Weekly Q&A: Azstarys for ADHD

Added: 2026-05-13

[00:00:02]Hello, I'm Dr. John Chris and welcome to today's question and answer hour where I will try to answer questions about the most recently released video about other videos and information about ADHD that's on this channel and and more broadly about mental health questions.

[00:00:18]And hopefully Elon Musk's Starlink will remain viable for this hour. Sometimes it goes down briefly. If it does, I will try to keep talking and repeat things. I might have said well the connection was bad.

[00:00:34]So the I'll summarize the video that was released this past week about Asteris and then after that and that should only take a minute or so depending on how long I go on. Um I see there's already several good questions waiting for me.

[00:00:51]So the video was on Asteris which is the brandame long acting methylenadate product. Um, it's available in the US. Um, it's not available in parts of the EU and I believe Australia, but there's certainly some companies that it's not available.

[00:01:11]Um, the company that just bought out the company that had been producing it paid, I believe it was half a billion dollars earlier this year because they clearly think this is going to be a blockbuster.

[00:01:24]It's been on the market a few years and I would be surprised if it is. So, it's based on a pro drug just as Viveance is and they're hoping for Vance's success.

[00:01:36]Vivian Vance worldwide has captured more than 10% of the stimulant market which is a huge share for any single product.

[00:01:46]Um, so Viviance is a prod drug of mrompetamine with the lysine molecule linked to it.

[00:01:53]um this new product and the same company iron shore that was one of the ones developing it had tried for years to make a methylenadate pro drug didn't succeed um and this is as developed by a second company so first off asteris is not just simply a pro so prod drug again is an inactive form of the drug it needs to be chemically modified or changed in the body before it becomes an active drug.

[00:02:23]So, eststeris contains both a prod drug and um immediate release methylenadate.

[00:02:30]So, the prod drug is called sir dexmethylenadate. So, it's a serene amino acid and a nascin molecule linked to the methylenadate. It actually needs to be cleaved in the distal parts of the intestine before it's active. And sir dex methylenidate by the FDA was actually only classified as a schedule 4 substance. So much less restrictive than schedule 2 as are all other methylenidate and embedine products. But then once they combined it back with immediate release methylenidate it jumps up back to a schedule two. So the sdexmethylenidate is when offered to people who've had some issues with stimulant not necessarily full abuse but have dabbled with abuse.

[00:03:25]Let's just say there was no appreciable excitement, joy, pleasurable sensations from taking this. And that's because the active stimulant medication doesn't start being produced by the body for several hours close to two or three. So when you take eststeris most of the first several hours are immediately it's released. So the down things one is they've immediately they are not a good candidate for someone who has a history of problematic use with stimulants. Um because again there is a potential for addiction with the immediate release component. They've stuck back in. So they've cannibalized or gotten rid of some part of their prospective market.

[00:04:14]And then my second objection to it is that people who like it proclaim it as being smooth. It goes in slowly. It wears off slowly. And when we say wear off, it doesn't wear off. There's considerable amounts of methylenidate being delivered throughout the night. So the pharmaccoinetics which is how your body handles the drug profiles that I've seen suggest that 24 hours after a single dose your blood levels of methyl feminidate are between 25 to 40% of the peak level. So, so it does go up quickly because the immediate release component it comes down fairly quickly and then somewhere about 8 hours out it's a very slow flat plateau but that plateau the amount in your blood is somewhere between a quarter to 40% of the peak level. So that's considerable amounts.

[00:05:14]There is very few studies were needed to get this approved by the FDA because methylenadase has already been approved.

[00:05:21]Um so it's just one study in children with I think 150 or kids. There is a couple longterm there's one long-term study by an child at University of Las Vegas um and collaborators. They've had several publications out of this following up a group of I believe 250 kids who were titrated to optimal dosage and followed for at least a year on this. And they showed that actually some parameters of sleep improved during the year, but as a group the kids on the stairs still had measurable severe sleep disruptions and particularly falling asleep worsened during the course of treatment of the I think some of the rest of the improvement in sleep comes from being in a study and also regression to the mean.

[00:06:16]Um, so I'm not denying this may work well for some people, but I do not I'm not predicting that I mean predicting that it will not become a big blockbuster even if they promote it healthily just because it it's not a particularly welldesigned drug.

[00:06:36]That's all. So, and I'm happy to answer more questions on that. And again, jumping to the good questions I've already seen posted here. So Mark asks, should children with ADHD go to a different school? And my somewhat flippant answer is different from what?

[00:06:54]So I would say ideally teachers and classmates and mainstream and and in the US we call it public education. I know in Britain public private mean different things but I think teachers and classmates teachers should be equipped and classmates should be taught on how to deal with work with AC if you want to use accommodate um people who learn by different methods. I appreciate that if someone's learning methods are extremely different than their peers, that may be a strain on the other individuals or the resources available. Um, so I'd say from the child's point of view, if a child can't get the education they want at their local school, then yes, they and I don't like using the word should very often, but yes, if they can't if if methods that meet them where they're at aren't there in their local school, then they probably should go to a school that has more expertise, more patience, more creativity, or whatever is needed to again try to meet and teach the kid where they're at. Because even though children with ADHD can be disruptive, they can be frustrating through educators or classmates, most of them are still interested in learning and are capable of learning.

[00:08:23]So, they shouldn't be deprived of learning. And I do think school's primary purpose is learning.

[00:08:30]So, that's what I would say there. Um and I'm happy to follow up on any of those points. So Mark's next question is if the parents don't want to give medications to a child, what can be done? What is the treatment you recommend?

[00:08:47]So part of it is education and part of it um not to so stepping away from school but educating parents, educating children about what ADHD is. And again the simple summary. I would say right now it's a form of neurode divergence. It's a brain that is wired differently and that learns differently and responds differently and processes information somewhat differently. And we have more than three dozen studies that have shown of kids who kids with ADHD who take stimulant medication compared to kids with ADHD who do not take stimulant medication. if you follow them down the line and some of the studies are only a few months, some of them are a few years. Um, but if you look at what the results are, it's the kids treated with medication have brains based on anatomy, based on brain activation, based on strength of wiring patterns that look more typical than kids with ADHD who avoided medications.

[00:09:58]So it flips on its head the concern, oh my god, you're giving powerful, addictive, deadly medications to my kid.

[00:10:05]It's going to harm them.

[00:10:08]If harm is is defined as continuing in an ADHD pattern, then you may be consigning your kids to greater harm throughout their life by not treating them. So that's part of what I would say. I would also acknowledge that there is potential for addiction. there is potential for psychosis. Those are both highly uncommon. There's, as is, severe cardiac problems, most of which can be screened out by EKG if you're concerned about that. Um, there's also some potential for some changes in eventual height, but that's less than an inch in height on average.

[00:10:50]um they may be lost and and summer vacations away from drugs seem to allow catchup growth. So one it's always listening to what the parents concerns and issues are. There are certainly some kids who are smart enough or their teachers are patient enough or the classroom structured with lessons that are interesting enough that they can still thrive even with their ADHD. Um, so if they're not willing to take medications, I would I think the focus is what else can we do to help make life more fulfilling and less frustrating for the kid with ADHD and their family?

[00:11:43]That's not a very detailed answer. I'm I'm aware. So, so hello Jesse.

[00:11:52]Excuse me. How would I treat a patient who has a good response to Adderall XR but needs a longer coverage and Aderal XR isn't lasting long enough? Is all day coverage of ADHD symptoms an unrealistic expectation?

[00:12:07]So, individuals vary in how quickly their livers chew up drug. Um so in general vivance does last a little longer in the body for many people than Aderal XR and Midas is an amphetamine based slowrelease product which is designed to last even longer. So many people get 16 hours of benefit from Middayis live it's usually in the range of 12ish.

[00:12:37]Um so so there are products Vance is available as a generic so it's relatively cheap. Midas has several more years on its patent so it's an expensive option unless insurance covers it.

[00:12:54]And the other option is taking multiple dosages. So there are certainly people who take a pill of Aderal XR or a pill of Viviance first thing when they wake up in the morning and then another one three or four hours or 5 hours later morning. The the risk there or the potential problem is if you take the extended release too late in the day. It can, it doesn't have to, but it can or has the potential for delaying sleep and then disrupting that night's sleep and that makes the person less functional the next day. So, a second. So, so there's the potential for creating too long a lasting scenario which as I just sort of talked about with that's what I think asteris has built into it and you can't avoid um you're getting too much drug too late in the day or throughout the day there.

[00:13:53]So I I guess the other question is is all day coverage of ADHD symptoms unrealistic? So, two things I would say there is that I've never seen I've seen medications be tremendously life-savingly helpful, but one is our medications never in my experience and what I see from the studies never completely alleviate ADHD symptoms. They can improve it, but they don't obliterate them. And two would be to appreciate we are not robots. We are not AI cyborgs. We are not um there should be in normal human life or not should I tried again to avoid that word. There's going to be normal fluctuations. So siesta time when we are less alert. So I I'd say part of learning life is learning your own body's rhythms and when it's good for you to be doing certain activities and not doing others.

[00:14:54]So blasting through every moment of your waking life completely other completely functioning completely productive I don't think is a realistic goal for any human even though some people boast or claim that they are but so that's my answer there. So Jesse has a follow-up question. Is a calming response slashred reduced anxiety to stimulants a further confirmation of an ADHD diagnosis?

[00:15:29]So what I would say there is no and yes and by that I mean we have to be careful in terms of how we're defining a calming response or reduced anxiety. So, I'd say reduced anxiety in someone who has an anxiety disorder or experiences high levels of anxiety and distress and that that is reduced by stimulant that is to me a very strongly supportive that the ADHD diagnosis was accurate. However, the first part of it which might seem to be the same thing is a calming response necessarily confirmation.

[00:16:10]So, one of the classic psych 101 lessons is that alertness shows a U-shaped function. So, if you're not alert enough, you don't function well on tests or performances, if you as you get more and more alert, aroused, um, revved up, you perform better. And then there's some sort of sweet spot which isn't just a narrow point but then if anxiety arousal increases that drops off and performance drops off. So anyone can feel a little more will feel more focused with a stimulant um if it's in the right dose and even if so and that focus can be calming whether or not you have ADHD. So sort of being able to lock in being able to be disregard extraneous stimuli can be calming for someone else. But again, if it's really an anxiety disorder or high levels of anxiety someone's experiencing that are reduced by the stimul, then I'd say that's supportive. If they're just feeling calmer and more focused, and again, you can certainly be calmer and more focused and have a reduction in anxiety. But if all we're looking at is someone feeling, oh, I'm able to lock in. That's that feels good. that and it's that part of it isn't confirmation because that should happen with everyone. So I hope I'm distinguishing those two aspects and I may be splitting hairs too much but you'll let me know.

[00:17:50]Hello Herman. Um have I ever considered doing a video on the SNRI roboxitine um soxitine for ADHD? There have been several studies on it and I want to get the word out. So that's a second unless I didn't check who wrote the last one.

[00:18:12]Um so raoxitine and not that I should be US- ccentric but that's where I well I don't think Trump is even aware that Hawaii is part of the United States. We won't get into that at all. Um, so Roboxitine I have sort of a funny not funny but just after maybe as I was still in residency training I'd go to the annual psychiatry meeting year after year after year and for at least six or seven years in a row and this is in the era when drug companies had big I mean they still do at big boots at these conventions and we give or you know plastic brains or the clock back there on the shelf that the yellow clock with the face or toys and trinkets and pens to attract people. Roboxifine had a huge booth because they expected every year for at least six or seven years in a row that they were about to be approved for treating ADHD and not ADHD for treating depression in the US and the FDA never found the studies to be adequate enough or impressive enough.

[00:19:25]So it so part of it is roboxine has not been approved in the US for any indication. Um, so that's part of what's reduced my interest in talking about it, but but given that there might be useful pointers or things. So it is a nor fairly pure norepen reuptake inhibitor like strera adamoxitine.

[00:19:50]They're not the same molecule and I'm not sure how differently they may bind to the norepinephrine transporter andor what secondary systems they may slightly bind to might affect how they behave in the brain. So, however, again, I've had more people asking about it, so I I'll probably bump that up.

[00:20:19]But no, I I don't have any direct clinical experience with it because it hasn't ever made it to the US.

[00:20:37]Um, so Bunk is asking, "What do I think about internalized PDA and how difficult can it be for others to tell and diagnose?" Um, my first reaction to what does PDA mean is personal displays of affection? And I am desperately searching right now.

[00:21:02]Path. Okay. Pathological demand avoidance.

[00:21:16]Yeah, I don't know what more I so personal uh pervasive demand avoidance is not an officially recognized condition. um it's not in the DSM as a and my experience with it has been that there's some I mean I'm not denying that that may well describe a phenomena that many people exist and resonate with but there's a at least in the US there's been a fattishness to proclaiming this and I've seen people who have pervasive and robust personality disorders, ADHD, other things that would seem to attribute for some of the behavior that didn't just seem to be meeting the criteria that the people who use the PDA term use. So, so I will I'm putting that down as a potential topic to research and talk more about.

[00:22:26]So, I'll I'll just drop that there.

[00:22:30]So hello Max. Max asked what's my clinical experience with clomraine in what situations do I consider prescribing it? So clomraine is one of the as we say old um tricyclic anti-depressants. Um it is the most strongly ser it's a serotonin reuptake inhibitor. So it's very good at that. There are some studies suggesting it's more potent for OCD than our our modern pure SSRIs like um fluoxitine, fluoxamine, certuline.

[00:23:14]So I've seen a few people or treated a few people with with OCD spectrum issues with it.

[00:23:22]One thing to be aware of like the old tricyclic other old tricyclic it is a messy drug.

[00:23:29]So in addition to having serotonin reuptake action and some I believe weak norepinephrine reuptake action. It has antihistamine action. It has acetylcholine action. has actions on sodium channels in the heart and all of so most the majority of people on SSRI do not have side effects.

[00:23:55]Does do big minorities have nausea when you start up? Yes. Do some people who particularly if they're put on too high a dose feel numbed out? Yes. Do a quarter to a third of people again in a dose dependent way at least initially have sexual side effects? Yes. But rates of other side effects and ongoing side effects, most people in SSRIs are not experiencing them. Whereas most people with the tricyclic are feeling sluggish, are feeling constipated, are bit dizzy when they stand up um gain weight um and have a potentially dangerous situation if they take too many and overdose. So to me, the tricyclics are not chronic pain syndromes or if you were neurologists treating ADHD.

[00:24:51]Maybe there's there's one other entity that I'm not remembering right now that they often use it for. And yet there's no evidence that I'm aware of that these tricyclics are better than a pure clean SMRI like for these conditions. And yet you're bringing in a multitude of other potential side effects, some of which are potentially lethal side effects. So that's what I'll where I'll end it on tricyclic. Again, they are they evil drugs? No. Um they work. They've alleviated depression. They've helped with chronic pain. They work with migraine.

[00:25:36]They work with OCD and anxiety disorders for many people, but usually there are safer, more comfortable options.

[00:25:48]So Nicole asks, "Would would I give black tea to a 10-year-old so he can focus better on doing his homework?"

[00:25:59]It's an interesting question and it's a hypothetical so I should back off here and say that I can't give recommendations since I don't have a doctor patient relationship with any of you and don't know all the facts in the case. Um, so one of the concerns is that from batch to batch of black tea, depending on where the plant was grown, where the tea leaves were grown, how they were harvested, how they were um cured can affect the caffeine level. So you and there are there's caffeine, there's theophilene, there's a few other potentially stimul psycho stimulants in there.

[00:26:43]Um, so one potential downside is you may be less certain of delivering a constant dose.

[00:26:51]On the other hand, my general approach would be if this seems to be helpful and you're not experiencing or witnessing other side effects or problems. And I guess the one potential that I would be most concerned about is taking it too late in the day and making bedtime more difficult.

[00:27:12]Um, so my approach to life is usually a pragmatic one. So I I try to pay attention to the research and the studies, but what's important is how this substance or this pattern of behavior is working for your body and if it's working and we're aware of potential side effects and we've tried to evaluate for them and they're not there, then it sounds reasonable to go ahead with that works.

[00:27:41]So that's that's a philosophy that's that's I can't argue that's true or the right or the best way to go. That's how I try to operate.

[00:27:51]Hello Hen. Um what could potentially be a cause of migraines from dopamine increasing substances including ADHD medication and even caffeine? Should I go see a neurologist or psychiatrist? Thanks.

[00:28:06]um one is and I know there have been advances since I've been in medical school and and there's still designing new drugs that have different mechanisms of action. My understanding is we don't know completely what migraines are caused by. I mean some of it does appear to be um expansion contraction of small blood vessels in the areas around the brain not within the brain itself. Um and caffeine often has been helpful for people with migraine but not always. Um so so often with migraine and headaches things that help many people also for some smaller subset make things worse.

[00:28:54]Um the other thing is I'm usually careful. So migraine is a very specific type of headache with a usually a aura or premonition and often visual or other sensory phenomena associated with it and it can be just half the hemisphere, half the side of the head or the other. Um so many people use the term loosely for any bad headache but migraine has a specific meaning. So I I would also caution there. um to to leave it at headache unless we're sure it is migraine. I'd say if if you're obtaining benefits from a medication and um I mean one of I would start with who's ever prescribing the medication should be able to help you sort out what might mitigate it might be what might be the pathways what might cause less of that problem. if that prescriber isn't good enough. Um, in my general experience, neurologists have more, at least in in the US, it's primarily neurologists who are treating headaches. So, they're likely to be more knowledgeable again.

[00:30:12]But jumping back to what I said just a few minutes ago, there's a much stronger tendency for neurologists to push things like treat TCAs rather than clean SNRIs.

[00:30:24]So, that's where I'll be back at. Hello, Jason again. Um, says asking for Jason's husband again.

[00:30:37]Can and there's been an ongoing issue with panic issue related to stimulant medication and fear of restarting the stimulant medication. Um, so I'm just providing some context that I can remember for others who are just cluing it out. So Jason's asking, can ADHD related norepinephrine dysregulation cause an almost instantaneous adrenaline doom response after benign palpitations or skipped beats?

[00:31:17]So, I mean, my answer to the question would be you don't even need the first few words of it. So once someone's had a bad response to something, whether it was a food they ate, whether it was a drug they took, whether it's a scary encounter with a specific person or a location, then they can have an virtually instantaneous adrenaline and norepinephrine surge response when that situation is replicated or and it appears that it's going to be replicated. So, we don't even need Can ADHD medications be the initial trigger for that? Sure. Um, is that what I would consider a potentially treatable reversible condition?

[00:32:11]Yes. Um, and is it a tricky difficult situation?

[00:32:15]because anxiety as this sort of FDR said all we have to fear is fear itself but fear builds on itself. Um so again my my general strategy is lots of education lots of reexposure at very very low dosages.

[00:32:37]lots of training to let the person know, okay, my body is in this state of somewhat agitation. And there are things I can do to bring agitation down because I I tell this I don't use this phrase for ADHD much. I use it a lot for depression and a anxiety disorders.

[00:32:57]Depression and anxiety disorders tell lies. I mean, with depression, the lie is it's bad and horrible now and it's only going to get worse and it's and that it's always been bad.

[00:33:09]Um, but most people, if you push them, can recall times when it hasn't been bad and for all their past AD or depressive episodes, they always ended. So, also a lie that it's only going to get worse.

[00:33:22]With anxiety, it's that it's bad, scary, fearful now, and it's only going to get worse. And that fear itself pushes someone further along to be more scared.

[00:33:34]But again that that can be countered because it is a lie. Um and bodies and brains can be retrained and we know that set points on your panic center can be reset um so that they're less easily triggered. It's not going to be obliterated. You'll always be able to panic which is probably a good thing.

[00:34:03]So Jason's asking, "What mechanisms do I think drive those early morning adrenaline jolts of panic like awakening and ADHD? What mechanisms?

[00:34:21]Yeah, I I don't know what level of mechanisms we're looking for an explanation. I mean one is that our we we often ignore our interosceptive nervous system. So that's the the aspects of the nervous system that are always scanning what's going on with our body um and monitoring it and registering this is a change this is different. So most of the time we're sitting. You know, right now when I'm sitting here, I'm not aware that I am fidgeting my legs, that there's pressure on my buttocks where I'm sitting and my low back here and less pressure cuz my feet are only moderately lightly resting on the floor. And my foot with the bunion like deformity is doing X, Y, or Z. And there's because of allergies, my voice is somewhat horserucy.

[00:35:19]I mean, we're getting thousands of points of information constantly and most of it does not need to be consciously processed. So, it's not in our awareness unless we choose to make it in our awareness. But again, we have a monitoring and there is some evidence that With ADHD, there may be a tendency to be less obliv or more oblivious, less aware of some of these sensations and or it may not be interosception per se. It's just the the threshold where introsceptive input converts to alarm input or activates. Yeah. The panic alarm system.

[00:36:03]So, so I don't know if that is more a handwaving explanation or more a precise explanation or what would help there.

[00:36:17]So, Nicholas says, "I sometimes feel like my contempt for Trump is really contempt for ADHDers in general. You said Trump wouldn't know Hawaii as part of the USA. make your type of awkwardness.

[00:36:32]One is that that's a pointed joke. I mean, part of it is when I say Trump isn't aware that Hawaii is in the US is that it's not just a oneoff lack of awareness. But unlike you or I, I don't know what your age is, he grew up in an age where Hawaii became a state. He was a cognitive human being who that was a major news item. And secondly, he used that as a political weapon to start his career where attacking Obama where there is a wealth of documented evidence that Barack Obama grew up in Hawaii. He did not grow up in Kenya. He's showed his birth certificate.

[00:37:23]There are numerous teachers, classmates, neighbors who can document that he lived here. And Trump built his initial career on attacking whether Barack Obama was a US citizen or not. So I feel it's fine for me, maybe I shouldn't, to pick on Trump and pretend.

[00:37:48]I don't know whether Trump really knows whether I don't think he cares whether Hawaii is in the US or not. I I don't.

[00:37:58]So, I'm sorry if you feel like I'm picking on everyone with ADHD when I attack Trump. Um, what I tell people is Trump's an American. Trump's an American. Trump's an American. Trump's a Caucasian.

[00:38:16]Trump's a male. He's all sorts of things. Just because I'm a male, do I have if someone attracts Trump? Do I have to defend him because I'm a male or because I'm an American or do I have to see an alliance with him?

[00:38:29]He's an individual where ADHD like traits are an important part of how he has governed or misgoverned um how he relates to people, how he ignores people. To me, identifying that and particularly given there is so much overlap with narcissism and understanding that some of it is obliviousness rather than malicious disregard. Some of it actually very clearly because he's told us repeatedly does fit a narcissism pattern. So, um, and I appreciate that even many people on the left find Trump so toxic that just mentioning him is not it turns people off. So, I will try to minimize those comments unless they're specifically requested or asked for. So, so that's maybe the lesson I need to learn is find other I'll I'll jump back sort of somewhat defensively. But part of the reason using him for an example is that unlike the era when I grew up and I didn't follow sports and I didn't follow the popular rock bands, but still there would be actors, there would be sports figures that virtually everyone knew because all of the media input was from three main channels which probably replicated each other and most tuned in people were aware of how. So you could use any one of a number of dozens of public figures and most people would say, "Oh, Joe Nameoth acted like this or Paul Simon and Art Garfuncle did this or that or so you could use them as examples for behavior in this fractured media age. There's almost nobody except someone at this level of media saturation as Trump where you can talk about, oh, someone rambling around the stage instead of standing in front of the left. Oh, someone bobbing and moving its head constantly and that's part of why he dodged a bullet or someone interrupting himself and others and not finishing a sentence. I mean, are there other people to do it? Yes. but calling on them or calling them out as examples.

[00:40:53]You know, I know sort of who Taylor Swift is and sort of what she looks like and she's one of the biggest names on the planet, but I don't know what she acts like. I haven't watched videos of her. So, so there's very few public examples that we can call out. So, I'll drop that one.

[00:41:19]So Neil used Concerta before being diagnosed with ADHD. Now in the process of diagnosis, I'm scared the psych won't prescribe stimulants because of previous usage.

[00:41:37]Yeah. So it's a valid concern. So there are some practitioners who would say, "Oh, you use it when you weren't officially diagnosed. That means you're misusing potential addict and I've talked with numerous patients who felt that they that anyone who there were certainly certain profession mental health professionals who do act and treat people if they use stimulants like they are addicts and abusing medication. I mean one is we know it's extremely common for people to experiment and share with and stim medications. Um most often it's from family members or friends. Um some people obtain them on in other markets but family friend extended network sharing is extremely common. Officially that gets classified as misuse. Um, we also know from repeated studies that most people who are misusing actually do have substantial ADD symptoms themselves. Many of them are undiagnosed.

[00:42:48]So, I'd say if my general policies in terms of working with the doctor is to not lie. So, if you're asked directly about it, um, you can try to inform what the situation were and what the effects are.

[00:43:05]So in my practice I would want to know you know has someone used medicines X Y or Z and what was the impact and what was the good or bad and you know whether they got that by prescription or they found a tablet on the sidewalk and ate it or whether their best friend gave it to them or whether they snuck it from their parents. I'd say maybe the last situation is the only scenario where I'd be more concerned about where the what the origin of the medication was. I again other doctors are much more uptight and I'd say unaware of what ADHD entails. Um, so where was I going? Um yeah so if the doctor asked specifically I'd say share it. I'd say given that you are not supplying every single fact your whole life during any initial evaluation um whether this gets omitted or not I it may make sense to not acknowledge it immediately. Um what else can I say there?

[00:44:36]Elizabeth is saying, "I am lying to everyone I know because I keep telling them that I haven't given up. I promised my mother on her deathbed that I would never give up. I promise." But it's not what I actually felt.

[00:44:49]So, um, so as with medications where I'm not supposed to give specific recommendations because I don't know you, what I would try to embrace or acknowledge is the very fact that you're alive and talking about this suggests that at least some part of you hasn't given up. Even if there are other parts that feel stronger, more robust, more pervasive that feel like they have given up.

[00:45:19]Um, so one is it sounds like there's at least some internal dialogue and hopefully being able to share that with others. It may be a therapist. It may be support groups like NAMI or Chad have specific knowledge and expertise with ADHD. Um, so and I would I'd say the other thing I would say there is I wouldn't even label it lying.

[00:45:54]So you may have consciously intentionally withheld information from others.

[00:46:01]But again I part of you hasn't given up because you are here alive. that that's a verifiable fact. If you had given up, you are gone.

[00:46:13]Um, if all parts of you had given up.

[00:46:16]So, so acknowledging that you're conflicted, acknowledging that you have feelings like giving up is a little different than labeling yourself or calling yourself a liar.

[00:46:32]That's the starting point. But again, I think hopefully finding ways to talk to other people about this can help you find a pathway. And for many people with ADHD and other mental health conditions, the pathway, your pathway may be not a common or typical pathway for finding satisfaction and fulfillment in life.

[00:46:55]That's okay.

[00:47:00]So this is Jason again talking about their husband who is stable for years on ADHD meds with no panic around exercise driving or heart sensations after the stimulant disruptive discontinuation then develop panic attacks. Um um and much of the trigger seems to be benign palpitations, flutters despite normal cardiac workup. Now even small flutters trigger near instant adrenaline doom sensations.

[00:47:39]And one is it may be more reassuring to sit down with a cardiologist who's willing to put in the time and many of them are in my experience to explain and we can see you know you can how common I mean that it would be extremely uncommon not to have some palpitations not to have some irregular beats um but again it's a heightened awareness of it and that this is not in any way a threat to life. It's not a threat to it. This is part of being completely normal and alive. And what's off is that you are introsceptive system is locking onto this and overemphasizing it and and concluding that it's a sign of disaster. That can be untrained.

[00:48:35]Um, and again, it may be more reassuring to get it from a cardiologist. It might even be helpful to do some of the training while someone's hooked up to an EKG and they can see what's going on with their heart rate. It it highlights a bigger or another issue which I talked a little bit about on sleep monitors and maybe on heart rate monitors. I've seen them most often be highly counterproductive in people with anxiety disorders because they encourage focusing on benign events and transforming them into catastrophic events. So part of it is this is what's going on in your heart.

[00:49:20]This is going on in your heart every single day that you are on stimulants for years. Um it was there. It was not a problem then. Why would we want to make it a problem? Now, I mean, your your body has I'm not pretending it was a conscious choice, but but making a conscious choice for it not to be a problem actually is a viable option.

[00:49:53]Yep. So again I can't make specific recommendations but in a um at anformational level um either quantine um which generally would be on a taking it as an ongoing basis or even a may help prevent it or I mean definitely would reduce the likelihood and a bzzoipene or a beta blocker like propranol also which would be more targeted in taking it only before a potentially scary situation on the other hand I'm not a big fan I mean so so part of it is again remembering we will not obliterate the panic center there will always be a potential for panic and the way to reduce anxiety about it is knowing I can have a panic attack and I you get I mean the the simple answer is Jason's husband has had multiple panic attacks and they survived each and every one of them regardless of how miserable they were. They are alive now. So why give this more power? Yes, it feels horrible. Yes, it feels intense. Yes, it commands attention. Yes, I can see one wouldn't want to go through it again. On the other hand, you've been through them. They're survivable. This is not the end of the world. And knowing you will have it, you can have one and can survive it is actually the key concept.

[00:51:31]I believe with CBT approaches to panic, which we know change brain chemistry and brain wiring.

[00:51:41]Um, but again, you've already experienced, you've had it, you've survived it.

[00:51:50]Um yeah so so part of the danger or risk of of any of a benzoazipine particularly but also of beta blocker or guanosine let's say he takes guanosine and you know several of the situations that have triggered panic or neuropanic in the recent weeks months year are okay and then you know first 3 months he's doing well with guanosine and then something is bigger something is more unexpected something out of the blue triggers that panic attack and then it feels even worse because it's like I was taking the guanosine that should have blocked it avoided it all and it didn't now I'm even in more trouble or in a more risky dangerous situation so so medications can unless that that angle of it is discussed ahead of time can be in the long run counterproductive.

[00:52:59]So thank you Elizabeth. Um I won't even mention the person's name you cited in your soy. Hello. Um, hello from Scotland. Beans on toast.

[00:53:28]So Neil asks, "What should I do about the anxiety right before diagnosis and the feeling of what if I'm misdiagnosed?"

[00:53:38]Um, so part of it, don't if I ever get around to it, my next book will be my quest not test book. I I think the quest not test approach to life is really empowering. So even if you've waited a long time for this diagnosis, even if you have limited resources in your area, even of xxx y and z, you don't need to make this a test. your goal is to your quest is for better healthier mental health. Um, some of that could happen through this intervention with this doctor. Would it be nice if it happens that quickly and efficiently and they listen and appreciate you and see you where you're at and provide you with what you need? Yes. But if it doesn't happen here, there are 101 other ways it could happen in this lifetime. Um, so we don't need to make a test out of it that this is not an all or nothing situation. If it works, great. If it doesn't work, then we either find out how to repair it, fix it, make it work better, or move on. There are other providers.

[00:54:53]So that's what I would say there and and if you know if they're worried about the diagnosis again I think your task is to provide the information about what you've experienced and how it has led to distress andor dysfunction andor if there's things you've done that seem to make it better and or worse. I mean that's your job in that that interaction and part of it is also the serenity prayer. You can present the information in the most effective clear-cut way and it's possible the other person won't listen.

[00:55:34]Um but you're you only control your end of the conversation. So the serenity prayer is is having um the strength and conviction to change the things you can, the faith of accepting what you can't change, and the wisdom to know the difference between the two.

[00:56:03]So I see we have a few minutes left, so I'll try to go through a little more quickly. Elizabeth is saying her mother had ADHD and depression. She allowed herself to slowly die in full view of my father, brother and I.

[00:56:17]She would not go to doctors or take care of herself and it was painful and long.

[00:56:21]She lied when she told us she went to doctors. She refused all begging.

[00:56:29]Yes, it sounds horribly painful and I'd say hopefully you can learn and do things somewhat differently and use that as a as a learning tool. Um, I'd say are there bad doctors out there?

[00:56:52]Are there bad psychiatrists out there?

[00:56:54]And bad is a judgment term. I'm aware and a vague one, but I'd say yes. I was actually saw a cardiologist yesterday after many months of waiting and it is the first time in my life I have raised my voice to a doctor who simply could not listen and process a very simple fact of what I relayed to him four different times. And I'm usually pretty good at explaining things. So I don't think again the serenity prayer. This is me here. Anyway, so hello theory. 20 milligrams of vance is too much for my anxiety. Same for other stimulants. So I think it's time to try nonseants. Do you have a preferred order to try the nonseimments on? I mean one is at least in the US that 10 milligram via antance is available. So if it's too much, it's like to me it makes sense to drop even lower in Vance. You can open up and get even a smaller dose. I bet many people do that. So um if anxiety is the biggest blockade then guanosine and I have a video on that may be a more comfortable way to start and guanosine may completely or may thoroughly address ADHD symptoms symptoms um most of the other non-stimulants such as bupropion or strera or calry at least have some potential for causing anxiety as well. So I'd say what I would say there is start low in general if anxiety has been a problem.

[00:58:49]Thank you Vandy who finds me knowledgeable and calming.

[00:59:00]Yeah. So theory I am not a big fan of of Stratera and I have a video on that just why that just objectively and subjectively in my experience is rife with lots of side effects that people don't feel is tolerable.

[00:59:26]Elizabeth says, "Mental illness is much more powerful than love." I Yeah, I that's I guess I wouldn't be in this business if I believed that. Um, mental illness can be powerful and sometimes it just takes repetition and delivering the same message or sometimes it takes cleverness and finding out different ways to get the same message across and sometimes it takes pushing on multiple fronts biochemical, social and personal, psychological balance has been on vivance equivalent 30 milligrams. for about a month and a half. Not every day it helps but can raise my resting heart rate to 100 to 130 with some palpitations and discomfort. I took breaks when that happened because this med likely off the table for me. I know there are other stimulants and bunch of non-stimulants.

[01:00:31]I speak with the cardiologist and psychiatrist soon but continues what you can say. So, so there's two different issues here. And some of this we've been talking about with Jason and Jason's husband. So, yes, absolutely. Most of the stimulants and most of the non-stimulants that are causing more availability of norepinephrine have the potential to increase heart rate, increase blood pressure. For most people, that's a small amount and not um particularly alarming. There is some tiny and tiny means less than 1% of people after a dozen years are running into serious problems and they're not deadly serious problems.

[01:01:16]On the other hand, having an abrupt having a drug trigger a cardiovascular symptom like an increase in blood pressure or increase in heart rate can evoke a sympathetic panic-like reaction or it can be a you know a lesser less severe than panic.

[01:01:39]So people can train themselves to have adverse cardiac effects and certainly so that may require intensive sort of retraining of the body that okay my heart rate's 100 right now even if the drug I'm taking is encouraging that even in the face of that we know it wasn't at 100 all the time you took the drug. So, are there things I can do right now with my breathing, with my body posture, with my thoughts that actually help my heart rate go back down? And again, I think several times of seeing, oh, okay, my heart rate's up. I can help it go back down even when I am taking this drug can be really powerful in helping train your body to accept it. So, that's what I would say.

[01:02:46]So um yep. So Elizabeth, I hope you keep reaching out here and to others particularly if you've seen others dying because of inadequate care. There there are many situations there's inadequate care. I'll just also say all of us will die at some point and people don't like to hear that or reminded it but I've I've come across several situations recently and maybe this is just on the top of my mind where someone lived an extremely long life and the fact that they eventually died got blamed on the medical system when it seemed they probably had months if not years of even functional life extended by the medical care they received. Um, yeah. So, with the Elizabeth, I would share again the quest not test. I mean, it sounds like every if you're constantly disappointing yourself, that means you're framing situations as tests. And if you still have friends and family members, they clearly have have worked with you or adopted a relationship that's not that dependent on making each interaction a test that you failed. They are framing it differently from their end. They're seeing something good, rewarding, positive, and wanting to continue a relationship.

[01:04:21]But I will stop there. Stay healthy, stay happy. I will be back next week.

[01:04:27]Um, I will be speaking from San Francisco next week where the annual psychiatric association meeting is. Bye.