E57: ADHD: Adult ADHD

[Music] Hello, this is your brain on drugs and this is the punk rock psychiatrist. So today I'm going back to ADHD and I think a lot of you out there will be interested in this topic because it's a pretty big topic in the world or in, you know, in the United States anyway and that's the topic on adult ADHD. It's a pretty controversial topic and it's something a lot of people are thinking they might struggle with, are struggling with and honestly, you know, I think a lot of people, when they find out that I was, you know, a military psychiatrist, the first thing that comes into mind is PTSD. Right, so PTSD of course, I saw quite a bit of that but it probably wasn't the type of PTSD that you're probably thinking about. Most of the big wars have been over for a while and the folks that were in those wars were nearing retirement or out and in the VA. By the time I was doing my job there, not that I, you know, of course I did see quite a bit of folks but not nearly as much as you would think. I probably saw more PTSD associated with sexual assault than I did with combat related things but the VA would definitely probably be seeing a lot more of that. As a military psychiatrist, I'm seeing active duty folks, their families and overseas. I'm seeing anyone and everyone that is working for the military base overseas. So I would honestly say that ADHD is probably one of the biggest things I saw. A lot of Suez, especially working overseas with young Marines, you see a lot of, you know, issues having to deal with separation from friends, family, home, girlfriends, boyfriends, things like that, young people, you know, imagine being 18 years old and being sent to a country, you know, halfway around the world. And your ability to go home is pretty limited and you're pretty locked down on where you're at because there's, you know, there's the idea that we need to protect a lot of local population from, you know, the craziness of these young people that are, you know, imagine college kids just kind of let loose in a foreign country, especially one like Japan where I was, where, you know, the population is much more organized and controlled. So I think that's what I think that ours is. So you see a lot of adjustment disorder. You see a lot of PTSD, you know, you see a handful of PTSD. There's a lot of suicidality, but most of it is associated with adjustment disorder and not major depressive disorder. It's, you know, life is hard. Hard stuff is coming at you. Tough stuff like that. You know, honestly, not a lot of major depressive disorder generalizing say disorder. Very little bipolar disorder, it's schizophrenia, but I can say, I'd say adjustment disorder is probably the biggest thing by far that I would see. And then, you know, a handful of PTSD and then quite a bit of adult ADHD. In fact, I would say that, you know, I probably saw more adult ADHD than most psychiatrist do because I'm dealing with essentially these are kids, right. I think in a lot of respects, we think of, you know, children, you know, you're an adult at 18, but this idea that the brain doesn't feel kind of finish until an average of maybe around 25, right. Some, some people would say even even later than that, maybe 27. So what I'm dealing with is kind of adolescence in many, in many cases, right. And so ADHD, it's a diagnosis of children and adolescents. And when you're dealing with a lot of very young military folks that are at their first duty stations. There's a lot of this ADHD. And so I saw a lot of this kind of late adolescence type ADHD. And I'd like to think that, you know, probably more than almost anything else that I did as a psychiatrist in the military. This is probably one of the things that I had the most experience with. Now, you know, I can think of co-workers that basically they, they ascribed to the idea that there is no such thing as ADHD. There's no such thing as adult ADHD. And if somebody came to them with concerns for this, they just were like, I don't believe in this. I don't treat it. I either don't believe in it, or I don't treat it. And those folks just, you know, I had folks that weren't even in the military. They were, you know, a spouse who had been treated for it for years. And I would see folks just say, you know, I'm not renewing your medications. Because I, you know, this is just not a thing. And so there's certainly that running through the psychiatric community, the medical community, the country. I don't ascribe to that. And so most of what we're going to be talking about in all these ADHD lectures is adult ADHD, because that's what I treated. And I'm going to talk about all the different treatments for that. And so today, I'm just going to focus on adult ADHD. And, you know, this is stuff that's not in the DSM. It's something that it's stuff that you're probably never have maybe heard quite before. I think like any diagnosis in the mental health sphere, since we don't have like good tests and scans and things to make those diagnoses, it's about having a conversation with a patient and getting to know what their life is like. Trying to piece it together and then doing your best to kind of pick whether they need to take a med. And if so, which one is going to improve their functioning the most in the long term with the least amount of harm. I mean, that's kind of how I look at things. And so I'm not going to tell you exactly how to diagnose someone with ADHD or if you're someone out there that, you know, things you have, you have adult ADHD, I'm not going to give you a clear idea of like, oh, you know, if, you know, I see these, I see these videos and these things on the internet that this is just so unhelpful. Like, I think certainty in any kind of science is just poison. And it will say like, if you have these five qualities, then you have a adult ADHD, you know, or, you know, if you can answer this question, or if you can't do this, then you have this or don't have this. Like, what is this based off of who made this up? This is just clickbait and it's annoying. Honestly, it takes someone who has an honest kind of idea that like these things are out there and that they're, you know, looking to help people and evaluate them and give them the best treatments and kind of taking their whole picture and look and see what they think is the most likely thing that's going to help them and what could be going on. It's not, you can't just simply get diagnosed with things and you can't simply just like self-diagnose. It's a big, it's a big process. And so I'm going to be throwing out a lot of stuff today that are qualities of what adult ADHD looks like. So you're probably going to be like, oh, I have several of those qualities. That doesn't mean you have it, right? This is about a whole story. It's about putting the whole puzzle together. It's about having key pieces of this. And I know the DSM likes to be all neat and tidy and be like, well, if you have, you know, five of these or six of these things, then was it like six of nine or something, then in two or more settings, then, you know, you have this. You know, you have this or whatever, you know, we talked about diagnosis before, like the technical way that DSM, you know, it has to say something. You know, it can't just like the DSM can't give this lecture I'm about to give you and say, here's like kind of what this looks like. Make your own judgment. You know, the DSM can't do that, right? But I can. And so that's what I'm doing it. And the end, I think it's a, I think it's a more honest way to do it. And it's a, it's something that I can do in the format that I have. And so I think it'll be something that you haven't seen before. So let's talk about this. So the big resource that I used for this show is from another podcast that it's basically like an exclusively ADHD podcast. It's called attitude spelled with 2D. So like ADD attitude. And so they have a magazine. They have a podcast and I think they put out some pretty good material on ADHD. So like I got a lot of statistics and stuff for them. And like I've tried to verify some of the statistics I got from them. And I feel like they're a little bit over zealous in like trying to like diagnose people with this stuff. And a lot of stuff I got on ADHD outside of the medication piece. that we're going to talk about, I did get from them and I'm trying to go through it to try and, you know, because I just kind of put this together for myself and now I'm putting it out there in the public. So I don't want to be throwing out false statistics. So some of them I changed, some of them I didn't, but I'm going to say, you know, I don't exactly know where this comes from, but this sort of sounds right to me. So I left it in there. So I just wanted to qualify that. The first one was that I got this statistic that it was like 90, it was something like 92% of psychiatric resonances don't receive training in adult ADHD and I tried to find where this information was and I could not. And it's like, how old is this information? We don't know. So I changed it to say many psychiatric resonances do not receive much training in adult ADHD. Okay. So it's not something adult ADHD in particular is just not something that psychiatry resonances really focus on. I mean, which is true of a lot of medical resonances, you're focusing more on the sickest of the sick, the stuff that's going to kill you, the stuff that's going to put you into the hospital. And ADHD is just, you know, not one of those things. And also like when you do your child rotations or your child fellowships, you're going to get a lot of ADHD training because that's going to be a big part of that. But when you're just, you know, and of course I did six months in in child residency, which I think most psychiatry resonances do. But you're once again, that's not adult ADHD. You are learning about ADHD and you're learning about treatments, but you're learning about it how it looks in kids and how to treat them kids. But I can tell you that I had staff that would, you know, that I treated patients with that were on these meds and we would talk about the ADHD. Now, did I get lectures on adult ADHD? No, I don't believe I got any. Did I get any formal classes on ADHD? No. I mean, there were patients that had it. And when I would staff the patients with the attending, we might, it might come up. You know, be like, Oh, this is a patient I treat and I treat him for this. And this is a matter I give him. And so forth. But they're really honestly is very little information. And I mean, I only went through my program, but I can tell you that I'm pretty darn sure that there's not a whole lot of education on this piece. This is just something that it's just, it's not a high priority. And so it's not really taught. And that's why I think, you know, this resource that I'm putting out there, hopefully is filling in some of those gaps. All right. So next is that and this was a statistic I was partially able to verify where they had said that 50% of pediatric residences don't receive much training in ADHD, which seems pretty shocking because like they're treating kids. And this is a disease of children. I think they kind of stretched that. I found the 50% statistic. And it was 50% of pediatric residents do not feel comfortable managing ADHD. So they, there is in my mind, no way that pediatric residents that there are pediatric residences out there where they received no training of ADHD. I just can't imagine that they're any of those. I can imagine some adult psychiatric ones where they're not receiving any training in adult ADHD or very minimal. But I can't imagine any pediatric residency that is not exposing their residents to ADHD at all. Like if they're in clinic, they're going to see this obviously. But the statistic that half of them don't feel comfortable managing it, that makes total sense to me. They are given a very specific algorithm. Actually one of my most frustrating thing is I was, I did a grand rounds where it was, it was like grand round, I don't know if I mentioned this before, but we were giving it was like a pediatrics and pediatric psychiatry kind of co-ground rounds. And every other grand rounds one of us would give a talk and then they would give a talk. And we would kind of work, we would be together. And since we were on child for six months, I get, you know, one of the months is my month to give one. And I think it was like monthly rounds, grand rounds. So I gave my topic on like basically trying to help them better manage ADHD and kids so that they would not have to feel uncomfortable and send them to us. And at the end, this one of their staff like stood up and basically nullified everything I said. And was like, don't worry about this. We have our, you know, and he's talking to his residents while I'm up there. He was basically like, I feel like he was like not wanting them to take in what I was saying. And like, you know, you guys don't need to worry about this. We have a logarithm. Just follow the algorithm. You know, do what your algorithm is and then send them to psych. And it's like, so if you have a kid that's having some weight issues, you don't want to know how to manage that. If you have a kid that's having, you know, having some growth issues, you don't want to know what to do with that or they're having some cardiac issues. You don't know what to do about that. Or they're having some maybe drug use stuff going on. You don't want to have any, you don't want to have any idea what we're doing. You know, I mean, to me, that's insane. Like, even if you don't, even if it gets to the point where you feel like you don't feel comfortable managing it, do you not want to know what we do? Like, because it could be an easy one that you could just handle yourself right there in the office. Why not take that nugget in? You know, it's like, I really enjoy the podcast curbsiders, internal medicine podcasts, because these are primary care internal medicine doctors that are having experts in all these different fields. You know, it's like, oh, someone's got the sniffles. Let's get the sniffles expert on the show. Oh, this person's got like stomach upset. Let's have the stomach expert. You know, it's like, oh, we deal with GERD all the time. You know, the expert's not really handling GERD, but let's have like the gastroenterologist on the show to talk about like every aspect of it, how to manage it, easy stuff, hard stuff, winter of fur, you know, and then they're gaining more knowledge on the stuff that they're going to manage and kind of knowing what's out there so that they can be like, okay, this is this is a time where like it's kind of and the GI doc might be like, hey, you know, I have no problem with you managing this if you feel comfortable, but you know, by all means send them to us if you want to. And that was kind of what I was trying to do and to be completely negated and here we have 50% of pediatric residents don't feel comfortable managing ADHD at all, like at all. So I mean, shouldn't you want more information? So kind of the point here is that people are not getting educated in ADHD very well. You know, I didn't go through a pediatric psychiatry fellowship. Perhaps they are, but psychiatrists in general are not getting well educated for adult ADHD and or or pediatric for that matter and sometimes adult psychiatrists are in a position where they're treating kids because there is no pediatric psychiatrist, right? And then here you've got pediatric residents not feeling comfortable managing kids with ADHD. I mean, family medicine is probably even less equipped because the pediatric should have more information than they do about this. So this is just something that's, it's, you know, it's, it's a huge interest topic out there, but not a lot of folks are that comfortable in it. Right? I hear I have another another one. There's never been a board question on adult ADHD. So that would be like on the psychiatric exam that I would take when I get or certified. There's never been a question where knowing anything about adult ADHD would help you answer a question. They, I mean, so they're not testing on this. So that's why it's nothing taught, right? Here I have as many as 20% of adults seeking middle healthcare have ADHD. I'm not able to validate this, but I mean, this can make sense. I mean, when we learned before, it was like 8 to 14% of, of like kids have ADHD, right? That's just like in the entire population. So here we're talking about like people that are seeking middle healthcare. So that is a subset of the whole population. So it's going to be a higher percentage of people, you know, if it's like, you know, if, say 10% of kids have ADHD, well, you know, 80% of kids are not coming in for middle healthcare, right? So that means the percentage of kids that have ADHD that come to see a psychiatrist is going to be much higher, right? And I think the pediatric psychiatrists out there are kind of on the lookout for that. But what about the adult psychiatrist, right? So I can completely think this could be true as many as 20% of adults seeking middle healthcare. So these are people coming to an outpatient appointment. They may be coming with the concern that they have ADHD or they may just be coming in with depression, anxiety, or something else that they don't know what the heck it is. And ADHD could be the reason for it, right? And here we have as little as 25% are identified fewer received treatment. So a lot of folks come in saying, you know, I'm anxious, I can't sleep or whatever, they're not diagnosed with ADHD, but they have it. that you know, it's like, no, this is anxiety. And then there's some of them that are like, okay, we actually identified you, but I don't want to treat it. So there's a lot. So basically the point here is, I think a lot of people have this impression that ADHD is over-treated, and I'm gonna wrap it up at the end and kind of addresses it over, or is it under, right? 'Cause it's both, spoiler alert, all right? Here's another point. The IQ of those with ADHD may be higher than average. Notice I said maybe, right? So I think there's this other thing where it's like, just because somebody is capable and accomplishing things doesn't mean that they don't have ADHD. In fact, someone's ADHD symptoms could be masked by intelligence. So if they're like a very organized, or maybe they're just like a really organized person. So you could have like traits that help you manage your ADHD, whether it be intelligence or organizational skills, or whatever it is, that may make the ADHD that you're suffering with not look so bad. But when, in fact, it's causing like pretty bad problems for you, and if it were addressed, you would be doing way better, right? So I think that who you're looking for, don't just assume that someone has to look this way to think that they have ADHD, right? That they're coming in with an issue, right? Now ADHD might, like I think ADHD should almost always be in the differential, right? Like that should be in the differential. Someone comes in with depression, ADHD's in the differential. Someone comes in with anxiety, insomnia, even like bipolar symptoms, ADHD should be in the differential. You should be thinking about that in the back of your mind that potentially that's the answer. Not me, not me, but you need to consider it because it can look like just about anything, all right? So I've seen a lot of people coming with all these presentations, and then treat them as ADHD and they do fabulously. And these are patients that maybe took all sorts of other treatments. I just had a patient. It was on a couple of different antidepressants. The guy was on like four different meds. And one of them was even given like he was on Bupropreion because it was like, hey, maybe I have ADHD, and it's like, well, then why are we giving him Bupropreion? You know, I swapped out the Bupropreion. And now I'm tapering off of the Scythalapram. And I started on Adderall and he's doing like way better. I know a lot of people will say, oh, well, everyone does better on a stimulant, but it's like, not everyone does better. I've taken them. They didn't do much for me. So like, I don't like this idea that like, well, everyone does, everyone will perform better on this. That's not necessarily the case, right? This is a guy who like ADHD fits his symptoms and fits why he's having the problems functioning better than anything else. And instead of being managed on like four different drugs, why not just get him on one? You know what I'm saying? So I see patients that are coming to me fresh that might look like something else. And I think ADHD is the problem. And I have people coming in that have been managed for a host of other things. And they're on time, when someone's on a ton of medications, that's assigned to me that they have a personality disorder. They have, these are all options. Potentially personality disorder, potentially PTSD, potentially they're just misdiagnosed or potentially they have a medical problem, right? And so it's like, well, we're just giving the meds to help with symptoms and none of it's really working and we just keep adding more stuff. This is a sign that something is wrong here. Perhaps they have ADHD. Now I'm not suggesting that all these people do, but there is a subset of those folks that perhaps the reason why they're not managed properly is because someone has not thought of giving them meds for ADHD or they just don't want to. And then they're giving a whole bunch of other stuff that just causes side effects, doesn't work or works a little bit, but not enough when really picking something that's engineered to help them with what's going on. All right, so ADHD is a neurodevelopmental disorder, so it doesn't have acute onset in adulthood. We talked about this before. However, just because someone has no history of it in childhood, that doesn't mean that they don't have it now. They may have had it in childhood and no one picked up on it. Okay, or their IQ or just kind of the structure of their environment may have made the symptoms not look as strong as they would need to look, but the underlying brain chemistry that was driving the process was there. And then when they get into adulthood and the executive controlled demands of adult life are different, they don't have parents organizing their entire lives for them. They don't have school as a structural environment for them. And there's a type of ADHD person out there that is just going to not function with that stuff. They're not going to do well with the structure. They're not going to do well with the authority figures. And there's other folks with ADHD that like, they're not the wild out of control type. They're the ones that like, oh, if you give me structure and you give me all this stuff, I'm actually going to function better in that and perhaps they're a little bit higher IQ, so it helps them do well in school. No one really, and they're more of a quiet type, less of a hyperactive type. It doesn't really come out. And then they become adults. They lose the structure of school. They lose the structure of their parents. Maybe school was interesting for them. Maybe the cons, you know, people with ADHD, like they have a tendency to like, not be able to focus very long. And it's like, I don't know. I kind of think of school is often like, every hour you're doing something different. And like, that could be really helpful for some people's ADHD where it's like, well, I can't sustain attention on something I'm not interested in for very long. But if I'm only in class and they're, you know, they're talking for 40 minutes and then I'm doing homework, I can actually accomplish that. But like, you go into the work environment and it's like completely boring. There's nothing intellectually stimulating. It's the same stuff over and over and over again. I mean, losing attention in that environment, it's a completely different environment. Someone could function in one environment well and not in another environment well. And it's just an environment they were never exposed to. So it can pop up in adulthood. But like, it was there the whole time. It just, they may not have been under the conditions that would cause it to rise to the surface, right? One exception I can think of as a TBI, actually this patient I'm telling you about before had a TBI. So, you know, that could be a reason. And that could have been an exacerbating factor in that. But a TBI could actually be a reason why you could have like new onset ADHD in adulthood. But for the most part, you had it the whole time, all right? And so, let's go into a lot of the details of how these symptoms kind of come out, right? The way that this presents, it's heterogeneous and itself, right? It can be, especially in adults. Especially in adults where it hasn't been picked up on before. So heterogeneous means it can look all different sorts of ways and subtle means it can be difficult to detect, right? So forget what you think about ADHD, because you're thinking about children, right? Let's, so the hyperactivity, nah, we're not really having that hyperactivity as an adult. The impulsivity, remember there's three, there's three kind of types, right? It's hyperactive slash impulsive and then you have inattentive, right? So the hyperactivity, you're not really, you know, that tends to like be rounded out by adulthood, but the impulsivity, not so much, right? So what happens is this impulsivity can move inward, right? So you've got motor disinhibition, leg shaking, pacing, fidgeting. So you're not like climbing all over the walls. But now, and so instead of being, you know, this motor, these motor symptoms kind of being outward and like obvious, leg shaking, pacing, fidgeting, right? Something that's more socially acceptable, right? Because adults learn, by the time you become an adult, you learn that a lot of the behaviors that you were doing when you were younger are just not acceptable. And you just can't get away with this stuff anymore than your adult. And people, as they mature in their brain, mature, as they're able to control those symptoms. But so, but that doesn't mean that they can still stop the motor symptoms. And so it's like, you know, they might be shaking, they might be, you know, like looking around, they might be moving quickly, you know, they might be like bobbin their heads, right? Like they're trying to keep it in, right? Verbal disinhibition. So they might blur things out, you know? You see these characters, right? These adults, they're adults that have, that just kind of say stuff. And it's just like, whoa dude, weird, you know, impatience, they can't wait, right? Have a difficult time, you know, waiting. If they have to wait, maybe they'll avoid it. So it's a lot easier to avoid things when you're an adult. It's a lot easier to kind of like come up with your own system to try and get around things. So you may not see the impatience, but they are impatient and are like, oh, I just, if I go into the store and there's long lines, I just turn around and go out. And I just, I'm not even going to deal with it. And they're like, you really? ever? Oh yeah, I'll just drive home. I'm not going to deal with that stuff. I mean, that's me. If I completely will not go out when I know it's busy. Like, I think other people just kind of like suck it up and deal with it. I won't personally. If I know there's traffic out there, I'll just like deal with what I have to deal with it a later time. I'm just not going to hate because I'm not going to deal with the panic attacks and all the crap and the anxiety that I'm going to have in dealing with that. I would rather just not do it. So these are kind of some ways that the impatience can come out. Right? Difficulty lingering and enjoying the moment. Right? So like, can't really, you know, you know, smell the, smell the roses. Right? Can't just kind of relax and take it in. Just got to keep going, got to keep going to the next thing. Got to check the boxes, got to keep, you know, let's get on with it. Come on. Let's go. Let's go. Can't wait. Come on. Right? So that's more what we're going to see as an adult. Right? And then the attention deficit, that continues. Right? The inability to pay attention. That's something that's going to persist into adulthood if ADHD symptoms are persisting. Now, we've already talked about before that as people's brains mature, they can improve their ability to handle these things. They can train themselves to deal with it and they can get to a point where maybe they don't meet the criteria for this. Not everyone does that. Okay, we're talking about the people who are unable to do that. Adults are more likely to self refer to treatment due to problems that impact their well-being. You know, this is another thing we talked about before. Kids don't refer themselves. You know, teachers, parents are having problems with the kids and they bring them in. Adults are, especially for ADHD, they're more likely to notice it in themselves. Right? At the same time, we tend not to be good self-observers. We don't really look like we're not really good at knowing how others see us or perceive us. We often will think that people are overly critical of us when they really aren't, or we may not notice that people are extremely annoyed by us. But we just don't notice it at all. Right? And so, remember, in childhood, you need six of the nine symptoms in either the hyperactive and pulsivity category or the attention, and you can of course meet both, but only one is required, and you need six of the nine symptoms. And remember, in adults, that's only five of nine symptoms. But it's still impairment in greater than or equal to two settings. So just to remind you what the DSM criteria is, I don't think this is a terrible guideline. We need some sort of guidelines, but I want to continue the discussion that we're having in kind of like what, how this looks as an adulthood. All right. So, you know, you could think of this concept of inattention, right? But you could also flip it on its head instead of saying that there's a deficit of attention, that there's an abundance of attention, right? So we have these situations I mentioned this before. Patients are super interested on a topic. So they're, you know, it's like they're very able to focus on this one thing that they're really interested in. You know, this could be like some sort of topic, like history, or you know, some subject they're interested in, or it could be a hobby that they're really interested in. And like they show no signs of ADHD with that thing. So I would actually say that this could be, this could be a sign they have ADHD because people with ADHD often have this super attention. It's almost like a counterbalance to the fact that they can't pay attention to anything else in their life and can't like, you know, they can't deal with any of these other things. But what they do is they find the one or two things that they really, really like and because they can focus on those things, they go like overboard on them, right? Folks that don't have ADHD, tend not to do this. They tend to just kind of pay attention like a normal person. And they've got hobbies and they've got things that they're more interested in, right? But I feel like people think about it. If you're, if you're having difficulty focusing and having interest in like most of the things that you're supposed to in life, that's probably really uncomfortable. And so you may then, if you find something that you really like that you can focus on, you may just put all of your energy into that, right? So whereas some people might say, oh, they can really do this well. And maybe that's, you know, like their job or something. It's like, well, then they're not impaired, you know? But this actually could be a sign that they have ADHD, all right? So when, when something's boring, be it reading a book, being in a meeting, having a conversation with somebody, whatever. And it's boring, the mind will go to whatever is enchanting without regard for danger or authority, you know? You're in a meeting with, in your bosses in there and you're just, you're in law and land, right? You don't care that you could be getting in trouble at work or, you know, maybe you're in a situation where not paying attention could put you at risk and you're just not interested in it, right? So you're not really thinking, and maybe you're thinking, maybe you're driving a car, right? And you're just focused on all these other things and you keep coming back saying, oh my gosh, I need a patient, you know, I almost, you know, didn't see that person coming or, you know, I need to focus. It's just like, but you just keep finding yourself going off into law, a land, right? And, you know, I think when I'm in traffic, you know, self-admission, I think I very well possibly could have ADHD. The more I think about these topics, I meet so many of these qualities. But like on the flip side, I was like an excellent student all the way through high school. I, you know, summa cum laude, 3.96 GPA in a pretty good university, right? Got into medical school, you know, she you're probably thinking, you know, never treated for ADHD or thinking, there's no way this guy who's like, you know, performing well, like the teachers like him, doing well in class has ADHD. But then I get into the workforce, right? Especially before medical school, bored out of my mind, can't focus on anything, twiddling, fidgeting, you know, not paying attention to what's going on in the meeting. Just so bored, I mean, I would bring flashcards with me to study other things while the meeting would going on and try to hide it under the table because I just couldn't stand being in there that much. I mean, I've never been diagnosed with ADHD. I've never had anyone tell me that I had it. But what I'm telling you is this is something that you might see, right? You're flipping through stuff, you're you're just you're doing something else. And just because you know, you somebody did well in all these other aspects, you know, and then when I'm driving const, like one reason why I don't want to get into traffic is because when cars are not moving, I do not pay attention at all. Like, I won't say that. I'm trying to pay attention. Essentially, what I do is I won't put myself in those situations at all costs. I used to like, when I was at work and I had a commute that would cause me to be stuck in traffic, I would actually stay at work later in order to not be in traffic. I would stay there till like 630 or 8, even though I was done with my work at 4, just because I didn't want to go into traffic. Like, I mean, obviously, I'm getting home hours later than if I just sat in traffic. But I couldn't stand it. And I knew I wouldn't be able to focus. And I knew that I would be a risk. And so I just, you know, if I could get out earlier for whenever reason, I would get out earlier. But normally, I would just stay late. I would just I would find stuff to do. I'd work on these presentations. I would stay late and I would avoid the traffic because I can't pay attention to traffic. Because the other thing I would do is I'll just exit. Right. I'm just like, I'm just going to take the long way home. I'm going to take every back road, every back street. It might take me 30 minutes longer to get back to my house. But if I am twisting and turning and curving and finding new pass and going down alleyways, I'm paying attention. If I'm sitting on the highway, not moving at all, having no idea when I'm going to get the heck out of there, I'm not paying attention. And then I'm at risk of, you know, getting hit by someone else because I didn't move or hitting someone else because I wasn't paying attention. So I just personally, I'm telling you know, it's a personal story how I'm saying that this can present. I just avoid these these traffic situations at all costs because I am that hard for me to focus. When I when I when I'm in a situation, I don't know anyone that goes to the leans that I do to avoid being in traffic because I am so unable to focus and so frustrated and so anxious of the situation. Most people just deal with it. See, this would be an example of someone going out of their way to do something that's almost bizarre. And there could be, I mean, that story alone could be explained by something else. It could be anxiety. It could be, you know, some sort of personality issue, right? But ADHD to me is in the differential until you learn more, right? So people that they kind of, they get bored and they're forced into a situation, they're going to, they're going to fiddle, they're going to daydream, they're going to, you know, try to get out of there, they're going to maybe not make eye contact, you know, they're trying to basically deal with the fact that they can't focus on what's going on. And that can have consequences as far as danger, right? You can get in a car accident or something like that, or you could not get promoted at work, you could have trouble at work, things like that. And then your productivity decreases and then, and then you can become depressed because you're not achieving what you thought you could achieve, right? Maybe you were a high achiever before, you were doing well and now you're in a situation where because of these barriers, you just can't deal with it, all right? So that's the abundance of attention idea. Let's move on to seeking high stimulation risk and conflict, right? So this is another thing. People with adult ADHD have a tendency to seek out high stimulation, seek out risk, seek out conflict, right? And this could be in one of many ways. It could be in the job they choose, right? Something like stock trader, trial attorney, neurosurgeon, entrepreneur, the military, right? These are, you know, in some cases, risky jobs, high stimulation jobs because the thing is, to deal with their ADHD, they can't be in the boring environment. Boring environments are just intolerable. They need high stimulation. What is something exciting? Stuff happens, stuff moves. You know, there's change, there's risk that, you know, something to keep me awake, right? And then avoiding things that, you know, avoiding details, paperwork, administrative things, right? It's like, you know, they're always like trying to find excuse to not have to do this paperwork or do this meeting or maybe get someone else to do it because they just can't sit down for it, right? So and these are professional jobs, right? So you're like, wow, someone with ADHD could become a neurosurgeon. Hey, a lot of people that are neurosurgeons have ADHD. In fact, they were gravitated towards that field because it's something that helped them control their symptoms and they may not even realize it, right? You might think, I don't want my neurosurgeon to have ADHD. Well, you may want your, your neurosurgeon to have ADHD if they're like hyper, this is the thing where they get hyper focused on. Here's another, here's some other things, right? Having lots of projects going simultaneously, right? They can't just do one thing and then finish it and move on to the next. It's like, no, you know, because everything gets boring at some point. So it's like, I'm, whoa, I'm working on this. This is exciting. Okay, it's getting a little slow. I need to start something else. It's going to stimulate me. Let's get another project going. All right. And sometimes I'll come back and work on that, but then I'll work on this other thing and then I've got this other thing going on. Like every day I'm doing something else. And you know, it's like you're juggling all these different things, but it's what's you know, it's like a treatment for your difficulty with focus, right? These folks have low frustration tolerance. Anytime they get slowed down by something, it's like they've got the paperwork, you know, it's getting bounced back to them. Oh, you didn't, you didn't dot this side. You didn't cross this tier. You didn't get this signature in the right place and they just cannot freaking handle it. It's just like, no, I'm done with this. I'm either going to just not care and just drop this issue or I'm going to like maybe blow up a little bit. Maybe people will see it. Maybe they won't, right? Difficulty following through, right? So things that require these kind of tedious tasks, you know, it's just like, all right, I'm just going to, you know, screw it. I was going to, you know, apply for this thing, you know, and it just took way too much work and I just kept getting things just kept bouncing back and they just kind of, they do the cost benefit analysis. Like, I put this much time and energy into this. This is what I'm going to get out of it. I don't want to put any more time and energy into this. I'm done. It's just not worth it to me. No fall through, right? They may have substance abuse issues. They may do excessive spending. They may have problems with sex like many sexual partners or cheating on their partner gambling, right? So these are all things that could be encompassed in this kind of seeking high simulation risk conflict. So this is almost like how people with alcohol abuse or anxiety use alcohol to self-medicate. Like these are kind of ways you could self-medicate the ADHD symptoms, right? And then this idea that women may have this like quiet underachieving, right? They're not outgoing and they're just not quite meeting up to what their potential is and they just, you know, they're kind of meek about it. But I mean, honestly, this could be men or women. I think that's probably like a stereotype that that's something more seen in women. All right. Let's talk about all the different ways that the impulsivity could present itself. So we've got cognitive impulsivity, motivational impulsivity, and emotional impulsivity. I think in kids, when we think of impulsivity, we think, you know, can't sit still in the chair, can't hold the thought in, have to blurt it out in inappropriate moments, right? It's like pretty obvious. But with adults, hey, we're better at hiding these things. We're better at like pushing things down and trying to be socially acceptable. So like how does this impulsivity present in someone with ADHD? It's like you still have it, but like how is it coming out? So cognitive impulsivity. This means kind of impulsively making decisions. Like, I don't want to go through the details. I don't want to check and make sure everything is smooth and going to happen. I just want the decision made. I'm not going to look into all the the pluses and minuses. Just boom, this is what we're doing. Let's move forward, right? Poor contemplation. So this is like, just it's kind of the same thing. Like instead of contemplating things and weighing the plus and minuses, just kind of being like, you know, I'm either not doing something or I'm going to do this and, you know, damn the consequences, right? So that would be like cognitive impulsivity. So like impulsivity of like thought processing, all right? Let's talk about motivational impulsivity, right? So motivation can be hard when you have ADHD. And, you know, how do we, you know, how are these people combating that, right? So they made, you know, they, they may have difficulty with discounting future rewards, right? So it's kind of like, oh, this isn't the future. This is such a long time from now. Right. I just, you know, they just can't value what's going to happen in the future. And so they discount those future rewards. And they, they're like, you know, they don't realize how valuable it is to do something now that seems boring and, you know, tedious for the payout, they're going to get later. And so they just like drop it and they miss out on the payout, right? This could lead to procrastination, you know, or it's just like, they just don't want to do it. And they just let it linger and linger and linger or an inability to generate forced effort. Like they just can't push through. Like it's like, I have to this, but I just can't force the effort. I'm just going to give up on it, right? Or just have a lack of motivation, like, oh, man, I just, I can't feel the benefit that's going to have from this. And so I just don't have any motivation to do anything about it. So I'm just like, I'm not going to deal with it, right? And there's this need for immediate reward. Like if I can get the reward now, I will do it. That's what will motivate me. The future thing, I just can't, I can't quite do what I need to do now for the future thing. And only do things that I'm going to get an immediate reward, right? And that could cause you to make poor decisions when it comes to a lot of the lifestyle stuff. They're when you're talking about it on the flip side, obesity, medicine podcast. So this could cause people to not have good sleep hygiene, not have good nutrition, not have good exercise, not have good health. Because it's like, they're discounting those future rewards. They're just like not worth putting in the effort to like, you know, go ahead and get them honest like that they need. Eat the right foods. Do the correct exercise, right? And it may lead to risk taking, right? Because they can't tolerate a low stimulation environment. And so if there's, if they're in a low stimulation environment, they might be like, I need to get out of this. I can't handle this. I'm going to go ahead and take some sort of risk. And, you know, I think risk could be lots of things. They could be, like I said, they could be gambling. They could be sex. They could be maybe quitting a job before thinking what you're going to do after that. It could be, you know, dropping out of school when, you know, you know, that, you know, finishing that's going to be beneficial to you. It could be seeking out some sort of high stimulation that puts you in physical danger or whatever, right? There's all different types of risk taking. Like don't just think of risk taking in a very simple way. I think people kind of have in mind what they think risk taking is. But it could be, it's, it's, we all take risk. risks every day and every moment. But this is about like not really taking smart risks. Like taking chances that they really shouldn't take because they don't want to deal with weighing the consequences of it. Right? And not not just being able to figure out that you know what? More likely this is going to go bad, but I don't want to wait and this seems really exciting. So I'm just going to like do it in anybody. All right? And the last type of impulsivity, emotional impulsivity. So this is like your mood, right? So this is like being really reactive to the situation. You know, like something bad happened and then you know, getting really getting really sad really easily without really thinking through it or something really great happened just getting really excited. You know, this is this is a quality borderline personality disorder, but it could be a quality of ADHD. Um, mood liability, you know, just mood switches from one to the other. Um, temper out bursts, you know, something's frustrating and then just you can't hold it in and just blah, you know, just get angry and just kind of throw a fit and when it when when really if you just think about it, calm down, give it a day, things will be fine. But then you've kind of made a scene and looked foolish, right? Um, the poor frustration tolerance, I mentioned. And then, you know, maybe having some poor social skills or lack of social judgment because it's just like maybe you know that this is like not social acceptable, but you just can't hold it in. And so you just react, right? And so, you know, a lot of this, like, there's a lot of overlap here, right? I'm not saying that if you have like if you or someone else has one or a few of these qualities that you have ADHD, I'm describing lots of different things that could point you in a direct of ADHD, right? So once again, I just want to make that point because these are also symptoms of a lot of other things. But I want you to think like they may you may associate these with like borderline personality disorder, but they could be ADHD. They could also be borderline personality disorder, right? Let's talk about executive functioning impairment, right? So what does that mean? I'm going to go through several points that illustrate that. So executive functioning is kind of like your ability to process and reason through things and come up with good solutions and make good choices, right? And so I kind of have in parentheses here and in quotations, adulting is hard, right? So we're talking about adults. You're not a kid anymore. You can't act like a kid. You don't have somebody like making rules for you anymore. You have to be an adult now, right? And some people they just don't do very well at this, right? So let's go through some examples. So the ability to stop an action when changes needed and have flexibility. So adults with the adult ADHD, they may have difficulty with this. So it's like, you know, you're going in one direction, you're liking going in that direction, but you're kind of getting the print impression that, you know, going in that direction is not really going to work out, but you just don't want to change anyway. And so you just, you're like, you know what? I'm going to see this to the end. I know it's going to drive me off the cliff, but I don't care, right? So that's what that would be, right? The healthy thing would be like, okay, let's stop. Let's reassess. Okay. Probably not a great idea. Let's, you know, put this on hold, brainstorm, what's a better plan. And then let's execute that. You know, this ADHD person is like, no, I'm not dealing with that crap. Let's just, let's just keep going. And let's drive this car off the cliff. If that's what's going to happen, that's what's going to happen, because I'm not dealing with with the, with doing the other stuff. Just not worth it to me. Once again, it's like that short-term game. Like, I'm enjoying this. I'm getting something out of this right now and I don't want to change. Um, difficulty organizing things and thoughts. So, you know, the older you get, you have to manage more schedules for yourself, for your family, for work, for school. Like, you got lots of things going on, right? And, you know, I'm not saying that multitasking is something that the human brain is not well equipped for, but being able to keep track of things, whether it's using a planner or your phone or some app or whatever and like, being able to follow through with that and keep it in, because the thing is, as an adult, you have to pay bills and go to work and get your kids to school and pay attention to your spouse. And, um, accomplish the things that work that you're supposed to do and wake up on time and do your hygiene and get enough sleep and eat, right? There's all these things and there's no one's telling you to do these things. And I think, you know, in those kind of late adolescent years, this is when you're kind of learning these skills. And most people grow into them and figure it out. Some people don't. And some of those people, it may be because they have adult ADHD, all right? Here's another one, overcommitting, right? So this is frequent overcommitting, like, you know, someone asks for something or there's an opportunity to do something and just not really assessing what future needs are going to be and whether you're going to be able to follow through this and just like being a positive person, just being like, I'll do it. I'll do it. And then when it comes time to do it, you realize you don't have enough time for it. You haven't managed your schedule well and you realize you're not going to be able to accomplish this and then you have to bail on people, right? That could be a sign of ADHD. Um, so talking about another executive function, issue, time blindness. So this is like knowing how long it takes to do something, right? And you need this in order to meet deadlines, whether it be paying bills on time or getting to work or getting children to activities and picking them up on time and remembering to pick them up and knowing how long it takes to get from one point to another at this time of day on this day of the week, you know, these ADHD folks, they tend to have two times now and not now. That's how that's how they think, well, there's now and there's everything except for now and everything except for now, there's a lot more going on there, but like it's just like, I know what's going on right now, everything else is something else. That's that would be like an ADHD way of thinking about it. Um, if it's not and if it's not now, then boom, gone out of my mind. I have no idea. It's in one ear and out the other. If you didn't write that down, if you didn't record something, it is gone and it's not coming back. You will not even remember that somebody told you that thing. They will remind you, I said that and then they'll be like, you did. Oh, I did you hear him? Who knows? All you know is that whatever it was was not, was in the not now category and boom, out of your head. Um, panicking adrenaline at the last moment can help with focus. That's another one. Hey, if it's now, then I can rock it, right? Like, I'm, you know, these folks are good at now. It's like, oh, I got to get something done now or I got a study for this test of the last moment. I don't know anything. I'll stay up all night and I'll get pumped and I'll use my adrenaline and my panic and I'll get it done and, you know, boom, boom, boom, boom. Yeah, I love, I love the rush, right? So that could be another quality. Let's talk about another, another executive functioning issue, um, sustained attention. So less likely to resist distractions. Some, you know, you're doing something and then you, you think about something else or you remember something you were trying to remember yesterday or, you know, you remember something that you wanted to look up and see you pop the phone up and so like, this difficulty resisting these distractions. And then after that, difficulty re-engaging and the thing that you were doing. So like, this being able to like finish tasks through to the end, right? Being able to sustain that attention to the finish. But there's also a difficulty in initiating a task. It's like, oh, I know I have to do this thing. Getting started with that, you know, like, I hate planning trips because there's all these frustrations with it. Like, I do, you know, I take a lot of trips. I get really good ones, but like, it's like, every time you have to do it, it's like, there's always a roadblock. Oh, this time's not available. No, this price is not, is too much. And this and it's just so much that it's just like, I don't even want to start planning because I know all the frustrations I'm going to deal with. And so I'd rather deal with something I know, I can, that I'm interested in, that I know I can do right now and do that and all initiate this task later, right? Um, goal directed persistence. So just like, staying on one goal directed thing, that's kind of like sustained attention, but um, it's a little bit different. And then awareness of your own thought process. So like, a lot of times these folks, they don't even, they don't realize that this is happening, right? All this stuff we're talking about, this is why I'm telling, you know, the providers out there and, and the folks that think they might be suffering from this, you know, just do you realize that this is actually what's going on in your head? All right? This next, this next slide, I want to talk about like how symptoms in childhood, what they, how they look different in childhood versus adulthood, like how does that change, right? So in childhood, kids doing poorly in school, they're not achieving what happens later. Job failure and under employment, right? As an adult in childhood, maybe they're getting injured a lot, you know, a lot of cuts and scrapes, spilling off the bike, stuff like that, that turns into fatal car wrecks risk taking. In childhood, maybe some drug experimentation turns into drug dependence. In childhood, like oppositional defined disorder, conduct disorder turns into criminal involvement. In childhood, impulsivity and carelessness turns into things like unwanted pregnancies, sexually transmitted diseases, stuff like that, right? So, I mean, what you're seeing is that the consequences in adulthood are way worse than the consequences in childhood, right? Because in childhood, you're being kind of coddled, hopefully, if you're in a good environment, you're being kind of coddled by school and parents. As an adult, you don't have this anymore. A lot of kids don't either. But let's just take it that you did. You don't have that anymore. So now the consequences become much greater. Some of it is like that same behavior, you know, doing it longer and longer and longer turns into something worse. Or, you know, things that maybe a kid wouldn't get involved in, but the same kind of thought process that's getting them in trouble is something. As an adult, they would then engage in these risky activities, right? And then the last one I have is like repetitive failure in childhood turns into hopelessness frustration and giving up. So a kid that's like, you know, maybe not depressed and stuff, but just like failing all the time. And then this continues in adulthood because, you know, they can't do anything because their attention problem is assuming the attention is the problem here. It turns into hopelessness frustration, giving up, maybe even suicide. I mean, I think I told you about the guy that was like trying to kill himself and then I treated him for ADHD. I mean, that was probably one of the most remarkable turnarounds from like an ADHD treatment I ever saw. All right. And these, this one is, you know, say you don't know where to get started with this patient. You know, you've got a patient, you're maybe thinking something about ADHD. You're worried maybe that they're gaming you or that you haven't quite got it right. What are some questions you could ask that are going to give you more information to help you make a good diagnosis of ADHD and adulthood? Were you a very active child? So like a lot of these questions are going to be geared towards what were you like when you were a kid? Because remember 99.9% of the time, this is starting in childhood, right? Well, it's starting, but then sometimes we may not see it in childhood, but we may get clues about childhood from these questions, even if they weren't diagnosed. I mean, one question to me, did you get diagnosed with this in childhood? If the answer is no, then how can we, how can we try and dig out that maybe you did have this in childhood? Did parents or teachers complain that you were difficult? Are you accident prone? How did you do academically? I always ask them, how did you do in school? Were your grades like? And then I want to know, you know, is that congruent with your intelligence, right? Do you feel like you should have done better? Do you feel like you struggled because it was hard for you or because, you know, of some other reason, like, why did you not do? If you didn't do well, why didn't you do well? Was it like a home situation? Was it depression you were dealing with? Is it that you didn't understand things? There could be a million reasons. So the answer to did you do well, not do well and why could give you a clue? If they're like, you know, I read a million books and I was great on the debate team, but I did poorly in every single class because I never did my homework. I never studied. I never paid attention in class. I skipped class a lot of the time. That could be a sign that they had ADHD, right? So not every story of poor academic performance is going to give you that clue, but that would be one example, right? If you've got kind of the hint that they probably should have done better, but for like reasons that were kind of not because of their environment, we're making them do poorly, ADHD might be the reason. And the fact is that person probably was passing and maybe they were quiet and didn't cause any problems. It's just never, you know, hey, they were a BC student. You know, they weren't disruptive in class. You know, they weren't they were average to below average student. It's the failing student that comes to comes to the four, right? It's the one that's this disruptive, the one that's causing problems. Those are the ones that are going to get tagged with ADHD or the ones that are like, you have parents that are just like very involved in the kids, you know, stuff and like, I think they should be doing better. If you've got parents that don't have time or don't have the knowledge to like recognize these things and then the kids kind of passable and like quiet in school, they could easily get through school with nobody coming to the idea that they had ADHD, right? So just because they didn't get diagnosed or get flagged for, it doesn't mean that they didn't have it. Other questions. Did you ever fail a grade or you ever suspended or expelled? And remember, a yes answer to these questions is not like, oh, then you have ADHD. If you answer yes to every one of these questions, that still doesn't mean that you have ADHD. But the answers and the explanations to the answers are going to give you clues, all right? So I don't want to, this is not a, if you have this, then you have ADHD. Now, was your performance at school variable or unpredictable? How many jobs have you had? How many times have you been fired? You know, we're getting to adulthood here. What kinds of things give you problems at work? Do you have trouble living with others, right? So we're getting it, you know, we talked a lot about their school performance here. Now we're looking at their job performance. We're looking at their social interactions. How much do you smoke, drink, use marijuana? Is substance abuse an issue? How many car accidents have you had? How many traffic tickets or speeding tickets? You know, looking at impulsivity here. What do you enjoy doing with your spare time? That's always a good question to ask someone. I will always want to know this because that's going to give me an idea of what their life is like. Okay. So that's just kind of generally like what's your life like? Do you have trouble with money, housework, being on time? So we're looking at time blindness. We're looking at getting boring tasks done. We're looking at meeting deadlines, right? Do you feel addicted to anything? Gamble, computer games, games? So we're looking at their impulsivity and their like addictive stimulation, seeking behavior, right? So these are all really good questions to kind of get at some of the points I've already talked about. All right. So I told you towards the end, I would talk about, you know, is it overdiagnosed or underdiagnosed? Spoiler alert, it's both, right? So many folks are going undiagnosed or misdiagnosed with other mood disorders, anxiety, bipolar disorder. This is totally a thing I see it all the time. On the flip side, many folks are seeking the diagnosis. They want to be on stimulants. They're wanting a performance enhancer. They're wanting something to make things easier for them so they don't have to do the hard work. You know, a lot of people, they don't want to do any work. They just want to be lazy. They're just lazy. It's not ADHD. It's just like laziness, right? And they want something to help them get through the studying so they can like pass the class, right? And a lot of people are just seeking a socially acceptable answer to their problems. You know, so like they don't want to be told they have a personality disorder or an adjustment disorder or they're just lazy or, you know, some something that sounds negative. But you know, oh, I have autism. I have ADHD. I have bipolar disorder. For some reason, those three things are like socially acceptable. I have major depressive disorder, not so much. I have generalized anxiety disorder, not so much, right? I have social anxiety disorder. I have seasonal effectiveness. These are not things that people want to say or use excuses. For whatever reason bipolar disorder, ADHD and autism seem to be like socially acceptable, like excuses for, you know, their personality, their behaviors. And so whether someone has that or not, they may want that and they may have it, right? So just because someone comes in thinking they have something doesn't mean they don't. It just makes me more cautious about because they're coming in with bias. They're trying to sell me on this. And I'm trying to figure out what's going on and I don't want the bias. And so like I have to like take a little bit more time, a few more, you know, to try and ferret this out and without is trying to get their bias out of it as much as possible. I want to see exactly what's going on, right? So they may be seeking this, right? How can you guard if you're worried about over diagnosis, what can we do? Right? So first thing, tell your patient you cannot diagnose or start treatment in one visit. I've already told you before sometimes I do, but that's when I'm like pretty darn sure and it's when I'm not suspicious that I think that they're trying to get a diagnosis from me. I mean, it's like, you know, I really think this is it. Why waste more time? Why waste another month? This is the thing I think it is. I'm going to go ahead and get started on it now. But if you're unsure and you're kind of, you know, just say, you know, you can't diagnose or start treatment in one visit. Some folks won't come back because they'll assume that you're not going to do it and they'll go find someone else or they'll give up. However, if they are seeking the diagnosis, but it seems like a reasonable explanation to their problem, I'll diagnose and treat on the first visit said that. And then it gives time to get collateral information directly and directly. So like, you know, I'm going to go ahead and get started on it. If you want to get, like, maybe you don't want to necessarily trust what they're saying because you feel like they're some bias there. It gives you chance to, like, maybe talk to a family member, get their permission for that. If they're married, maybe have their spouse come in with them next time, maybe get some outside records, have them contact their family doctor when they were a kid, get you those records to show that, "Hey, this person actually was diagnosed with ADHD when they were younger." So, you know, give them some work to do. "Hey, get me your record. Let me talk to a doctor you saw before. Like, bring your spouse in, you know, bring a friend in. Can I, you know, give me permission to talk to someone on the phone. It gives you time for that. It gives you time to get the diagnosis right." So, like, those are some things that you can do to prevent over diagnosis if you're concerned about it. And then, just to kind of finish up, like, I'm kind of talking about kind of all the negatives that can be associated with, you know, adult ADHD. But let's talk about some of the positives, right? So there are some good things that can happen from this, right? So there's a lot of Nobel Prize winners that actually have ADHD. There's a lot of self-made millionaires and billionaires. I mean, I think I can think of a few offhand, you know, these are risk takers. These are, you know, folks that are not afraid to cut through the crap and go straight to the point. And sometimes they get it right. You know, a lot of polls are prize winners have ADHD, right? So some people, if they're, there are positive qualities that you can have with this, that if you can learn how to control those, you can manifest those into some pretty cool achievements, right? What about the distractibility? Hey, another way of thinking about the distractibility is curiosity. That's a good quality, you know, distractibility. Oh, I can't focus on anything. Well, we could think about that. You're just curious. You want to know a lot of things. It's like, you have difficulty focusing on one thing because it's like, oh, I wonder about this other thing and I wonder about this other thing. And being curious about the world and things is good, you know? So, you know, if you can learn how to use that curiosity for something positive and get the distractibility to be lower, right? So this could be a good quality. Impulsivity. What could be good about that? A lot of impulses of people are creative. They have good imaginations. And then spontaneity can be a great thing. Who doesn't like, well, some people don't. But like, people that are spontaneous are often really fun people to be around. It's like, if you're someone that's like more controlled and more like, you know, like not ADHD at all and you're just kind of thinking, you know, I wish I had more fun. I wish I could think of things that were fun to do. That ADHD friend of yours is like, hey, let's go do this. And it's like, whoa, let's think about this first. But like, hey, I had a friend that was super spontaneous when I was in high school. I probably had more fun than I ever had my entire life just kind of like following his lead. At the same time, we probably could have gotten ourselves killed doing some of this stuff or in serious trouble. But like, you know, within reason, spontaneity, you know, can be a really fun, cool thing. And it can add spice to your life and it can make a boring existence a little more interesting. Of course, I mean, you don't want to take undue risks. I mean, but you know, as teenagers, that's what people tend to do. So like, you know, I'm not going to get down on my teenage self. But you know, that spontaneity can be real fun, you know, and it can help with finding a romantic partner, you know, oftentimes romantic partners really value spontaneity. It's, you know, oh, I just got you this thing and, you know, and like, oh my gosh, you thought of me, you know. So that can be a great thing. And then the restlessness, you think, oh, what's good about restlessness? Well, that means you have a lot of energy. If you're restless and you're moving around, you're doing all this other stuff, hey, having a lot of energy is good. Let's use that energy. Let's go, you know, exercise. Let's go lift weights. Let's go play a sport. Let's, if it's middle energy, let's focus on a task and achieve something really awesome, you know. So, you know, I think, you know, I think ADHD in many respects, and I've heard, and I've heard this, this argument about alcoholism, like that the people that have alcohol dependence in today's world, when you think about them 10,000 years ago, when we used to like live in the woods, these were the people that were the risk takers. They were the leaders. They were the ones protecting the village, right? They were out in the forefront, and they were ready to, you know, these people were vital. And now, like in today's society, these kind of characteristics aren't needed as much anymore. And a lot of these folks, they're still seeking this, like stimulation and these things. And because there's not like the village to protect and like all these sort of things going on, they might turn to alcohol because that's the risk they're taking. They might turn to gambling because it's like, well, I can't take risks in the forest. I'm going to take risks at the casino, right? So, and I think ADHD can kind of be thought about in this way as well. Like, of course, there's folks that back in the caveman days, if you couldn't focus and pay attention, you were going to get eaten by a lion, right? Because you just like weren't doing what you were supposed to be doing. You couldn't like stay up all night and it was really boring, you know, watching things. But at the same time, there's a lot of folks that were, you know, in that world, we're getting a lot of stimulation that they're not getting now. So it could have like always think of everything in an evolutionary fashion. Like, why does this exist today? It must have had some sort of evolutionary advantage. And like, we can still probably give it an advantage. But a lot of the advantages that we developed this for, you know, society has changed so much. And I think a lot of mental health outside of your like really severe stuff, like schizophrenia bipolar disorder, which are like, you know, and really legit severe bad suicidal major depressive disorder, just like melancholia to the max. Like, those are diseases of the brain, just like any other disease that someone might have. But a lot of the stuff that we're dealing with with these personality things and adjustment disorders and ADHD, these things that I think people think of is severe. They become severe because maybe these were helpful before. And now in the modern world or whatever environment this particular person tends to find themselves in, it just isn't. And, you know, can we then figure out how to harness the positive qualities that go along with that? Maybe treating with medication as the answer, maybe changing something else as the answer, maybe changing work is the answer. Maybe you went to the wrong job, maybe you're with the wrong person, maybe, you know, you're in the wrong place, right? Maybe you need to pick a different job. Remember those jobs that people with ADHD tend to have, maybe you need to look at something like that, right? But then, you know, let's wrap up the negatives. Okay. The prison population, full of people with ADHD, people with addiction, full of people with ADHD, multiple failed relationships, people with multiple divorces, filled with people with ADHD, the unemployed lot of ADHD, accident prone people, ADHD. So ADHD can get you into a lot of problems. And I think a lot of people don't want to treat people with ADHD prisoner with a drug, right? Or someone who's addicted with a drug, right? And they want to think of these like the reason why you're addicted and you're in prison and you're failing relationships and you're not employed and you're accident prone, this is all personal failure, right? But if we think of it that this person could have ADHD and then treat it, they may not end up in these situations or we may be able to get them out of it. And this is, you know, one reason why I love treating ADHD because it's so responsive and people just do so well with it. But you've got to find the right person. You can't just say, "Oh, everyone has ADHD, I'm just going to treat it." So, you know, I mean, I really enjoyed doing this episode. I think this is going to be like for me, this is like the core of what we're going to be talking about. Like I'm going to go into all the treatments for ADHD for, you know, for the next several episodes on ADHD, I'm going to go through all the drugs and how they work and how to pick one. And then we're going to talk about all the stuff about, you know, all the side effects and what to do about those and how to time things and how to, you know, how to use them and how to, you know, how to dose and stuff like that. But I think, you know, when I'm thinking about adults with ADHD, which is who I know, first we have to find the people to treat. And I hope that after listening to this episode, if you're the person that's finding the person to treat, you may be thinking, "Oh, man, maybe that guy had ADHD or that gal had ADHD and I thought they had something else. Maybe I reconsider." And if you're a patient out there or a potential patient and you're thinking, "I wonder if I have ADHD and you listen to this episode and you're like, "You know what? That's not as much me as maybe I thought it was," or "Holy crap." You know, like maybe I thought, you know, people have been telling me I'm depressed, but This like fits way better. better. Hey, go and be seen and say, you know, you, you know, hopefully, you know, I know there's tons of content on adult ADHD out there. And I've watched it. And it's mostly garbage. It's, it's mostly people that think they have it, whether they do or not. And they're, and they're talking about how this is how they have it. Or these quick little, like, if you've got this, then it's this, um, I'm hoping I've added something to the discussion. I'm hoping that like I've filled in some of the gaps with this. Um, I'm sure that those that are skeptical will question everything I said in this episode. And, you know, if I haven't won you over, then that's fine. Agreed to disagree. Uh, hopefully with those that that's not the case, you feel like, you know, you've learned something. Um, but I wanted, you know, once again, thank everyone for tuning in. And hope you enjoyed the episode. Um, I've got another episode on BC medicine coming up. We're getting into nutrition. And, um, at when we get back to ADHD, I'm going to talk about the treatment algorithm. So I'm not going to get into the drugs, but we're going to talk about kind of what the treatments are and how to do it. And for today's song, I have chosen a song by one of my favorite bands, Blink 182. Um, some of you that are in your 40s may remember this song. It was their first major hit. Um, Dammit from the album Dood Ranch. And I chose this song because they say, "So this is growing up. This is an episode about ADHD. It's seem fitting to me. So I hope you enjoyed the song. Hope you enjoy the episode. And I'll see you next time. [Music]