ADHD In the Media

Preston: [00:00:00] So how's it going? 

Margaret: I am ready to talk about ADHD today. Uh, yeah, 

Preston: hopefully we can stay on topic. And so 

Margaret: our track record is not great, 

Preston: but it's okay. So how was your week last week? 

Margaret: My week last week, I went to Colorado for the first time in living memory. The last time I was there is one, I think. Um, and I remember that I have weak ankles and that I am not good at hiking and I'm afraid of heights.

Preston: But it was good. It triad for Colorado. Oh, it was a bachelor party. 

Margaret: Yeah, yeah. But it was beautiful. And it Was great exposure therapy for me to work on my fear of heights and my fear of my my weak ankles. So were they having you hike for the 

Preston: bachelor party? 

Margaret: Um, it was like supposed to be like, it was like a walk.

It was supposed to be a walk. I made it to the little waterfall. Uh, but it was. [00:01:00] It was challenging for, I do truly, I think I have Ehlers Danlos, and so, I really truly have the weakest ankles in the world, and I twisted my ankle twice walking down, so it's, you know, people are like, don't worry, just like, walk faster, like, you're, you're just afraid you're gonna fall, but there's no way you're gonna fall, I'm like, I'm like, quite sure I could fall, I'm very clumsy, 

Preston: Yeah, you're like, there is a very realistic possibility in this case, 

Margaret: Yeah, 

Preston: yeah, everyone else is like, all you have to fear is fear itself, and you're like, no, I, A fracture is on the docket here.

Margaret: I was here on the side of the mountain. It wasn't even a mountain. It was literally like a hill and a creek. Um, but it was very, very fun. And it was whenever there's a bachelorette party, there's always like, I, this may be true for bachelor parties. I don't know. There's always like a, is, are we going to gel as a group?

Because it's like people from different parts of their life. Like what is the vibe going to be? Someone from each 

Preston: season of the bride's life. 

Margaret: And it gelled great. I think top one of my top bachelor parties in terms of like, I feel like everyone had a similar sense of humor. So it was like, very, very fun.

Preston: Yeah, I think [00:02:00] guys, it's pretty easy. Um, if you're like a season three friend and you meet a season one friend, you're like, Oh, what's up, dude? I'm like, I'm college and they're like, I'm high school. And then you're like, cool. 

Margaret: But what do you do? Like, what about when there's like quiet times on bachelor parties?

Like, Because that's like I feel where the bachelorette parties like they're going to bond super well 

Preston: sports or something 

Margaret: but like You don't talk about how you all know the, the guy and are like, here's my favorite memory with him and like, here's why I love him so much. I mean, maybe. I think it just, 

Preston: it just turns into a guy hangout.

Margaret: Have you been a groomsman? 

Preston: I have. Yeah. 

Margaret: And what's our count at? 

Preston: One. 

Margaret: One. Okay. Well, that's probably more normal. So, one 

Preston: out of twenty seven. Um, so I had a different weekend. I went to Austin city limits and it was incredibly hot and it was, I think it was 99, 

Margaret: it's like 199 degrees. 

Preston: Yeah. It was funny. So, [00:03:00] um, when I went to the concert, I was like, Oh, I have this small Osprey backpack will be fine.

Cause I figured, you know, they're going to search my bag and they're like, no, like fanny pack or like clear. And so they, I had to go hide my backpack in the woods. By the river in Austin. Were the woods just there? The woods are just there, yeah. Cause it's in the city limits. So I, so I go and hide my backpack.

And then I shoved my pockets with candy bracelets. Cause I was like, oh, these will be fun. And then they made me empty my pockets out. And they're like, yeah, dude, you can't take anything with you. That's food related. But what 

Margaret: about my candy bracelets? Well, they were in the trash. What about my gumdrop buttons?

Preston: Yeah. And then, um, chapel came on. She was really good. The crowd was packed. Um, I mean, I like red wine, supernova or pink pony club. She think of the basic ones and honestly. Pink Pony Club. I, I respect it though, because she, she's been having all this controversy [00:04:00] in the media and about like taking a political side.

She came out. She didn't talk. She was straight to business. She's like, I'm going to open with my song and then she would finish the song. She, she would like go down to her hydro flask, just chug it for like 30 seconds and then get back up and sing the next song. And then the very end of the club, she was like, bye.

She literally said, said bye. And she ran off the stage. I was like, that's someone who like clocks in and clocks out, but it was such a great performance. Like I didn't, I didn't need anything else. I was like, honestly, like, look at this transaction. She, she wanted something like she was there to perform her job and I purchased a ticket and we both came away satisfied.

Margaret: I feel like I wish, I wish someone would model those boundaries and like working in healthcare. Like, can you imagine someone who's like, I'm gonna do a really great job. And when I'm not on call, and when I'm not here, I'm, I'm not looking at Epic, I'm not chart tracking in the middle of the night, not ruminating about my patients that [00:05:00] day.

Can you imagine doing 

Preston: that in therapy? You like, you're like, talk to them, you're like, okay, great session, then you literally run out the room. 

Margaret: You're like, bye, yeah. Do you feel better? Well, I feel like, I don't, like, I, I mean, I, you do feel, do that in therapy though. 

Preston: Yeah, a bit, I guess sometimes if time's up, you're like, okay, this is kind of a weird spot.

We got to end it. 

Margaret: Yeah, but I feel like, see, this is our differences though as therapists because I'm pretty psychodynamic, so it's like psychodynamic, or I feel like either way, I'm like, I need to keep the frame, like I need to keep the frame of this is the time when we talk and this is how we do it, and if we end in the middle of a weird place, then when we come back the next time, I mean, there's also that classic thing of like, ending in a weird place in a therapy session, and being like, you don't really talk about the thing that maybe needs to be talked about for the whole session to the last five minutes.

Are you familiar with the concept of like door handling 

Preston: or door knobbing? That happens to me. I tend to, I tend to blame myself when that [00:06:00] happens. 

Margaret: Nice. Which 

Preston: we, we should, we can reflect on in a different episode. We can come 

Margaret: back to in, uh, at another time. Yeah. 

Preston: So, so pivoting the topics, we're going to discuss ADHD today.

And I think it's especially relevant because it's been one of those disorders that. Has managed to take center stage. I think or or at least it has good press. I think at this time in 2024. I saw you. You hesitate a little bit when I said that 

Margaret: I feel like. So I guess 1 thing for people listening to this podcast that we've talked about, but.

Concretely, if you're not in psychiatry residency, Preston is in his 2nd year residency, and I'm in my 4th year. And for most psychiatry residencies, you have a little bit of outpatient 2nd year and then all your most your outpatient is 3rd year. And what that means is that Preston and I have different kind of clinical experiences.

And so I think that I would have said yes to that. Like, I think [00:07:00] I agree with you that there's like more of a. An openness and less stigma on it than there once was and like, especially like compared to a decade or, you know, longer ago than that, but I feel like there can be stigma now in the outpatient world because like people, I don't know, I don't know.

The doctors always know what to do when people come in with like a self diagnosis, which we will get into. Um, but so I feel like it's, it's sort of, it is and it is not controversial in a new way. Yeah. 

Preston: Yeah, it's it's happened upon new controversies. 

Margaret: Yeah, I think I agree with you that people are more open to like receiving the diagnosis And it's not as negative or like stigmatized.

Preston: Yeah, so when we come back We will go over a quick overview of ADHD kind of like it's learn about the history of it You can understand that it has some neuro anatomical connections and then we'll go into the tick tock of vacation of ADHD and And kind of see [00:08:00] how do we get to this point where we're at today 

Margaret: and then we will also talk a little bit about things that can be helpful for it outside of the meds, which will touch on briefly and also things that are helpful from our view as people who are learning how to be psychiatrists of how to.

Learn about the diagnosis process and also what tiktok can offer maybe in terms of helping people with adhd 

Preston: Because it's easy to view tiktok as only good or only bad, right?

So I have before me a bit of a timeline of ADHD. And so, Margaret, are you familiar with any of the history of ADHD? 

Margaret: I feel like little like bits and bobs of it, but like not the overall picture. So I'm also curious to learn. 

Preston: Okay. So for anyone who's, who's listening and has a passion about this, I know that some people have reported back in the 1700s and 1800s.

We're going to start our story at. 1930 [00:09:00] or in the 1930s. So back, I want you to take yourself back to Rhode Island where Charles Bradley is a psychiatrist and he's taking care of these kids in a home where he's handling people who are behaviorally challenged. So you have. Your classic like 1930s misbehaving child.

And so this is the 1930s. So we're like, what treatment should we get to someone for anything? How about a stimulant? So, so Benzedrine was actually one of the main medications that we were giving for a lot of different reasons. Um, if you look up old advertisements of like Excedrin and Benzedrine, they were talking about.

Pilots that should use it so they can stay awake longer run this period between world or one world or two They were advertising it to women for weight loss because it could suppress their appetite and Charles was interested in giving it to these kids initially for headaches And i've also seen accounts that it was for like, uh, your eyes or head colds and it kind of makes sense [00:10:00] if Let's say you had a headache, nasal congestion, you're feeling kind of down.

If I took a stimulant, it's going to put some pep in my step. I'm going to wake up a little bit. Maybe the nasal congestion is going to improve because stimulants increase norepinephrine, which is going to constrict the vasculature in your nose. So it's good. It's like afrin, basically. I mean, a milder version of it.

So like, wow, like, we're curing the cold, you know, but then he discovered something really weird, which was. When these kids took this medication, they started performing better in school. 

Margaret: Mm. Mm hmm. So why was, why was he giving them the medication? 

Preston: Because, because he was just helping them out with their headaches or their colds.

Margaret: Oh, I see. 

Preston: So, this kid, he just happens to mis, be a misbehavior. And he comes to Charles for a head cold, gets a stimulant, and then goes back to school and starts performing better. And everyone's like, this is kind of weird because I thought these were morally bankrupt [00:11:00] children. Why, why, why are they all of a sudden, like, interested in academia now that we give them this medication?

And he talks about how they developed this drive to accomplish things. They, like, wanted to get stuff done. And that actually of the Children that had these, this Benzedrine, they tempered their emotional responses. So I think what he's commenting on is like their outbursts or their disruptions decreased.

So I think we would interpret that as they were able to apply judgment better. So it was interesting. He did. 

Margaret: Disregulation was less notable. 

Preston: Yeah. So he did a lot of experience between 1937 and 1941. And it's fascinating. Fascinating. Because. Everybody likes to think of lithium as the first psychotropic medication that we really used in the, in the early forties.

But if you want to make a case, Benzedrine was treating ADHD four years earlier in 1937 in Rhode Island. So in a lot of ways, [00:12:00] ADHD is one of the oldest. Applications of psychiatry. 

Margaret: Yeah. Yeah. And it's, it's interesting. And I'm sure that you happened upon this, like in, in this case, the, it's always interesting to hear the kind of old descriptions of psychopathology that would use like some words we still use today.

And some words we don't, um, and I'm sure with, with this, with these kids. So what, what happened from there? Like, did he continue, you said to like 1941, which is auspicious year. What did he continue to, Yeah. World War II's impact on psychiatry cannot be under, like, appreciated, I'm realizing. So 

Preston: there's kind of just like a huge pause on a lot of stuff there.

And it's funny, so, so I went to the, to the Air Force Academy. And it was a similar thing where we were supposed, the Academy was supposed to be started right after World War I, 1949, 1950, and then the Korean War happened, so everything got delayed. And, The university and up until 54 and I think with a lot of advancements in [00:13:00] medicine, a similar thing happened where they're like, oh, darn it.

Only there wasn't another nation trying to take over the world. 

Margaret: Yeah, I know. It's interesting. The primary 1 thing I'm thinking about also is like PTSD, um, and shell shock, but we will come back to that in a different episode. 

Preston: Yeah. So. Um, I guess going forward through the, through the history in 1944, Ritalin was first synthesized.

And so that's methylphenidate is generic. It was actually made to help with blood pressure. So it was, uh, it was a chemist that made it for his wife, Rita, who she would get orthostatic while she was playing tennis. So he created this stimulant that he was like, Oh, this is going to have a lot of like alpha one adrenergic activity.

It'll help her blood pressure stay up. And it's for Rita. So it's retailing, not Ritalin, but we're Americans. So we turn our T's into D's. 

Margaret: That's 

Preston: and it turned out it was way more effective for treating the symptoms of ADHD. 

Margaret: I thought she was locked in on that tennis game though. 

Preston: Yeah. So shout out to Rita.[00:14:00] 

Shout out to Rita. Yeah. Rita. So then to kind of fast forward through the, into the seventies now, there was a lot of concern about ADD being something that was overdiagnosed, which is, it was fascinating for me to look back and see that. This is something that isn't new. Yeah. So in the 70s, there is this estimate that somewhere between 5 to 10 percent of kids in elementary school were receiving a stimulant for behavior disruption.

Okay. And people like it's being overdiagnosed, which is interesting because our statistics are similar today. And it actually makes me think of you ever see those news articles where they're like, nobody wants to work anymore. 

Margaret: Is this 

Preston: generation the lazy one and then you can go back and find it in the 1960s, go back and find an 1890 and then they go all the way back until there's like an Egyptian stone tablet where someone were like some pharaohs written like this generation doesn't want to work anymore.

Yeah, yeah, [00:15:00] it's just the same story just retold over and over and over again and people act like they're coming home for the first time ever. Yeah, yeah. So during this, this period, 80, 80, she's had this evolution of a lot of different. 

Margaret: Uh, 

Preston: names and a lot of it has to do with how it's perceived by people.

So it's been called hyperkinetic disorder, minimal brain dysfunction is one of my favorite ones. Yeah. And so I think that came from its correlation with autism and other things. People were kind of trying to clump a lot of these. Neurodevelopmental disorders into one bucket, and they're like, it's not totally basically 

Margaret: like small brain, like little brain dysfunction.

Preston: Yeah, and it's like, what a, it's a stupid name because isn't everything brain dysfunction at some point, like every psychiatric illness to some extent, brain dysfunction. Yeah. Yeah. Okay. Great job guys. So then it was in the DSM three was a D D. Yeah. Attention deficit disorder, which you see a lot of [00:16:00] older attendees use.

And then finally we adopted ADHD. So hyperactivity as a part of it today. 

Margaret: And at what point did we start thinking about, well, I don't know if we want to jump to that. I was thinking at what point did we start thinking about the sort of inattentive or the misnomer that is even ADHD, which is again, as you said, attention deficit disorder and how we think about, we still call it now.

That's still a DSM 5 diagnosis, but, um, Now, I think we have a different understanding of what the attentional problem is, uh, maybe not as clearly a deficit as, as we originally, but certainly a better name than minimal brain disorder. 

Preston: And it's, it's been helpful that we're able to use fMRI studies and some neuroscience to, um, an examination of the brain where we couldn't before.

We just kind of looking at this black box and making assumptions about behavior. I think one thing that's always going to follow ADHD is this assumption that it's [00:17:00] a lack of a moral compass or it's a lack of willingness to do something because even hyperactivity, which can lead an impulsivity, which can manifest as poor judgment or inability to sustain focus is perceived as like a lack of interest or like a lack of care towards something.

So I don't know, even with this kind of new understanding that comes out. People will still have that perception that ADHD is not real 

Margaret: choice to be exactly. 

Preston: It's it's volition. And I think there are cases where it is the decision of someone to not pay attention, not wanting to do things. And the reason why we even discover this illness in the first place is because the kids that behaved poorly.

Started behaving well when we treated their headaches with a stimulant and it shows that there actually was a gap between what these kids were trying to do and what they were accomplishing and that gap was closed with a medication. 

Margaret: Yeah, yeah, [00:18:00] no, I think that I think ADHD is 1 of our diagnoses that even as stigma is, you know, hopefully somewhat reducing as people talk about it more, it's still like, you know.

Philosophically kind of kind of difficult like it's because because in psychiatry, we still don't even as we have like more fMRI data and things like that. We don't have like a diagnostic blood test or image. That's like, okay, you definitely have this and someone else doesn't and no one can know your internal sensation of things.

So no one can know if it's costing you 100 percent of your day to day energy just to Get to school if you're a kid, or if it's like, no, I could actually do it and it doesn't cost me much. No one can. We can't measure that. 

Preston: We're not the ones who draw the line for disorder. 

Margaret: Yeah. Yeah. Well, we are somewhat, but like, we can't know, like, we can't measure that distress 

Preston: necessarily.

Yeah. Getting into the neuro anatomy of ADHD to start out with. We don't know a lot about [00:19:00] it. And so a lot of these are kind of. Yeah. Brain, um, studies done in, in mice or fmri studies with pretty low, um, censuses. So. A lot of his kind of hypotheses and in guessing so that's and I'm saying that to caveat this because there's there's a reason why we can't just put someone in an fMRI and know whether or not they have a psychiatric illness.

So, as far as what contributes to the pathogenesis of ADHD, all we really know is something. Something cytokines is the best thing I'm going to say. So it has a lot of the neuronal pruning that occurs. Um, in utero is mediated by immune cells, and there are a lot of steroid hormone receptors on the insular cortex and on the ventral medial prefrontal cortex area.

So what they found is that there are correlations between higher oxidative markers and higher inflammatory cytokines, [00:20:00] and they can actually have a linear relationship between the severity of ADHD symptoms and Children and the presence of these 

Margaret: cytokines. 

Preston: But, like, that's like the most nonspecific thing you can ever find.

Margaret: Right. And like, how do you like, is it genetic? Does it, is it environmental? 

Preston: Correct. And there are, so all we know is that if you try to look in the black box, something to do with hormones or something to do with immune system regulation, if you look outside the black box, we see severity symptoms. And then the other thing, the input, we see that people from lower income areas, people that were had mothers with a higher age.

Higher maternal age, exposure to cigarettes, poor air quality index, things like that all increase the risk of ADHD, but we're not sure why we can guess that it's related to this immune dysfunction. The other thing we know is that. There is a correlation between things like autoimmune disorders like asthma and eczema and ADHD.

So when we do transsectional studies of patients of [00:21:00] let's say use albuterol or inhalers the likelihood of them using a stimulant or having ADHD is much higher. But we also don't don't exactly know why. So the hypothesis right now is that there's something with T cell dysregulation that leads to impaired pruning of these centers in the ventral medial prefrontal cortex and in that striatum or posterior cingulate area.

And the reason why that's relevant is because This is connected to one thing that we call the frontal striatal network, which is exactly what it sounds like. You have your prefrontal cortex here and it connects your striatum, which is kind of like if you think about your forebrain, it just sits right in the middle.

It's like a little hook. And without getting too much in the details of it, it the frontal striatal cortex helps you with triaging goals and following through on tasks. So 

Margaret: executive function 

Preston: is pretty intuitive for like why that could be a problem. [00:22:00] The other thing we see is that the ventral media prefrontal cortex has a lot of implications in goal directed behavior, emotional regulation, regulation, responses to things, um, you know, like rejection, hypersensitivity, and then it has to do with, or plays a role in initiating sustaining intention.

So that kind of brings me into my next point. One thing that you're mentioning, which is, We use these big words like attention, and then no one really knows what it means, right? 

Margaret: Yeah. Well, and I think one of the things that this gets at, um, is one what you said of like, what do we mean by attention, but also kind of the overlay of both comorbidity and like the differential diagnosis for for HD.

Um, so when we talk about attention, I feel like the thing that I thought about before Especially before I had like an attending who talked a lot about ADHD and sort of [00:23:00] specialized in it was a very broad sort of like, Oh, you can, you know, there's like the clinical examples that you think about in the ADHD, like questionnaires and things like that, of like paying for kids, like paying attention in class or being able to sort of regulate emotions or like being messy or organized in terms of the executive dysfunction when we think about attention, there are these kind of components that get broken down.

Um, and I think sometimes they're also hard to delineate from like, yeah. How do you differentiate like working memory and attention and attention from like alertness, um, or fatigue? And I think that all plays into the complexity of diagnosing clinically ADHD in addition to the like resistance. Sometimes people have to it, but I'm curious what you think about when you think of like a definition of attention.

Preston: Um, yeah, so it's, it's interesting. You should say that I'm, I'm working with the behavior neurologist right now, and I brought that up and they were like. Here's this wonderful paper on why we're all passionate about how attention is such a crap [00:24:00] definition and it kind of delineates What they call the taxonomy of how to describe attention.

Which paper 

Margaret: is 

Preston: this? And so I'll, yeah, I'll see if I can find it and send it to you. I don't, I don't have it with me right now, but the thesis of the paper was essentially that there's two big branches of attention, which are external attention and internal attention, or, and usually I would say stimuli from external sources or stimuli from internal sources.

So external attention is if I recognize something in my environment, how do I Shift my gaze towards that thing, pay attention to it, and it has to do with a lot of different things, like how do I filter out what stimuli even pay attention to? And then now that I filtered out the stimuli, because my eyes can perceive a million things, my nose can perceive a million smells, I can listen to a bunch of different things, what's important and what's not important.

And then I assign emotional values to those senses, As I triage them and then I make a decision about what I want to do in [00:25:00] regard to that. So a lot of that has to do the salience network and that has more implications in schizophrenia than it does in ADHD. So we won't cover that now. ADHD has a lot to do with internal sources of attention, which is if I have an idea for something that I want to do.

Because right now I'm sitting here at this podcast and I could do a million things like there is an infinite amount of tasks pressing could accomplish technically, but I have to be thinking about which ones are deserving of my attention and I triage that importance. So that is the type of attention.

Almost I think about almost like a laser pointer, but I have this internal laser point. I'm trying to point it at things. So within that it's divided into can I sustain it on one object for a long period of time? And then how do I prioritize what deserves my attention? 

Margaret: Right? 

Preston: So that kind of goal directed behavior is the frontal straddle network that we were talking about earlier, which we talked about.

No, has a lot of impairment in ADHD, so I think it's important to [00:26:00] like help people understand that it's even a small subset of their attention that's affected and if you have something like anxiety and you're hyper aware of stuff in your environment and that's impairing your attention, it's not necessarily an issue with your ability to point the laser pointer somewhere.

It's that you're Your threshold to pick something up and the noise in your environment is just so low, right, 

Margaret: but to complicate that, right, like actually being able to pinpoint that as like an individual or as an individual and a doctor diet or, you know, relationship, I think is, is quite important. Hard because like, is it that you're anxious because you're in sort of like an overstimulating environment or is it that you internally react to that secondarily with like a strong like thought pattern or internal stimulus?

But yes, this like regulation of attention. Um, is as the difficulty and also that that's not just present in ADHD in some way. So there's like quite a bit of overlap 

Preston: and both can be [00:27:00] present like ADHD, anxiety or comorbid, super comorbid. So it's always been really challenging for me to discuss someone's attention when they come in and say, like, hey, I'm having trouble focusing.

It's really, it's really a vague differential and to try to say like, okay, I usually start with, is the problem starting a task or is it staying on task? And I'm curious how you kind of attribute this, but I think about procrastination as mostly an emotional process. A lot of our reluctance to start a task is more so like how we feel about the task, but once you're starting on the task, that is your ability to sustain focus.

Margaret: Yeah. I think that like, if we think about learning how to do life with like an ADHD brain again, it, it, it kind of stirs those two things together. Um, I think I maybe more orient myself towards like domains of people's life and then like where they're noticing it and like, what is, you know, [00:28:00] the, the regular kind of diagnostic stuff for ADHD in terms of using um, Um, the, the different kind of like set of forms and like childhood and adult observer forms.

Um, but I think what you're getting at too is that there's different ways that lack of attention regulation plays out and. Like, how do we, how do we delineate those? I, I mean, I think when someone has an ADHD question and they're like, focus, concentration, being able to complete things, disorganization, when they come in and they say that to me, I tend to be possibly annoyingly thorough.

And so I have them do. At like all of the things that can impact like I have them do all of the forms that evaluate ADHD as well as ones looking at anxiety, depression, and for some patients like PTSD in terms of like the sort of like ability to. Respond to an environment and have attention be focused and then [00:29:00] enact a task.

Preston: Yeah. And so I think kind of the questions I'm asking, maybe like 1 of the lines off of something like the brown questionnaire, which I've always found these like to be interesting. So I pulled it up. It's. When you have to do a task that requires a lot of thought, how can you avoid or delay getting it started?

So I think that's a great example of someone who maybe has had a lot of trouble staying on task their whole life. So then they have learned to associate those tasks with negative emotions, right? And now they have a reluctance to start anything. So maybe I, I'm emotionally have a bad relationship with reading because I've always been bad at it.

And so while like my ability to sustain attention isn't the reason why I'm not starting reading, it's actually a consequence of my inability prior in my life to hold my attention. So this is like evidence that someone has developed. Essentially a poor relationship with tasks that they have to sustain their attention [00:30:00] with.

Margaret: Well, I think that's also one of the things about, you know, broad, more broadly, this kind of question of the adult ADHD diagnosis outside of like, what we see online or what doctors say that's good or bad is that for, that there is a lot of missed. Diagnosis, likely an ADHD and when we miss it and we don't get medication or therapy until into adulthood, kind of how does that change how we think about it for ourselves?

I think a lot of like, sometimes there's some like patients I've had who came into my like younger clinic that were like in their late teen years and so weren't necessarily they were somewhat late diagnosis. But if someone comes in and they're like thirties and. They've had to live their whole life with this ADHD symptomology.

Maybe they've coped with it. But like, how does that impact? I think what you just lined out the like behaviors they have, but also how does it impact their vision of their self and their vision of themselves and like how [00:31:00] they because they have at that point, 30 years of learning 

Preston: that this is who I am.

It's like a part of my personality, right? And so maybe they've come to the conclusion I'm just not someone who likes reading, right? It's just who I am. Whereas maybe they do have a curiosity for like books and stories and things like that. They just kind of taught themselves to hate it where it's really interesting for me to see kids that get treated early and they have, I think, a healthier relationship with their idea of the disorder because starting at age six, they've been able to see themselves on and off of medication.

And so maybe if that person doesn't like reading, they're like, Oh, when I don't take my meds, reading is hard for me. And that's the relationship they have with reading the rest of life. They haven't thought, Hey, this is just a part of my temperament. 

Margaret: Yeah. And you know, at the worst is, and I definitely think people.

People with ADHD, like, it's still an invisible kind of disability, but, and the medications don't take you all the way there, but kind of this explanation of what we kind of started the [00:32:00] episode with, or like, what we talked about with the history of, I don't, like, I can't clean my room as a kid, and part of that is because I need to do it in a different way, because I have a disability.

Because I have ADHD and I have to do things a little differently versus I can't do this and everyone around me is telling me I can't do it because I'm lazy and bad. Um, I think in particular, um, thinking about who did not fit on the historic diagnosis and ADHD and also who is more likely to present for care.

So in this, anyone 

Preston: who's not a white male. 

Margaret: What? Yeah. 

Preston: Essentially the answer. Unfortunately. 

Margaret: Yeah. Do you want to talk a little bit about why that is from your understanding? 

Preston: I think a lot of it just comes from our interpretation of behavior. So one thing we know is that minorities, specifically black males, if they exhibit a lot of ADHD behaviors, they are more likely to be diagnosed with something like oppositional defiant disorder [00:33:00] than their white counterparts.

Well, this has kind of been the theme of the episode people interpret the symptoms of ADHD as moral dysfunction So if you're in an environment where there's aspects of like systemic racism or a lot of implicit bias Someone's more likely to have like to lack a generous interpretation of of someone's misbehavior And so it's in a lot of ways you're trying to rule out other things that before you come to the conclusion hey, this person is just Disobedient.

And so for like white kids, pull out all the stops. Like, we're going to go do this full neuropsych workup before we say that you're misbehaving because it has to be something else. Whereas maybe other kids, the teacher has already dismissed them as misbehaving from the start. And then they don't work up this ADHD diagnosis.

Margaret: Right? Yeah. No, I think that is definitely one. I think from the perspective of like, why did little boys in the nineties get diagnosed [00:34:00] versus little girls? And it's not true across the board, but yeah, I agree with it. Was that the idea of ADD and then ADHD, and I think still is to some extent, is the kind of behaviorally disruptive, you know, running around a mile a minute.

Little boy with ADHD, um, versus the inattentive subtype in both boys and girls, um, is also, you know, an attention regulation issue, but doesn't make them get in trouble. Um, and I think particularly for little girls who are socialized to behave in a certain way as a girl, it means that ways of coping and dealing with attention dysregulation can remain hidden for longer.

Because they're less disruptive. 

Preston: Yeah. And so if I believe a majority of kids are combined type, it's most common when we see, but if someone is, has the inattentive subtype. So just a reminder, there's there's three subtypes of [00:35:00] there's primary hyperactive, hyperactive subtype, inattentive subtype, and then combined, which is just both.

If someone is inattentive, they're more likely to be female. And if someone is hyperactive, they're more likely to be male. And. Yeah. In addition to what you said, the the women that are socialized in the back of the classroom, they're just kind of seen as not paying attention and you can slide through the cracks.

But if someone is getting up and moving around and then they take this medication, they stop getting up and moving around. It's just that. The radar we have to detect the changes in their behavior is just more sensitive than this girl in the back of the classroom that if she took the medication, she would stay on task and maybe she wouldn't be perceived as stupid, which is the conclusion was being drawn prior to that 

Margaret: and that there was more.

I was reading, I don't know when the original copy of this came out, but it was, it's the book Women with ADHD, and talking about [00:36:00] the idea sort of that it was more acceptable, and maybe this is hopefully changing and not as true now, but like, I If a girl was underachieving and wasn't, you know, getting really good, you know, scores in her class that there is, there has been historically in, in school systems and emphasis on men are the one who should go to school and they're the ones who should do well again, hopefully that is changed even in the nineties compared to prior, but that this is like a legacy that also impacts how much girl little girls are pushed in terms of yeah.

Figuring out why they're not achieving at their maximum quote unquote 

Preston: potential. Mm hmm. Like if I'm not performing, it's Consistent with my concept of self 

Margaret: right or if I'm if I'm a girl who can't do math It's because girls can't do math not because I have ADHD 

Preston: Right, and if I'm a guy and I'm struggling for any reason bring out the psychologist We're getting 

Margaret: to the 

Preston: bottom of this Unfortunately, it has a lot to [00:37:00] do with socioeconomic status.

Yes, and the even ability to Have a parent advocate for you and suggest that it could be something so I have I've had patients who they Had parents who didn't believe in medication or didn't believe in ADHD and They end up with a stimulus disorder later in life, and I kind of asked them about the relationship with methamphetamine.

I'll say It's really weird, but it's the only thing that helps me work on the job site. Yeah. Like I get up in the morning, I take a hit of methamphetamine and then I go do construction and like, I'm a better boyfriend. Like I remember stuff from my girlfriend. I ask him things at work. Like I function in my job.

He's like, I don't know how to explain it, but it's like taking a cup of coffee times a million and, and I function well with it. And, and it sucks because this is someone who I think could have definitely benefited from a stimulant earlier in their life. And now they're self medicating with an illicit substance, which has a lot more risks in.

And on top of that, [00:38:00] they've been labeled someone with a stimulus use disorder, which means they'll never actually get, be able to treat this disorder. 

Margaret: Yeah. I mean, I wouldn't say never. 

Preston: Yeah, but like, I guess it's, I mean, dramatic, but. 

Margaret: Well, one of 

Preston: the people say, like, I'll never give you a stimulant because you have this history of, of methamphetamine use 

Margaret: one of the papers I was reading for this episode is it's from BMC psychiatry and it's adult ADHD and comorbid disorders, clinical implications.

Um, it's from 2017, but one of the things that I think we, I've learned before, but it was just interesting to read about was kind of the impact on studies of kids on stimulants at like. Entrance of adolescence and kind of like quality of life and, um, sort of like achievement attainment and that in kids who had gotten stimuli, like been diagnosed and gotten stimulants and kids who hadn't, um, and certainly there's like co variables with that in terms of who has access to treatment, [00:39:00] but just that kids who got stimulants and their level of achievement in adolescence and like in their twenties and thirties was very different, including a much reduced Likelihood of substance use disorders.

Preston: Yeah. I think I've actually seen that paper too. It's really fascinating. 

Margaret: Yeah. And so there's this thing of like the comorbidity of substance use disorders and people with a diagnosis of ADHD and kind of a chicken and egg where people will kind of talk about it as I think sometimes as like the impulsivity part of ADHD, but it's also like a self medicating component and that having kids on stimulants or having people take the gold standard medication for ADHD at whatever point is.

Rather than be this risk for substance use disorder. Addiction is actually likely the 

Preston: opposite. 

Margaret: Yeah, 

Preston: the 

Margaret: opposite 

Preston: it decreases the risk of it and and not even for just substance uses, but the impulsivity or maybe this is another chicken egg egg situation, um, [00:40:00] with the engagement and like dangerous activities and accidents.

So, as we know, for adolescents, 21 through 30, I believe the number 1, if not 1 of the top causes of death is accidents. And so people that are engaging in these risky activities, who may be impulsive and also maybe they get some kind of sympathetic high from whatever they're doing. And it's kind of taught them.

Oh, you know, like, this is a reward pathway for me. Those accents are also, um, have the benefit to be reduced and. I think there's, I don't want to be misquoted as well, but there is another study that looks at mortality benefit of stimulants started early in adulthood and looking at kind of just like you described, we don't know exactly why, but if you're less likely to develop a substance use disorder or engage in these dangerous activities, you are intuitively less likely to die.

Margaret: I mean, I think one of the [00:41:00] populations that I work with is the perinatal psychiatric population. And this question. Of, like, actually really thinking, like, being thoughtful about the benefits of a stimulant versus, like, the risk of taking a stimulant while pregnant and the concerns for the fetus on growth restriction and some other, other parts, um.

Is a really difficult conversation and often I'm the one not necessarily like pushing for the stimulant to be used during it, but talking about things like when you weren't on a stimulant, how many car accidents did you get it? Like, how much function was added to your life? And like, you know what you're talking about of 

Preston: did you remember to eat?

Margaret: Yeah, like, remember to bathe? Right? Because we know that not treating Mental health concerns in pregnancy, not treating it. It's not like you either have this exposure to a medication or it's nothing. It's unmedicated ADHD, unmedicated depression, bipolar, whatever, and the risk of that on, on fetal outcomes, not to mention maternal outcomes, [00:42:00] uh, versus the risks of the 

Preston: medication.

So. Yeah, I think it's helpful to view as it's always an exposure. I'm either exposed to the medication or I'm exposed to untreated ADHD. 

Margaret: Yeah, yeah, exactly. 

Preston: Like I'm exposed to lithium or I'm exposed to untreated bipolar. Right. You know, having a manic episode is terrible for a child. So we're going to weigh that the risk of relapse against the risk of lithium in pregnancy.

Right, right. So now that we've kind of ventured through all the clinical science of ADHD, we also have this other aspect of it, which is how it's used in social media. And I think this is unique for you and I, because we're both content creators on TikTok, maybe a little bit chronically online and have been exposed to the TikTok world and ADHD.

As I, as I think. A lead character, I would say, for at least my for you page for the last four years or so. So [00:43:00] when we come back, we'll kind of talk about how we see TikTok and ADHD. And then also, is it useful? We know there's a lot of misinformation out there, but is it all misinformation? And how do we kind of I

remember the first time I saw, uh, ADHD related Tik Tok, I think it was someone, they were filming themselves in their house and they were like five sides. You might have ADHD and they're playing like dance 

Margaret: and point at things. Yeah. They got like 

Preston: funk music in the background and all of the things they highlighted were extremely relatable to, I think anyone who's a human being.

I think one of them was like, if you hate going to school in the morning, Or if you, it was like, you have trouble maintaining relationships. Yeah. You don't like doing your laundries or I think it was like you have laundry piled. All over your room and [00:44:00] I like to think it was well intended and it's cute to say, like, yes, these are all things that people with ADHD can experience, but then the implied logic is if I experience these things, therefore, I have ADHD, right?

And it's kind of like saying, like, I don't know if I have malaria and I experience a fever. And then someone I go up and say signs, you might have malaria and it's like your temperature is over 99. And I was like, oh, my God, it's malaria. And like, you know how many things can cause a fever, please? And they're like, you're right.

Brucelosis. I know exactly what I have. Yeah. 

Margaret: I think it's also, I, I feel like the same phenomenon. I feel like I first started noticing on actually like Instagram before the pandemic with like, People talking about, like, trauma, but it was, like, here are five signs of, like, things that are normal day to day struggles, similarly with the ADHD stuff of, like, five signs you might be acting out in a trauma bond, [00:45:00] or, like, here are three things traumatized people don't do, and it was the, uh, You know, I think similar with every diagnosis, like a diagnosis can be something that helps like open up your world or closes it down and we don't want to pathologize the human experience because it often can make it harder, not easier to cope with.

Preston: Yeah, exactly. So fascinatingly, they did a study. In the Canadian Journal of Psychiatry on the accuracy of these tiktok videos that we're seeing. So this is called tiktok and attention deficit hyperactivity disorder, a cross sectional study of social media content quality. And so essentially what they did is they looked at 100 different videos.

A hundred of the most popular videos, I believe with the hashtag ADHD or classified somehow as being ADHD related, and then they assess them with criteria for if they were misleading or if they had factual information and what they found is that 27 percent [00:46:00] were classified as misleading, 21 percent were classified as personal experience and or somewhere in the middle, so around half of them together, so 27 percent plus a 21%.

We're not like medically factual information when we're just like personally anecdote that we're being shared as facts And that I think another interesting thing is that some of these non factual videos were posted by health care providers Hmm, so I think there is another tendency that I see too on social media, which is that Somebody has the title health care doctor.

So and so. And then they feel empowered to talk about anything in medicine. And I don't know if you've seen this, but I've seen plastic surgeons or dermatologists happily weigh in on schizophrenia and ADHD. And I'm just kind of like, What you know, like why why do you feel like kind of comfortable like sharing your two [00:47:00] cents on this?

Margaret: Yeah, my for you page is a very different world. I think then yeah, then yours But I 

Preston: and I think I'm probably deeper in the the head talk. Yeah. Yeah, it's just it's just like fascinating to me And I think some of them maybe they're just they see themselves as they make medical content related to anything But then I kind of can lead to this complacency about 

Margaret: Right.

Talking about stuff 

Preston: that's like not really in their lane and I think I have, I have a hesitancy to that. And it's funny because I know other people feel similarly, like I was, um, an intern on medicine. So, so I was, I've been on the wards for like two months, so I feel like I was getting pretty good at sliding scale insulin.

So I wanted to make a video about sliding scale insulin, just kind of like how I approached it. And I got like a decent amount of clap back that was like, you're a psychiatrist, stay in your lane. Like they'll talk about internal medicine stuff. Yeah. And I was like, honestly, like kind of fair, like all I have, yeah, all I have is this two months of experience in, in, uh, my internship that I'm trying to, to [00:48:00] parse along.

And I think the same goes to these other clinicians who essentially have the training of a third year medical student in psychiatry. And now after they've finished their six year fellowship in something else are coming back and then sharing their opinions on a, a mental health disorder. 

Margaret: Well, I think like, I mean, you know, this from our conversations offline that as a trainee.

As someone who, like, I mean, I'm applying a fellowship, but as someone who could be a psychiatrist basically in six months and be done, I have a lot of kind of, I think, imposter syndrome, but also real respect for the complexity of our field to even do this podcast with you as we've, we've been working through together for me.

Uh, and so I think. I think the other part of this for me, and where I see it come up a lot, is like, even if you give factual information, it's given in a vacuum that is like, non contextual, so even when there are psychiatrists, and like, we've only done a few episodes at this point, like, there are so many lenses, or so many kind of views you could put on [00:49:00] perspectives of what a psychiatric symptom means, um, that all have a lot of validity, but also that there's like, fair disagreement.

And so I think one of the issues is just like, how do people apply general, um, psychoeducation online and how do we, how do we communicate it in a way that is helpful without being almost prescriptive inappropriately. 

Preston: Yeah. And I think maybe it's all further notice. My solution to that is you just can't do it.

And I think like we can have these conversations about ADHD here. And I think even right now we've been talking for almost 40 minutes and we're taking a small lens of it. We're not scratching the surface in the way that we could. It's I think if you take a video and list a bunch of transdiagnostic symptoms imply they're exclusive to ADHD.

And post it online. I think it ultimately does more harm than good because leads people to come to this [00:50:00] conclusion that maybe they have ADHD and then it leads people that don't have ADHD to kind of view it almost as this like kind of cartoonish sensationalized phenomenon, which I think is. Unhelpful to I think our relationship with mental health disorders as a society.

Yeah, I think that yeah, we, I think it's an overcorrection. Like, we have this drive to normalize mental illness. Wouldn't that mean to make it treated? The way we treat other illnesses, right? So, for example, I don't think I would put in my instagram bio all of the, like, times I've had an upper respiratory infection or a UTI or something else, but we kind of interpret our mental illnesses almost like they're, they're a badge or something to celebrate.

And I think, I think sometimes that changes how others perceive. Our relationship with our mental illness, like, is it [00:51:00] if this, I think it's seen by the person that has it as like an ownership of their symptom. Like, this is something I've been stigmatized against. And now I'm taking my chance to own it again, which is 

Margaret: valid.

Yeah. 

Preston: Yeah. Which is I think it's a reasonable thing to want to do. And also taking back and celebrating isn't isn't going towards normal. 

Margaret: Right? I think you're saying, yeah, I get what you're saying. I think I think this is a super complicated topic in terms of. Yeah. And even if you just zoom in on like the ADHD kind of community of they'll, they'll be kind of, I don't know if controversy is the right term.

Um, because it's like in a subreddit. Um, but like, they'll be kind of like, okay, well, some people find it helpful to view the sort of increasing creativity or kind of divergent thinking that people with ADHD have as like a superpower. And some people say, Okay. This causes me so much pain. This illness causes me so much pain.

How dare you, like, kind of silver line it. Um, and I think similarly with this [00:52:00] question of how do we ask people to own something that is both difficult and in some ways and it's at least something in who they are, right? Like with mental illness, making sense of who we are versus who the ADHD is and trying to actually parse those out is, is really, really, I don't know that there's one answer to it.

So I say all of that to say, like, I think probably. Making, uh, like ADHD or any mental illness, the entirety of who you are reduces who you are, but also that there's been so much to say to get people to try and hide their illnesses and their struggles that I, I understand the desire to kind of react to that and make it like, I'm okay with this.

And if you're not okay with it, then like, you can see that I'm, it's, it's part of who I am. 

Preston: Yeah. I think in a lot of ways, it's, yeah. The category that ADHD gets put into or these other illnesses is almost like, um, gender or sexuality and, and, and I [00:53:00] think that's maybe where the pursuit of neurodivergence as like a label comes from, because my sexuality, whether a heterosexual, homosexual or transgender, cisgender, those aren't necessarily disorders, they're just pillars of my identity.

And so they could argue that, oh, my ADHD is just another pillar of my identity, but it's not a disability. And I think there are some people that are even under the kind of the belief, like you said, that ADHD isn't a disability, it's a superpower, if anything. 

Margaret: Yeah, and it's broadening of what the idea of, 

Preston: quote unquote, 

Margaret: no, broadening the idea of what is normal or what is like, Natural quote unquote, that's human.

What exists in the human, you know, world, just not because a set of things is good. I mean, and let's be real, like the DSM five is based on saying some things are quote unquote normal and some things are not because they're outside of sort of two standard deviations, even though. [00:54:00] That's also debatable. Um, so yeah, I think this kind of idea of like a spectrum of symptoms, but that's also why in the DSM, it's always, is this getting in the way of the kind of life that you want to live?

Um, including with ADHD, like, are you creative or is, and that's, that's it. Or is it like, I'm creative, but also. My life is really, really hard because of this attentional disability. 

Preston: Yeah, I think one analogy that is coming to mind is tick disorder. So, I'm in adolescent clinic and we are treating some patients that have tick disorder.

And my attendings approach, which I agree with is How much the tick affects them is really how much you got treatment. So if somebody has a tick like, like they just shrug their shoulder continuously and you ask them if it bothers them and they just say, no, then the tick is just a quirk really. But then if.

If, if you took another person and put them in that brain, they said, yeah, this, [00:55:00] this shoulder shrugging bothers me, I want to stop it now. It's a disorder. Now it's tick disorder. 

Margaret: No. And I think I, I, I remember having med school, like some of my friends being like, I'm thinking like leaning towards like emergency medicine or other kind of like fast paced, um, specialties because they were like, I can't do, yeah.

Like, they're like, I don't want to sit for an hour in a room like a psychiatrist would. Like, that's just not the way my brain works and that would be kind of painful. In some ways, uh, whereas like, I, I hate the emergency department, but like picking the space also with this, this idea of neurodivergence is like, like the, the, the cliche quote that everyone says, like, if you judge a fish by how it climbs a tree, you're going to think it's like very dumb, but neurodivergence allows this kind of like, that there may be are different places where people with an ADHD to subtype brain thrive and they just have been forced into, you.

Situations that are not that can't measure that [00:56:00] their talent or their strength 

Preston: and they're more adaptive in the pharmacy department would be the argument. Yeah. We're like in Percy Jackson, the Olympians. 

Margaret: I've read those. Yes. 

Preston: Yeah. I think at some point he was like, he was diagnosed with ADHD. And then he shows up to Camp Half Blood and they're like, actually, like your A DH ADHD is just your demigod sense telling you, like to be aware of things and like focus on stuff.

So I think even in that, like it was 

Margaret: your Gods , 

Preston: A DH ADHD was literally his superpower. He's like, yeah, he's like, your, your half God. And like that's what being a DH ADHD is. I love, and I guess like anything you have these. Traits on a spectrum of an attention and these traits on a spectrum of impulsivity and impaired judgment and whatever environment you're in is going to determine how adaptive those traits are.

So, I think there are some people that their traits are so extreme that they will have a gap between how they live their life and how they want to, so they will meet the definition of disorder just about every context. I think there are other people that. [00:57:00] Depending on the context, then they may be perfectly adaptive and they'll function well.

And in other contexts, like struggle a lot. So school is a place where you, you have a lot of demands on your attention and your judgment. So maybe you do have a disorder in that sense, but outside of school, people may function. Okay. Right. So like philosophically, they do have disorder. It's like, well, when one of their environments they do.

Margaret: And what makes that person, like, if, if I put someone who, like, thrives in the very structured, like, modern school environment versus, I mean, like me, like, hated the emergency fire, hate kind of like these, like, unstructured, whatever environments, like, what makes us say the person with the ADHD brain is the abnormal 1 versus the person who can't thrive where the ADHD brain could.

Preston: Yeah. And I guess. Maybe that comes from our definition of disorder. So like[00:58:00] 

Margaret: we're not going this is the dark history. Yeah

Preston: You have to say like I think there's this assumption that if there's a disorder We're saying that there's pathology and that pathology is because of some kind of failure or issue with the person involved ease Yeah, it's yeah, it's just disease And therefore, like there's something wrong with you, which is the ultimate implication and people want to say, like, there's nothing wrong with me.

This is a normal reaction. You know, of course, a fish wouldn't like this, but I guess, like, we can still have disorder and quote unquote, like pathology and normal reactions. So, like, the analogy I use all the time is like, if you get hit by a car or if you get burned or something, it's a normal, reasonable reaction for you to break your leg, but it's not your fault.

And so I think just like how someone may have. Yeah. Normal traits that when confined in this like rigid academic environment may manifest as disorder doesn't mean there's anything wrong with them. [00:59:00] 

Margaret: And I think like this to tie this into what we talked about a couple episodes ago. Um, it's interesting how you could take someone who's like, especially in like the adult world, so not just the child world, but take the but also this is true in the child world.

Um, someone who's like exhibiting ADHD symptoms and. Instead, take it and look at an attachment lens and say, it's not attention. It's they don't feel safe. That's why they're doing this, this and this. And this seems maybe somewhat tangential, but I just I think it's interesting to think about what we talked about a couple episodes ago and be like, we could frame like, kind of the same clinical approach.

And obviously, we try to use all of these frames at once and integrate them. But just to get it, that kind of contextual part of it. You, someone, someone could take a different lens on ADHD and people have to both help and hurt in the history of ADHD and Have a completely different set of recommendations than what we've talked about right now.

Preston: Um, [01:00:00] 

Margaret: I wonder, you know, in in kind of our last portion here, what do you think is helpful about the online world for people who are wondering if they have a D. H. D. 

Preston: So I think. One thing that it offers them is, um, validation for problems they already have. So I think if someone is experiencing a lot of issues and then they seek out the on world and feel validated by that, that can be helpful.

And I think there are a lot of people that do discuss ADHD with nuance. So what's really great about something like tick talk is that you have neuroscientists and psychiatrists who try to engage in these very like long and nuanced discussions or caveat. Well, the information that they're giving and it's, it's amazing because essentially you get to have a FaceTime conversation with someone who's an expert in the field.

So while you have to filter out. [01:01:00] The memes, you still, you also get to see a world expert discuss it. So I think it's, it's a double edged sword. And as far as the solution to like knowing who's. Legit and who's not it's hard. I would say just about every time look at someone's credentials So there are people that will put doctor in the handle And then you look them up in their naturopath where they're a chiropractor And they really have no meaningful training in mental health at all at least not by the definition that most people will Yeah, not not by our With mutually agreed upon.

Yeah, like understanding of being a mental health provider within the united states, so 

Margaret: I think if anyone's trying to sell you something more than a book, be a little nervous, be a little nervous. Um, I also, I kind of agree with you that like we, and we know [01:02:00] there's not especially right, like one of the biggest shortages in psychiatry in terms of access to care is in child psychiatry.

So, like. We're talking about like, oh, we should get people diagnosed. We should get them the care they need. We should this that and the other. And there's also a shortage for access for adult psychiatry and for the other portion that we didn't talk as much about, which is, um, different forms of therapy and like executive, um, function kind of oriented psychoeducation groups.

There's also not a lot of access to. To those things either. So I think that the thing that online can offer when they're nuanced is access to information and like an ability to self advocate, especially for folks who in the past have historically been underdiagnosed. 

Preston: We've 

Margaret: talked about a little bit and that advocacy though, it sometimes I think annoys doctors, um, is not always a bad thing.

Preston: Yeah. And, and that like everything has to find balance. The other thing I would add is. And I think this is just a golden rule for finding a [01:03:00] scam is it to build upon if someone's going to sell you something is if somebody presents you with a problem that you didn't know you had, and then immediately happens to conveniently know the solution to that problem.

And for some reason, it's, it involves you being separated from your money 

Margaret: and a webinar. 

Preston: Yeah. And like, and it's sad because Even though we say like, look at credentials, like there are psychiatrists with like MDs that still will be kind of quacks in this regard and we'll be preaching stuff that's inconsistent with the general like scientific consensus.

Like, for example, I think there's this one psychiatrist who's talking about the carnivore diet. And he's like, actually, like all of our problems come from like us having too much oxalate from. Salads, like stop eating vegetables, dude, and so, and so it sucks because people want to trust [01:04:00] this person and they look at them up and they're like, they have an MD, but they're just spewing absolute nonsense, right?

Margaret: Well, I think one of the things you and I can speak to, right? Like in our, we're in training to do this. Um, it's really hard to interpret the data like alone. Not that there's not answers in it, but it's like, there's a lot. And so. Yeah, anytime there's like a this is the one way and this is it and this is right and everyone else is trying to fool you 

Preston: And those are satisfying answers.

And for they 

Margaret: are 

Preston: I have the answer 

Margaret: we have the answer on this podcast 

Preston: Yeah, exactly. So it's almost like the more unsatisfying the answer is 

Margaret: the less the closer to the 

Preston: truth. You probably are 

Margaret: Exactly. Yeah, unfortunately I always tell my patients like, Hey, listen, I wish I could, I wish there was one answer like that would rule.

I wouldn't have a job anymore, but honestly, that would be okay. Like, if there was one answer, that would be [01:05:00] amazing. Unfortunately, for both of us, I don't think there is 

Preston: like, well, they'll sit there and be like, I just feel like I don't have any purpose. I'm like, I wish I could prescribe you something. I wish I could give you a sense of purpose.

How easy would that be? You know, this is, this is, this is why you're drastically unsatisfied with your life. The only thing that stands between you and self actualization is this. Our online 

Margaret: coaching. Patreon, behind the 

Preston: paywall. Yeah, which is personalized. 

Margaret: Super personalized. It's a personalized template.

Preston: It's just like embarrassing that even like, as someone who's like attached to healthcare can could be like ever associated with that type of advertising or business. Yeah, it sucks. It does suck. And the same is so true for the fitness industry. And I guess [01:06:00] what I see a lot there is that people have those like secret hacks for the satisfying answers.

And the reality of a lot of fitness is that it's very simple, but that doesn't mean it's easy, right? It's like exercising and eating healthy. Are not mysteries, I guess. They're not scientific mysteries. We're aware that they work. They're just extremely challenging. Yeah. And I think a lot of it is true with, um, things within mental health.

Like, we know that having a sense of community, having a good sense of purpose, having daily 

Margaret: movement. 

Preston: Yeah. Being in touch with your emotions are all like easy things to say on paper. It's hard to be challenging to execute. Yeah. Have access to. 

Margaret: Yeah. I mean, I think. I think the thing I would like to end with is, is talking about places that we like, in terms of like, learning from people either who have ADHD or from clinicians or just anyone who's kind of involved in this that we think are good places on TikTok, but also online in [01:07:00] general.

Um, I think a classic that I recommend to my patients is the how to ADHD channel on YouTube, which has got a ton of great videos that are like also super helpful for learning skills that are parts of the like behavioral and executive functioning therapy that we use for ADHD. So she also has a book out that I have not yet read, but.

Love that channel is really, really helpful for a lot of people. 

Preston: And then one that I thought was really fascinating is Priyanka at little miss adhd on tick tock. So I believe she's a pharmacist and she has a lot of discourse about the how like. ADHD is sensationalized. And then we'll, she'll contrast that with how much it challenges her in her daily life.

And I think kind of a lot of her narrative is actually around like, please stop making a, she seemed like it's this quirky fun illness. It causes me a lot of turmoil. And I think she kind of, she has this sobering. Retelling of a lot of her symptoms. And so I think for for [01:08:00] people, it can be very validating because they also experienced the symptoms.

But then it's also someone who's not trying to sell them something at the end of the day. They're really just trying to have this lucid, undoctored report of their experience. 

Margaret: I do think that, like, even though that one paper was talking about, like, what's anecdotal, I do think that People having stories, like one of the things that we know that helps people on inpatient units and in group therapy is, is hearing how other people cope with illness.

Um, and so I, I do think that's also something, and it sounds like this person does it well, is hearing other people's real thoughts about how they cope with the symptoms or diagnosis that they're struggling 

Preston: with. And I'd like to add, there's, there's Different values to anecdotes. So there's I have HD and this is what my morning is like.

And then there's if you struggle to do laundry, you might have ADHD because I have ADHD and I struggle to do laundry. So like using the anecdote as like [01:09:00] proof or as like an assistance to help other people diagnose themselves may not be rational, but It's really validating for you to just say, Hey, like, Hey, I have a DC mm-hmm

And let me tell you about my experiences. 

Margaret: Yes. Yeah, totally, totally. So we will be talking about the carnivore diet , although I will say as someone who has to take iron supplementation, eating steak did actually help my energy level . 

Preston: Oh. So yeah, maybe, maybe he's on something. Maybe 

Margaret: he's onto, so with the anemia, girls, get up

Preston: Um, and then yeah, I'm on, I'm on the creatine diet as well. So, so what's 

Margaret: the creatine diet? I mean, I, do you just take creatine? Oh, I take that. Got to get huge. Got to get, yeah. When are we going to do our exercise episode? 

Preston: That will be a good one. We'll have to do it in the gym. So I mean, 

Margaret: live episode at the gym.

Preston: Yeah I think preaching would be a great one to cover. And then I'll be working on my, my bench press until then. So it will be a good competition. Yeah. So, um, my hope is that [01:10:00] actually Priyanka will be able to come on the podcast and chat with us a little bit about like her experience as a content creator who discusses their mental illness so openly.

And has to navigate a lot of the both the stigma and 

Margaret: sensationalization 

Preston: of the illness. 

Margaret: Yeah. And it also online and in the world that we're in. 

Preston: Yeah. Yeah. And I think she kind of sits on the other side of the table from us as almost the role of a patient. And On the same side of the table as us as a content creator.

So, yeah, I'll be curious to hear your perspective. All right. Well, that's all I had for today. Same. Um, Margaret, I am now going to end the podcast. Okay. I just don't know how to do this. Yeah. Hey, hello. How was the show? You, the audience member. I have a couple of questions for you. Did you, did you like my voice?

Do you like the jokes that I make? Please tell me that I'm cool. Please like them. [01:11:00] But seriously, if, if you have any questions, um, please come chat with us. Talk to anyone in the Human Content Podcast family. We're on TikTok, we're on Instagram at Human Content Pods, or you can reach out to us at, at, we have a website too.

Howtobepatientpod. com. I always forget the pod part at the end. But it, but it does exist. Otherwise, otherwise the website is not real. Um. And then also like we're dynamic. This is a new podcast. So if you guys want us to cover any topics, if you want us to dive into things, if there's things that you want the 

Margaret: live us, the gym episode.

Preston: Yeah. If there's stuff you hated, tell me. 

Margaret: Tell him and not think about it. And 

Preston: there's stuff you liked. I also won't tell Margaret and I'll just, I mean, neither side of 

Margaret: the coin. 

Preston: So if you want to see full videos, you can look at my YouTube channel at it's press row and Those are the places you can find us.

So thank you again for listening We are your hosts Preston Roche and Margaret Duncan Our executive producers are me Preston Roche will Flannery Kristen [01:12:00] Flannery Aaron Corny Rob Goldman and Shanti Brooke Our editor and engineer is Tracy Barnett. Our music is by Omer Benzvi. And you can check out our show notes to see references and resources we use in their discussions in this episode.

To learn more about our program disclaimer and ethics policy, submission verification licensing terms, and our HIPAA release terms, go to the website howtobepatientpod. com or reach us at How to be patient at human dash content. com with any questions or concerns. Remember how to be patient as a human content production.

Thank you for watching. If you want to see more of us, or if you want to see, this is Lilac. She's my cat. She's going to be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac, point to the other episodes. [01:13:00] Lilac doesn't know what the internet is, but I swear they're there.

They, they probably exist for real. But in the meantime, I'm just going to pet Lilac and then I'm going to go dance in the background.