Extended replies to comments on FB

[jack]

Why go for medication rather than coaching/therapy to start with? What about feeling squeamish about taking things that might alter your personality?

That's an excellent question, and it is one that is very personal for a lot of people including me, but I'm basically happy to talk about this stuff forever 🙂

Medication mostly fixes hardware problems and counseling mostly fixes software problems. Hardware fixes can help with software problems, eg if someone is depressed for a year initially for a reason and antidepressant gets them back to normal. But software fixes usually can't fix hardware problems. Sometimes they can work around the problem. Sometimes you can grow some brain to compensate for the missing bit. But often you can't, or only can a little bit.

I have the same feeling as you, not wanting an augmentation. But it doesn't feel like that (or look like that to careful consideration). It doesn't feel like it's giving me extra oomph to compensate for not enough oomph. It feels like, I'm doing all the right things that OUGHT to make me able to do things, but the connector is missing, and when I get that fixed physically, then doing those things NOW has an effect.

But of course, even though the difference is quite distinct, it's all internal so it's subjective to judge whether the difference is real even when it's quite distinct, even for yourself.

But of course, there's always a spectrum of problems. Some people have weak muscles, which are *harder* to improve by exercising regularly than they are for most people, but only a bit and that's still the most plausible approach. Some people have insufficient muscles such that if they give up on having a family and a career and dedicate themselves to working on them, they can maintain 75% of a normal level of mobility. And some people have conditions where normal practice can't help more than marginally.

Like, if someone has short-sighted eyes, or epilepsy, or schizophrenia, do you think it's sensible for them to ty to get over the problem without the suitable medical treatment? If so, I have disagreement. But if not, why not? Is it, stooping to indulge in sarcasm, because IT DOESN'T WORK? (It often is needed *as well* as medical treatment.)

Like most people, I definitely thought, SURELY internal things like "unable to do important things" or "excessively negative emotional responses" OUGHT to be able to be fixed. I didn't have much guidance but I tried a lot without recognising the underlying pattern. I think most people naturally feel like that must be the case. But when actually presented with first hand evidence that no, some internal things some people just have 1% of the ability of most people, I acknowledged that that was the case, and fixing that problem was sensible.

I definitely hesitated to try the medications, but I thought it was well worth trying, and when I did, it felt completely natural, like healing a missing part of myself, not grafting something extra on.

I think the reason I saw it like that was, it doesn't feel like the drugs give me "more function" and I need to judge the "right amount" of function and be careful not to take too much and get too much function. It feels more like there's a bit that doesn't work, and when you take sufficient medication then it starts working, mediocrely at first and normally after, and more than that doesn't help *more*.

Like, most people don't have a conscious process of "wanting and deciding to type an email, then SOME MYSTERIOUS STEP, then doing it". 99% of the time, the mysterious step just happens automatically unless you're REALLY exhausted or INCREDIBLY scared of the thing. You're not even conscious of it, not any more than being conscious of the ability to tell the difference between red and green. People put off actually starting for things they're nervous about, but if you sit down at a computer in an empty room and say "I'm going to write this now" most people then can DO it, not feel an invisible force holding them away. But I used to. Lots of important things I would sit at the computer, shaking, asking myself why I let it get this out of control. I'd set a timer for 60s and say "I have to LOOK at the email" in that time, and maybe I would or maybe I wouldn't. I didn't really talk about it, because it felt like, each individual thing I just had not been organised enough about and that it was my fault I let it get that bad. But now I think, it was the lack of that mysterious step. Since medication, I can make myself do anything REALLY important (although the problem is finding normal day-to-day difficulties still leaving things left off).

One thing that makes this harder to understand is that stimulants are different to other ADHD drugs. Most ADHD drugs have a subjective but important effect of allowing you to focus normally, or to initiate doing things normally, or to have normally proportionate emotional responses. Although sadly some people find only some drugs help and some people find none of the drugs help.

But stimulants are the most common and first discovered ADHD medication, and have that effect (in many people with ADHD but not everyone), but do also have a side effect of giving you more "oomph". That happens to everyone whether they have adhd or not, and isn't a long term solution because you acclimatise to it. But can help some people with adhd, if their main problem is "being able to KEEP concentrating on something". So everyone has the experience "oh, this is great" at first which makes it seem like stimulants are effective for more people than other drugs, but I don't know if that's actually true. I would love an experiment which tried to establish whether for people with ADHD symptoms, ignoring the "burst of energy" effect, how OFTEN the different drugs worked. And if there's a commonality of (if you ignore the stimulant burst of energy effect) if many-but-not-all people find either most drugs work or no drugs work, or if they're all independent.

This is completely speculative but my metaphor is, people have some sort of "motivation system". In some people that is broken. The most common way it is broken is fixed by THESE GROUP OF DRUGS (weirdly, completely unrelated ones, because brains are weird and we've only guesses about how this WORKS inside). But it can also be broken in other ways in which case the most common drugs don't help.

And FWIW, I think it IS possible to improve at coping with the problems. Some people have to because the medications don't work. But often that means, avoiding the things you can't do. Which is plausible if it's "desk work" but hard if it's "things that I care about". Or trying to achieve either a constant sense of excitement, or a constant sense of tranquillity, which therapy helps with, but isn't what most people are able to achieve.

And FWIW, my problems were not primarily the classic "able to focus". When I say my problem was starting things, I include "a day's work", but it was just as much a problem for "playing a computer game I was interested to play" or "leaving the house to go to a social event I was excited about" or "leaving the house in the sunshine"

And I often had excess negative emotional response to normal setbacks, feeling like everything was terrible each time. That does improve with practice. But it's like, some people get, if they're hungry, then everything feels more prickly, and they can learn to cope with that better, but it overrides their typical emotions so they need to be a LOT better in order to act normally without being able to fix the physiology. But more so and all the time. Which makes it harder to be AWARE of.

Now with the medication, I'm more aware of it because I notice an 80% correlation between "being proportionate and calm about stuff" and "stressing out about problems" and whether it's during the day when the daily medication is still active, or in the evening when only the long-term medication is.

social media is notoriously bad for this (you always seem to have a pretty good life (good job, married, plenty of friends and hobbies)

That is really good to hear, actually, thank you. The social media definitely presents a lens on my life -- it can easily look great when something is really bad, or look bad when everything is basically good. But it is true that my life is *overall* pretty decent, and fortunate, and it's useful to keep reminding myself of that.

your side effect of 'feeling blah about things' is the sort of thing I'd be worried about

That's a good question I hadn't really thought about. ADHD drugs do sometimes have side effects like that, which can be hard to spot, and is a bit scary to realise you might not notice. My impression from second hand accounts is that some people (probably people with ADHD) taking the most common adhd drugs DO get emotional blunting, and that's heart-rending when it happens. And that is where stories like "children drugged into compliance" come from. And some people end up choosing between "blah" and "unmedicated" because those are the only options, or the only drugs available in their country.

I did ask myself if it could be a side effect. But it's noticeable that I feel most normal and content during the day when I'm on the stimulant, which makes me think the problem is "not enough medication" not "too much medication". And that I think the excessive blah-ness is partly "what I improved to after not being in crisis all the time" and partly is "grown up from the couple of years of pandemic, and insufficient adaptation to the worries about career and life stalling etc"

the sort of decisions I could imagine making

Yeah. What I often say about things like this is, consider how much you trust the evidence that someone *says* they saw, and consider how persuasive it would be if you saw it (in addition to the usual instinctive response of considering how plausible the conclusion is).

I found it surprising that meds could have an effect like they do, but, well, they do!

like you tried out solving it in various ways and then figured you needed medication

I think almost everyone tries to solve internal problems the "normal" way before thinking there may be a medical problem, whether that's a hyperactive or distracted child, or an adult struggling with depression or motivation, etc, etc. Noticing the problem is almost synonymous with "can you less this" and only when it persists do you think there's reason for intervention. It is definitely true that for some conditions software fixes like counselling work better and meds work less well, and for others hardware fixes like medication work better and counselling works less well -- it depends where the problem is.

But FWIW, I can't see any downside from giving everyone 2 months of Intuniv at like age 15 and seeing it makes a positive difference or not. I think the worst case is you get some side effects and stop. And if it helps, you probably had ADHD without realising it. I don't know how many people Intuniv works for, but I proposed that rather than stimulants because stimulants always FEEL like they work so it's hard to be sure if they do.

I think people have an intuition for which treatments they EXPECT to have downsides based on what we're familiar with, which is only accurate about some things and not others.

I think people imagine a lot of brain medication as something poking around in your personality trying to make some large-scale changes which screw up something else and might not be as good as what you'd have if you built the right mental software to be motivated when you ought to be and not when you shouldn't be. And some is a bit like that. But a lot just fix a particular problem and don't make anything worse, or fix a problem and have unrelated side effects. Like, they fix the bit of the brain that ALLOWS you to build those software structures.

Trying to build the motivation without that fix is often all developing workarounds (which CAN be massively damaging and change your personality) -- most people maybe develop "ability to do something" with healthy-ish things like "making sure you think it's worthwhile" and "recognising the risks are manageable", but executive-functionless people get only a little bit of benefit from that, and (I think) end up with making themselves do things by constantly forcing themselves into a state of emergency. And maybe only learn how to do things "normally" over decades (which isn't enough time to learn how to do all the things")

I think almost none do really CHANGE your personality, even though they could in theory.

Like ADHD meds are different for different people, but as far as I can tell for me it's basically been upside. There's some side effects with increased/decreased blood pressure and sleep cycle, but don't feel like they change me at all.Reply

"operation that had some significant risk, but would improve some debilitating but not life threatening element of my life"
Also consider *how* debilitating conditions to imagine in this analogy. I've talked sporadically about the problems I had, but a lot of things I haven't talked about much because I was embarrassed not to be able to fix them! 🙂

That's things like "out of work for a year because not able to apply for jobs", and "going to work and just, doing things around the sides of the work but months not really able to actually WORK on the work" and "not able to pay bills".

Now that's far enough in the past I can think about them more openly, but it feels imaginary like did that really happen to me? And obviously I wasn't unable to do those things EVER I wouldn't have got this far through life, but it was unable to do those things without months or years of effort and stress. Which at the time I thought "it's just hard because it's stressful because I put it off so long", but I now know, it was much harder than it should have been from the start.

And I was fortunate enough in my abilities and support network that those problems rumbled on making things worse than they might be, but didn't completely blow up my life and could be sort of swept amount under the rug and let me continue doing normal me-things, just like it might for someone who had a similar life background but had those problems for being generally irresponsible or incompetent or entitled, or for having some physical disability or subject to some prejudice that meant they could work and enjoy social things, but always with extra hurdles. And I could have done better asking for help or lots of other obvious steps, except that I couldn't, because -- doing things 🙂

What I said when I started taking medication was, there is an increased risk of mortality from long term low dose stimulants raising your blood pressure, but I think that it's a lower risk than the risk from being unmedicated, hence the choice between the trade off.