This segment explores the career paths often favored by individuals with ADHD. It contrasts "importance-driven" versus "interest-driven" brains, suggesting that engaging and interesting work is crucial for success. The discussion highlights the importance of finding work that aligns with individual interests and preferences, rather than solely focusing on traditional career paths.This segment discusses the challenges and successes of parenting with ADHD, emphasizing the importance of family-based training. It also challenges the traditional view of a single, long-term career, suggesting that multiple, shorter careers may be a more suitable and fulfilling path for many with ADHD. This section offers a more nuanced perspective on career choices and family life for those with ADHD.This concluding segment shares a personal anecdote about career changes, illustrating the points discussed throughout the episode. It reinforces the idea of adapting career paths to individual needs and interests, offering a relatable and encouraging message to listeners. days I was getting it in and many days I wasn't getting it in till bedtime, which is the, again, I slept really well till I was around 40 and not so well the next 20 years, both the mostly with the trouble falling asleep, even though I knew relaxation techniques and others. So I wound up just consistently doing it to do it more for the general health. And I do have slightly elevated blood pressure and relaxation and to see what effect would have. And it was clear, so I do about 5 minutes and much more than 5 minutes. I tell people, and I might be doing it a little slower than most count out about 20 or 25 reps of it. And if you lose track, doesn't matter. Just go back to the lowest number because again everything we're trying to do is decrease arousal if you have a timer on it and you do it for 5 minutes and then you're woken up you're reversing or mitigating some of the benefit benef of doing it so I my recommendation is do it for five minutes about but do it by counting reps and don't focus or you know if it's six minutes if it's four I mean there's so many aspects of this and we know the exhalation has to be longer I was trying to find is you know is anyone systematically you know is a 4-second exhalation better than 10 versus 6 and those studies would be so simplistic and easy to do but you know there's lot lot of variables that we can play with to see what's optimal I don't think we know at all what's optimal but we know what's good enough to work oh delighted to hear that it's worked so well for you i i'm as people know i'm a huge fan of the physiological sigh and I take no credit for having discovered it It was discovered by physiologist in the 19 data point that I i shared with you is that prior to trying cyclic sighing at night time I was waking up virtually every single night once a night to urinate and in the 18 months 20 months since i've been doing it i think it's been a total four times that I've woken up during the night to urinate fantastic so we're talking about sleep you mentioned earlier um encouraging people with ADhd or who think they might have ADHD to keep a somewhat regular eating schedule or at least to make sure that they're eating yeah um and to not let their meals get fragmented into starting a meal then finishing it later like have for some people it's breakfast lunch and dinner for some people like myself it's lunch snack dinner whatever it is keeping a regular schedule um exercise aside from encouraging people to not exercise too late in the day um certainly not um caffeine and exercise late in the day. Are there any data about specific types of exercise being better for um adhd Independent of effects on sleep? I realize they're hard to tease apart. Yeah, there's a few studies looking acute aerobic exercise Part of it is that it's hard to study people when they're exercising during many exercise I mean you're not going to wire someone up when they're swimming for example so there's not a lot of studies in anyone approach and there's so much diversity that often it just gets lumped together so there do seem to be some acute effects of measurably improving some of the executive functions associated with better attention from acute exercise. And there seem to be some more general or longer term benefits from people who are consistently actively exercising, having, you know, being able to concentrate longer, being able to switch of attention more appropriately or effectively. And there's a huge body of sort of clinical literature of patients reporting, you know, I know I feel much more alert today, I get my workout in the gym in or I feel better or that, you know, the week I took off from that was a big mistake. But I would say identifying at what's the most valuable or what's the best duration I've ran through the data about a year or two ago and it's I would say that we can't make any conclusions. And I would say at some level try it and see what works for you and that's what's important it isn't what works for everyone is there a relationship between ADHD and addiction because of the impulsivity component yes and and so the answer is and these are really rough statistics I actually one of my pet peeves is people who quote oh the rate of this is 27.4. 3% well it might have been in that study but that's looking at one population at one said it so I use ballpark figures the ballpark figure is Americans in the last 20 years more than that about 20% of Americans run into some addiction substance addiction problem either alcohol drugs people with ADHD have a rate that's almost double and it's higher in men than in women double almost double almost 40% risk and that's for substance abuse not behavioral addictions yeah that's substance abuse and that's looking at abuse and we can get into the related topic of what's misuse and versus abuse and I have pet peeves there however kids who are put on stimulant medications when they're young and and I should say the stimulant themselves do have a small potential for addiction but putting kids on stimulants pretty much normalizes their rate of addiction problems so half it protects them this is a really important point that I think maybe we just hover on for a second um because I think many people including myself assume that well if you we're you know putting these kids on amphetamines of which you know many of the medications for ADhd are that were creating kids that are addicted to amphetamines or to a hypers stimulation period but you're telling me it's actually protective to put kids with real ADHD on medication for ADHD. I can say not absolutely every study has found this but several large metaanalyses have gone back and most of them have found this fairly dramatic benefit to being on stimulant as a kid in terms of specifically reducing substance abuse risk and some of them that have looked at this when I said it was a yes and um, it seems to be that it's not just the impulsivity traits but some of the inattentive ones too. You know, if your teachers lecturing about the risks of alcohol or this and this and you're zoning out at the window and looking at the plane flying by you have less pertinent information on the topics you may be less attentive to the negative effects that other kids are seeing Among the classmates who are stoners at this age or XY or so. It seems that both inattentive sets of ADHD symptoms and the impulsive, you know, thrill seeking, not weighing the consequences as heavily are all contributing to this heightened risk. I have this model in my head that is, um, perhaps completely wrong, maybe partially wrong. Um, and it goes something like this that we know that the neural circuits involved in executive control and directing attention and maintaining attention and avoiding distraction. This kind of thing, um, use dopamine and epinephrine and norepinephrine, um, at least to some extent And we know that people with ADH are capable of focus. As you said, it's a it's a failure to direct that focus, maintain etc. So I've heard from you before this discussion that, you know, people that, you know, tend to drink lots and lots of caffeine or who can drop into an activity but have a lot of distractability that, you know, they might have AD dhd so what i'm imagining here is that the threshold to get dopamine epinephrine and norepinephrine released is either much higher or more complicated um for people with adhd and so what they're seeking is these catacol amines these three chemicals dopamine epinephrine norepinephrine and that if they're given a a medication that puts them in that range where they're getting it then they're good they can stop seeking it so to speak um and i'm raising this now because we're talking about addiction addiction is a you know pursuit of things essentially and i guess what i'm saying is it it seems to me that the model of adhd that we hear about is that you know people can't focus um you know their dopamine circuits are all out of whack and then you put them on this dopaminergic drug and you know basically you get them addicted to that tunnel vision or something but I I have this model in mind now that what we are all seeking is to have portions of our day where we are directing our focus towards meaningful bill the things that are you know generative in our life work school relationships etc and that whether or not it's pharmacology or exercise or or what have you that it's it's just about getting into this plane of of consciousness and I say that in no-woo or abstract terms is is that right I mean are what we really talking about here is a failure to access enough of these neuromodulators and and these medications which we're about to talk about are really about putting us in the realm where those neuromodulators are just more accessible I'll just say I can go with that okay well you're the expert I mean, I mean i'm i'm putting this together based on kind of what we're talking about like getting enough sleep to me is a way of being able to have enough arousal during the day um you know exercise or these medications just different ways of being able to access arousal like if you don't sleep you can't access arousal during the day so okay well that i'm going to hold that model in mind and i'm going to keep testing it to try and destroy it as we go forward um let's talk about the medications since uh you raised those um and you know the first one i ever heard about was rin mh um let's start with rin um how often is rlin used nowadays and what is rlin doing um neurochemically and what are your thoughts on rlin as a a useful drug for childhood and adult adhd and i'm happy to repeat those questions so rlin is or generic methylphenidate and there's dozens now of slow release versions and there's even a patch a skin patch instead of an oral version our definition of what a stimulant is is really squishy and vague in its broadest sense it's any drug that has an effect in the body like the sympathetic nervous system which is a neopine phrine driven fight or flight arousal system so by the loosest criteria caffeine's a stimulant um albin's a stimulant even though we classify it as an anti-depressant um some of the decongestants are stimulants but more often when we're talking adhd medicines we're using stimulant more specifically for amphetamine based products like aderall and viance and again there's a host now of newer branded extended release forms and methylphenidate and we lump the two together probably most adhd experts agree with and this is where I'm going to be disagreeing with most of them I don't consider rlin a full stimulant so the NeuroP pharmacologists differ a little bit but amphetamine is a strong dopamine and norepinephrine reuptake blocker so it prevents what's already been released from being taken back up so more is available longer but in addition to that amphetamine is a pretty potent to a vesicle manipulator so it's actually forcing a bigger release from the vesicles when they're synaptically released so it's not just that the signal lasts longer and is stronger because of that it's a bigger signal depending on what study you look at most of the studies suggest that methylphenidate is actually a pretty weak vesicular manipulator and some studies don't find any impact there at all which means if methylphenidate is basically a norepinephrine and dopamine reuptake inhibitor that's what well buttin is that's one of the comp you know it's and so so why I would further say if you look at the efficacy data how well do these work in resolving ADHD symptoms all the metaanalyses lump aderall products amphetamine and methylphenidate products here and say you know they're here cu they work better this is you know success in reducing ADHD symptoms and allar stratera at motine wellbutrin I use symol toot mfil guanosine all these other things are down here as less effective but if you actually look at any of the plots that I've looked at and separate out methyl fenity is actually closer to the pack below it's that amphetamine products are head and shoulders above everything else methylphenidates usually at the top the rest of the crowd but if you just looking at the the data objectively there's a clear decision point so in terms of efficacy amphetamine products are stronger um but in terms of some of the side that you know the the side effect that I worry most about it's not at all common but it's one of the horrible ones is amphetamine induced psychosis now that we're finally looking at that a little more closely because for years the ADhd experts have said yeah it's really rare let's not look at it at all let's not pay attention move along you know don't look um with amphetamine adderal products and that's probably dose dependent but it's close to one out of 500 people and what's I'm going off on a tangent here but I'll keep following it because it's an important tangent it's only one out of 500 people that's uncommon but this is a really bad condition because so amphetamine induced psychosis is a schizophrenic like picture usually someone is really paranoid really worried that their friends are manipulating them or police are spying on them I mean if you drink too much alcohol you can be bat crazy as that's a highly technical term there you can be out of touch with reality you can be hallucinating you can be saying all sorts of nasty things but if it's alcohol induced you fall asleep at the end of that night you wake up the next morning you may feel horrible at the hangover you're not hallucinating you're not psychotic anymore hopefully you're regretting what you did probably not remembering much of what you did people will let you know with empet iine induced psychosis on the other hand classically and characteristically in what I've seen clinically it continues for days weeks or months after stopping the medication which means we are we've changed someone's brain and we don't have lots and lots of data and it's actually only come to us because people are concerned about marijuana causing a similar picture. So now we're studying this a little more but with amphetamine induc psychosis about and these are again rounding from different studies about 20% if you look 20 years out about 20% of those people are in a permanent psychotic state still so again it's uncommon but it's such a bad outcome that we really should be alerting people to it and I've been I saw much higher higher risk of this for I can get into it if we need to reasons in my population in in San Francisco but I've had people coming from all the most prominent ADHD clinics over the years who just moved to the area And when I'd say this give this as my introduction to you know I'm happy to continue on this But are you aware to a person they said no one ever told me that now maybe they have ADHD and weren't listening. But it's so uniformly consistent that they didn't hear or know that that was a side effect. And one in 500 isn't a trivially small number. No, it's not trivial. And I mean, why I got alerted to it is my rate in San Francisco is actually higher than one out of 100 Um, and so I'll go into I think a couple different reasons. One is I worked with a lot of HIV positive men and we know HIV, particularly in the days before we had effective antivirals is a virus that goes to the brain and effect, you know, there's a HIV induced dementia. So probably some of these people had brains that were compromised because of that and were vulnerable two a high incidence of methamphetamine. So methamphetamine street speed is a chemically different molecule than amphetamine has an extra methyl group and an extra methyl group can mean a lot. Um, so it's a cousin but methampetamine we know has higher rates of psychosis, higher rates of addiction, um, is tends to be more re-wording but again in that population and many of them would hide that history from me. But I think that the very first person I had with them phetamine ind psychosis, A guy in his 40s Hiv positive for years, this was back in early mid 90s, was able to finish school in his mid-40s get a good paying job in two years on stimulant and then had a full-blown psychotic episode where he, his data died of a heart attack 10 years earlier He was threatening his mom because he believed his mom had poisoned her. He flew over to