that someone with ADHD would struggle with. So lastly, I'd like to just touch on medications that we prescribe for ADHD in the UK, how they work, some of the risks, some of the common side effects. And this can help inform your choice. If you do get a diagnosis of ADHD as to whether or not you'd like to pursue medication based treatment. And the first thing I'd like to point out is, as with most other mental health conditions, especially if you're an outpatient in a non-emergency situation, whether or not you take medication for ADHD is entirely your choice. Just because you have ADHD, it doesn't mean you're obligated to take medication for it. And in fact, you're the best person to judge the potential risks and benefits. And even once you're on the medication, you're the best person to judge if on balance. Is the medication a net positive for your life and therefore should you continue taking it? So this is some information that can help you make that decision in the UK. There's four medications we prescribe for ADHD. Our guidelines suggest that the first line medications we recommend are the stimulants. So those are methylphenidate. Common brand names for that are Ritalin or medicated or amphetamine. Common brand names for that are Liz Dick's or Adderall. So these are the stimulant medications. What they do is they directly cause the increase of certain chemicals in the brain like dopamine and noradrenaline, which we mentioned before, which seem to be at lower baseline levels in individuals with ADHD. And so it makes sense that these would help to relieve the symptoms if neither of those work or they cause too many side effects, then we try a medication called a tamoxifen, which is technically an antidepressant, but it seems to have good evidence for improving symptoms of ADHD. And if that doesn't work, then the last resort medication is one called Guan forsene. And what Guan Forsene does is it dampens down the sympathetic part of the nervous system. That's the part of the nervous system responsible for the fight or flight response. So again, that kind of makes sense that that would work, because if you look at someone in an extreme fight or flight response kind of resembles something like ADHD. So how often does medication actually work? On average, based on different studies that have been done. Something like two thirds of individuals with a diagnosis of ADHD feels that medication significantly improves their symptoms. Now, two thirds is actually quite a good result. It's a good result for any medical treatment, but it's particularly a good result for mental health. So if you compare it to something like an antidepressant, where commonly one third of patients would say that antidepressant typically improves their symptoms significantly, two thirds is a really good result. And so it's worth considering. Seriously, if you do have that diagnosis and you feel those symptoms are significantly impairing you in different aspects of your life, it's definitely worth considering medication. But it's also worth pointing out that, of course, two thirds feel there's a significant benefit that means one third don't. And that can be either because they simply don't seem to get the benefit of medication for reasons which are mysterious or there are too many side effects. Common side effects of the stimulant medications are things like headache, irritability. They can worsen sleep. They can cause dizziness, nausea. They can cause loss of appetite. Unintentional weight loss. Those are the really common side effects and more. Really, stimulants can also cause more severe mental health symptoms. They can cause psychotic type symptoms like auditory hallucinations, hearing voices, visual hallucinations, paranoia. It's worth pointing out that these are really rare, and especially if you don't have a history of these symptoms yourself or a family history of these symptoms, it's pretty unlikely that you're going to get them, especially if you take them as prescribed. But it's also worth pointing out there are possibilities that you're aware of them if you start taking these medications. The main safety concern we tend to look out for when starting someone on stimulants is the potential effect on the heart, because stimulants can put a strain on the heart. So typically anyone that's starting a stimulant medication, they're going to have their blood pressure checked very regularly and their heart rate checks very regularly. Again, this is unlikely to be a problem if they take it as prescribed, but the blood pressure and heart rate is checked. And if it goes above a certain level, what will usually happen is that medication is stopped and an alternative is tried. So important to be aware that it can put a strain on the heart. If you have pre-existing heart conditions like heart disease or an arrhythmia or some sort of valve abnormalities in your heart, it's quite likely that your prescriber wouldn't try a stimulant, but would try one of the alternative medications. So we've covered stimulants, how they work, some of the common and less common side effects, and some of the safety concerns at amoxicillin and gram 14 have their own side effects and concerns, but they're prescribed less commonly. So I'm going to put a link in the description where you can read more about those and what you will likely experience if you're taking those medications. Before I conclude, I'd like to comment on one other point, which is this concern about the possible overdiagnosis of ADHD. This is being talked about a lot, particularly on the internet. And what I would say about that is I think there is a risk of ADHD both being overdiagnosed and underdiagnosed at the same time. I think because of the nature of the diagnosis in that it just involves a clinical interview. I think there is a risk of the assessor not asking in-depth enough questions, not getting enough examples or context from a person's life, not getting enough concrete examples of impairment when they're interviewing someone who potentially might have ADHD. I think it is possible that diagnoses can be given out too easily. At the same time, I also think there's a risk of under diagnosis and under recognition. I think for many people who are experiencing these symptoms, it can take them a long time to try and figure out what's going on. It can take a long time for health professionals like their GP to recognise what's happening with them, and a long time for them to reach the point of an assessment or potential diagnosis. So what I would say is if you think you're experiencing symptoms suggestive of ADHD, if you live in the UK, your first port of call would be your GP, who would be able to direct you to the appropriate specialist services to get you a thorough assessment. And when you are undergoing that assessment, I would advise any patient to make sure that that assessment is indeed thorough, that the person assessing them is asking in-depth questions about their lives, about their experiences, is getting that important information about different examples where different things go wrong or different signs of impairment, and is definitely doing an in-depth mental health history, medical history, family history, history of things like school and work to make sure they're doing a comprehensive assessment. And if you feel that the assessment was a little bit shallow or lacking in some depth, it might be worth getting a repeat assessment or a second opinion. That being said, for many people I see who have been struggling with these issues for a long time. The diagnosis itself can be incredibly therapeutic, as it's finally an explanation for the variety of problems that the person has had for their whole lives, often problems which are seemingly unconnected. Like it's not that obvious why someone would have problems with reading needing to read things over and over again, but also problems with organizing, but also problems with fidgeting, restlessness, or impulsive decisions. And a diagnosis like ADHD can finally give someone a bit of an explanation as to why they've been experiencing so many difficulties for so long, and importantly, can also give them a bit of a roadmap to some potential solutions. So while I do think there is a risk of over diagnosing ADHD if the assessment isn't thorough. Or in-depth enough for many people. I think a diagnosis of ADHD is absolutely appropriate and can give them the means of accessing interventions that can really significantly improve the quality of someone's life. As I said before, even the lower estimates of prevalence, which suggests that the prevalence of ADHD in adulthood is something like 3 to 5%, that's pretty common. And with a few tools and strategies, some structure and some medications, as I mentioned, a lot of these problems can be significantly handled and improved upon. And many people with ADHD, some form of psychological treatment can be really helpful, especially something like CBT, cognitive behavior therapy, which at the end of the day focuses on behaviors but also links to thoughts and emotional patterns. So often something like CBT can be the ideal form for a patient who's been diagnosed with ADHD to try out different non medication interventions and see how these interventions impact their thinking, their feeling, their ability to behave in different ways and discuss the results of that with someone like their therapist. In a structured environment. It can be an ideal space for someone to begin to handle their problems without medication. And lastly, it's worth talking about the gender question. Of course, gender and ADHD is talked about a lot on the internet. Now, classically, ADHD is much more common in men than women, with a ratio of diagnosis of something like 2 to 1 or 3 to 1. But it's been increasingly recognized now that perhaps we've underdiagnosed ADHD in women because women are much less likely to present with overt hyperactivity than men are. Typically, they tend to present with more overtly inattentive symptoms like daydreaming and zoning out. It's possible that these diagnoses can get missed in women, especially during childhood. So often I see women in adulthood who haven't had that diagnosis in childhood but have had a lifetime history of different problems as a result of inattention. Regardless So I'm sure most of you probably know this, but ADHD can of course occur in women and it can present slightly differently as well. So I hope you guys found this useful. I hope you're walking away from this episode, having a bit of a better understanding of what ADHD is, who it affects, how it likely presents in different people, and some of the potential solutions for managing ADHD symptoms. As I said before, I will be putting some useful links in the description. I'm keen to know what you think. If you have ADHD or someone you know has ADHD, what are the biggest problems that they're facing? What are the most useful solutions, be it medication or non medication that they've found? If you want another mental health condition covered in this kind of systematic way, the way I covered ADHD today, let me know. Any and all feedback can be directed to our social media accounts on Instagram or Twitter. Or you can email us at Thinking Mind podcast at gmail.com. As always, thank you very much for listening and I'll see you here next time