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    Old 09-11-2009, 03:00 PM   #1
    berrygirl
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    Question AD/HD Paradoxical Effect

    I have read some interesting things about the so-called "paradoxical effect" of stimulants on people with AD/HD...

    What perspectives exist on this topic? Does anyone have any personal experiences, medical/scientific information, or other thoughts on this ?

    What about treatment tolerance?


    I was recently diagnosed with ADHD combined type (after a series of interviews, questions, and 4 grueling hours of cognitive testing). According to the neuro-psychs I've seen, my history and testing results support a solid, unequivocal AD/HD diagnosis.

    Since being dx, I have found a lot of contradictory information on AD/HD and my head is SPINNING! I would like to know more about these things (particularly the relationship between tolerance, ad/hd, and allostasis).

    What I do know is that the medical and scientific communities appear to have [generally] accepted ad/hd as a neuro-biological condition with well-established correlation with certain traits. Still, because of all the anecdotal stories and forum arguments I've read, I uncomfortable committing to the idea of taking medication because I feel like I need more, or rather, BETTER information.

    I do NOT want to begin taking any controlled substances if unnecessary... Because of all the talk about this supposed effect and it's common with AD/HD-ers, I'm wondering if the tolerance I experience when drinking coffee regularly and the occasional jittery-ness from several espresso shots may prove that my apparent cognitive deficits may be, in fact, due to something other than AD/HD.

    Here are just a FEW of the things I have read (mostly opinions probably)
    "If you're really ad/hd, you can't become tolerant to stimulant treatment..."
    "paradoxical effect is a medical myth..."
    "paradoxical effect is due to brain chemistry differences..."
    "true ad/hd-ers can't get 'over-stimulated' by stimulants..."
    and so on...


    I'd really like to find out what other people know/think about the validity of the "paradoxical effect" or ad/hd treatment tolerance...


    also, a very interesting post on the issue (which I wish I could know more about) is located here: http://www.healthboards.com/boards/showthread.php?t=625475&highlight=parado xical+effect+add

    Last edited by berrygirl; 09-11-2009 at 06:30 PM. Reason: typo

     
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    Old 09-11-2009, 06:01 PM   #2
    Thunor
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    Re: AD/HD Paradoxical Effect

    I'm sorry, I don't have the energy or the focus to respond properly now, but I will leave you with a couple of notes so you don't feel we're ignoring you. Addressing your primary questions:
    1. [*]

    There are non-medicinal and non-stimulant treatments for ADHD, though they vary drastically in efficacy from person to person. The non-medicinal treatments include ADHD coaching and Cognitive Behavioural Therapy. These generally work best when accompanied by stimulant treatment, at least in the short term. Non-stimulant options consist of a couple of reuptake inhibitors, Wellbutrin and Strattera, again, these may or may not be effective for you.

     
    Old 09-12-2009, 11:15 AM   #3
    berrygirl
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    Re: AD/HD Paradoxical Effect

    First off all, I've seen some of your posts and was really hoping you might add your 'two cents'...

    Thank you so much for your added insight--I've been lost in the sea of "stuff" about ad/hd, it's nice to read something that is straight-forward and based on more than opinion.

    I'm fairly interested in finding out about stimulants because I'm unable to cope with non-stim. therapy. I have terrible side effects to depression/SSRI meds and the like. Most seem to have severe sedative effects. I was put on wellbutrin a couple years ago and it made me an absolute monster --the only thing I DIDN'T do on that med. was grow horns and start stealing peoples' souls [i.e. it didn't turn out well]. Needless to say, I quit after about a month.

    Quote:
    Originally Posted by Thunor View Post
    "...I suppose one would call the Paradoxical Effect an observed effect, as opposed to an actual effect."
    That's quite interesting. You're one of the first ad/hd folks I've encountered who've said that. So, does that mean that feeling more awake mentally/physically (perhaps even a little hyper) from heavy doses of caffeine (for example) isn't an automatic reversal of diagnosis? Or, is the "observed" calming effect some people see/experience still an decisive factor?

    Quote:
    Originally Posted by Thunor View Post
    [*]You can, and most likely will, develop a tolerance to stimulant ADHD medication.
    • So, I've heard people say that they've taken the same dose for years on end without seeing any change in efficacy. Is this is an indication that the stimulants are being used appropriately? Or are people with years of efficacious use just "special"?
    • How long is the average efficacy period (based on what you've read, experienced, etc.) for the appropriately diagnosed AD/HD patient? Is that kind of delay in stimulant therapy tolerance (e.g. "10 years") typical??

    Finally... where do you find info? I won't be seeing my doc again for a while and I'd like to get some more info in the meantime. I suppose I could probably get into pubmed or google scholar and see what I find but I'd like to get a better handle on the "textbook" reference material first.

    Anyways, thanks for taking the time to play 21 questions with me! I already feel much better about my prognosis...

     
    Old 09-12-2009, 09:25 PM   #4
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    Re: AD/HD Paradoxical Effect

    It's possible that I've oversimplified the 'paradoxical effect' in one specific way, so I'm going to slap a caveat on what I said yesterday. In children, I've read that meds can often have a different effect than they have on adults. I am familiar with children complaining that stimulants make them feel like zombies (my own son is among them), so it's possible that in children there is support for a 'paradoxical' effect.

    In adults, there is no room for a paradoxical effect. The stimulant stumulates, which is what we need. Because the ADHD brain lacks the 'normal' supply of certain neurotransmitters, some messages get lost in the mix because we don't have enough messengers to carry them. The problem areas such as lack of self control, lack of focus, memory and recall problems don't exist because the impulses for these don't originate properly within the brain, it's simply that the messages don't make it all the way to the end of the line, where we act on them. Stimulants help us attain 'normal' function by increasing the supply of said neurotransmitters, thus permitting more of our impulses to make it through the spaces between neurons.

    To address your question specifically: The fact that caffeine makes you more alert, hyper or even jittery has no bearing whatsoever on your ADHD diagnosis. Moreover, if you get too high a dosage of your stimulant med, you will become overstimulated, hyper alert or jittery. You may suffer from tremors or rapid heartbeat, and you may experience the worst insomnia of your life. None of this means that you're not ADHD. The stimulant, for you, is addressing a shortage of a necessary chemical, much the same way as a shot of insulin is addressing the shortage of a necessary chemical in a diabetic (I'm always leery of this comparison, because it's not 100% apples to apples, but it does serve to illustrate my point).

    Ultimately, the intent of stimulant medication for ADHD is not to invoke these 'overstimulated' effects, however. If your dose is appropriate, you shouldn't feel anything overt at all (hoping that you don't get unpleasant side effects). What you should feel however, is that you can focus better. Reading should become easier, getting off your butt and starting or finishing that project should be a little less difficult. Once you're on the proper med at the proper dose, you shouldn't feel that you're stimulated at all, you should simply find that doing those things you struggle so mightily with on a daily basis can now be tamed. That said, the med is no panacea, you'll still have to do the right thing with the new tools you've gained; do the reading, take the coaching or the CBT, organize your life.

    Tolerance is a difficult issue. There are some who stay on the same dose forever and don't seem to need an increase. Others jack up their dose regularly. Unfortunately, there's no magic formula, everyone's different. The best we can hope for is a smart doctor that takes the time to find the right dose and the right med, and see how things go. If you develop tolerance to one med quickly, you may find that another med works better. There are two primary classes of stimulant and two different flavours of reuptake inhibitors, so there is some variety out there, should you find that you become tolerant to one of these quickly. Indeed, some find that after a few years of stimulant treatment, they're able to stop the stimulants entirely because they've learned the skills to cope without. Ultimately, the best we can do is learn how we, as individuals, respond through trial and error.

    As to where I find my info, it's all out there. I've been researching ADHD for a little over 2 years now. This website doesn't permit links or specific references to other websites, but there is a plethora of info out there on the web, you just have to look for references and make sure that any studies or info are from legitimate sources. Beyond that, check out the book You Mean I'm Not Lazy, Stupid or Crazy?! By Kate Kelly and Peggy Ramundo. This book has been called the adult ADHD bible, and is a good jumping off point.

     
    Old 09-17-2009, 05:37 PM   #5
    berrygirl
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    Lightbulb Re: AD/HD Paradoxical Effect

    Thank you for your response(s). Things are [finally] beginning to make sense.

    I have been perusing the medical literature on the paradoxical / calming effect--you're right on point. At this rate, I'll have more papers on ADHD than on my own research by the end of the year!

    I suspect that issue of clinically effective dosage in ADHD vs non-ADHD disappears when people are trying to explain/simplify the neuro-biological effect of stimulants for patients/families. Even I had to ask for a more detailed answer from my doc. That might explain overwhelming number of forum posts to the tune of: "if you don't get sleepy when you drink coffee, you're not ADHD."

    I have since been put on a stimulant and frankly, it hasn't made me the least bit hyper. Rather, it has made me fidget a bit less and remain at my desk for longer periods of time (thus far). I do feel like the world is generally a little "clearer". I'm assuming that's a good indicator that my dose is probably on the "low to appropriate" side.

    The crashes thus far, are nothing short of being punched in the face. I wasn't quite sure what to expect the first day but when the med. wore off, I was very quickly (and acutely) aware of it. On the upside, I completed more tasks than usual. Unfortunately, I was in the middle of working on a project when the med. wore off. (We can all guess how well that went!)

    I am still a bit concerned about the issue of tolerance. My doc appears to be somewhat skeptical of tolerance to stimulants in ADHD patients. Hopefully, I won’t have to worry about it anytime soon.

    Also, thanks for the book suggestion--I just got hold of a copy. I am also looking through "Driven to Distraction" based on recommendation (appears to be another well-respected resource)

     
    Old 09-17-2009, 10:59 PM   #6
    Thunor
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    Re: AD/HD Paradoxical Effect

    I'm glad things are working out.

    I agree, it sounds like your dose is appropriate. You may choose to tweak it a little higher to see if you get more efficacy out of it, but don't expect too much. Reading 'night and day' and 'veil is lifted' comments led me to spend more than a year experimenting with varying meds and doses seeking greater efficacy than what I was getting originally; though the original effect was good, I was always hoping for more. I feel that now that my expectations are more realistic, I'm having more success. Above all, resist the temptation to self adjust your dosages, at least upwards, no matter how tempting it is to get more out of your meds. Work with your doctor on any dosage changes, because to change on your own can cause all kinds of issues, not the least of which is losing the trust of your doctor, something you can ill afford when dealing with restricted meds.

    The stimulant is there to assist you in breaking the bad old habits and forming new ones, but it won't do it all for you, another fallacy I fell victim to. Look into options such as CBT as soon as you feel balanced enough to handle it, I'm finally seeing some small balance in my own life, and bringing up CBT with my shrink is a priority at my next appointment.

    As far as the crash, I'm guessing you're on Adderall. I think most here can relate to you on the Adderall crash, it can be rather shocking, at least early on. Watch yourself carefully for depression late in the day and keep your head straight, I became very depressed during Adderall crashes. The good news is that they get better with time, within a week or so I hardly noticed the crash at all. On the other hand, apart from the crash, Adderall is probably one of the best stimulant meds available, so you're in good shape.

    Thanks for the book suggestion, I'll check it out. Don't be afraid to come back to vent or ask questions, you'll find the community here is very friendly and helpful.

    Good luck!

     
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