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Old 08-18-04, 11:39 PM
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Stabile Stabile is offline
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Hey, SB:

Weíre Tom and Kay, and we have an ADD family.

Kay and I both take Adderall, and occasionally Ritalin. Next week Iím planning to try Strattera for a bit, to see if I can get a feel for how it works.

Strattera isnít really classified as either a stimulant or an anti-depressant, so it should be interesting to see whatís up with the effect.

Now, about your question:

Iíve been taking Ritalin for a while, starting in the sixties. Iíve been taking stimulants non-stop for over fifteen years now. Kay has been going for more than seven. We typically take 20 mg / 10 mg / 10 mg of Adderall, starting when we get up and spaced out over the day, four to six hours between.

We may add to that a 10 mg Ritalin, or substitute 10 mg Ritalin for any or all of the Adderall. Currently, Iím taking Ritalin 10 mg x 4, spaced about three hours apart.

Our son Bryan also takes both Ritalin and Adderall, but his schedule is task oriented. Heís a jazz saxophonist, and he plays the effect of the drugs off against what heís trying to do at any given moment.

For quite a few years, while he was in college, he didnít take any drugs at all when he intended to play. Now that heís a professional, there are times that the drug effect helps him with what heís trying to do creatively, and times that he lets them alone.

None of us has ever experienced the effect youíre calling tolerance. If I understand you correctly, youíre referring to the drug losing its effectiveness for its intended purpose. (That is a quite common use of the term in the ADD community.)

However, we have all experienced what we believe causes ADDers to feel that their drugs have become less effective. Only, itís not the drugs, itís us. Or rather, our changing lives.

To clear the murk from the discussion a bit, I should state that tolerance also has a formal clinical definition that is very specific. It refers to a measurable decrease in some effect of a drug during a time course of regular use, for a given dosage.

The formal use of the term is associated with physical effects, despite popular misconceptions about speed freaks and junkies. An addictís need to increase dosage to achieve the same perceived high is directly related to actual physical effects.

Similarly, addiction is also a formally defined term, referring to the behavior associated with the experience of a person that has established a state of physical dependence on a drug. And that, in turn, is usually associated with a physical tolerance.

Withdrawal is the third part of the formal picture of this stuff. Often, physical dependence is due to physical tolerance; the brain adapts to the effect of a drug, perhaps by increasing production of a neurotransmitter to counter a diminished sensitivity.

Continued use of the drug then becomes necessary just to maintain the normal activity levels of the neurotransmitter. When the drug is suddenly discontinued, there is a lag between the time that the inhibiting effect disappears and when the brain finally readjusts its compensating overproduction of the neurotransmitter.

Too much of a neurotransmitter can be a bad thing, and there are other scenarios that have a similar outcome. Getting more of the drug is the obvious answer, even though the brain has compensated for the original desired effect. The addictive behavior that results is a classical example of classical conditioning.

In our experience, all of the discussion about tolerance and addiction in these forums refers to something else, the feeling that the drug may lose its effectiveness. When a person has mentioned addiction, it has usually been associated with other (illegal) drugs and/or alcohol.

Also, the idea of a drug holiday has a very shaky origin. We strongly believe that it is related to the same kind of ill intent that is responsible for the rumors about horrible physical harm in children from long term forced Ritalin use, and comas induced by an innocent combination of Adderall and alcohol.

Our physician, when pressed for a reason, initially said he felt that a hiatus of a few weeks in the summer would give a child time to recover from any ill effects due to appetite suppression.

But a few weeks later he apologized and said heíd been completely out of line. I had asked if the kids he treated ever responded by gaining weight, and he had realized that, in fact, thatís what kids do. They tend to growth spurt at any time, but itís always most noticeable over a summer vacation.

When his patients werenít on meds, they didnít have any reason to come in unless they fell ill. So he had the same experience we all did growing up, when our friends came back from the summer break seemingly much larger than when school left out.

But the kids didnít jump on the growth charts at all; their progress was essentially normal, without any unusual spurts. And all the kids were in the same range as they were before they began their medication.

So he told us not to worry about Bryan, and definitely not to worry about ourselves. We let Bryan have as much responsibility for how he took his meds as he could handle. Our Doctors feel thatís a significant step for any ADDer trying to take control of their life, and Bry responded extremely well.

Now, a little bit about tolerance, as I believe you meant it in your post.

Kay and I have very specific ideas about how the drugs we take work, both in terms of the perceived experience and also the way they help a person with ADD.

We also have specific ideas about how the anti-depressants work, and what ADD and ADHD are, as well. We base that on over thirty years of formal research into human communication and some specific kinds of theories of mind.

With that background, the various effects that have been described as tolerance here in these forums make perfect sense. Kay and I both experience times when the drugs donít contribute in the same way to how weíre dealing with our ADD. Sometimes this can go on for quite a long time. But the drug hasnít changed; our lives have.

ADDers all have some period of adjustment to the idea of having/being AD/HD; how long and to what extent varies with each individual. After that period of adjustment (which can take years), there can be a letdown of sorts.

We begin to focus on the ordinary problems of modern living that may have been swept into the background while we were learning about ourselves. At the very least, the excitement of the discovery that there is a reason for the things we have experienced all of our lives fades. The same old normal difficulties remain; sometimes we can fall into a quite serious depression.

Our understanding of the (on the surface, somewhat contradictory) use of both stimulants and anti-depressants to treat the same symptoms doesnít require looking too deeply into the details of the biochemistry of their effect on the brain.

We just note that living with ADD has consequences, and sometimes those consequences can loom sharply enough to interfere in our daily routine just as AD/HD itself can. Which is more significant, the AD/HD related inability to focus and organize your life, or the depression related inability to care enough to try?

Outwardly, the effect can look and seem the same, even to us. But the drug of choice for helping us think in the unnatural patterns required by the world of Normals is a stimulant, whereas if depression freezes us in our tracks, anti-depressants are called for.

And just as life is change, the mix of direct AD/HD effects and the hit we take as a consequence of living with it changes over time. The drugs that seemed to help at one point may not do the job once we enter a different phase.

We have heard many stories here that we feel are related to exactly this phenomenon. Often, the natural thing to do is increase the dosage, leading to a sense that we have hit a plateau, or developed a tolerance.

Increasing the dose of a med that isnít appropriate for the new situation only delays the moment when we begin to deal with it correctly. And if the drugs have significant side effects, we may introduce a new set of problems as the dose increases, on top of whatís already there.

Fortunately, the reaction of ADDers to these situations seems to be fairly benign. Usually, we reach a breaking point, blow everything off, reset, and start all over. There arenít too many stories of falling into a downward spiral after weíve been diagnosed and treated successfully.

Of course, as you pointed out, our sample is hopelessly skewed. But now that youíre here, youíre a member of the club, too, so the stats should apply, meager as they are.

There is one other effect that Kay and I think we see on the stories that people have told here. We know from personal experience that there is a much larger set of issues associated with having/being AD/HD than what we are typically discussing.

To be clear, we believe that AD/HD is symptomatic of an ongoing speciation event. There is quite a bit of evidence to support that idea, and in general a fair amount of interest in the idea that a speciation event may currently be under way. But as far as I know, we are the first to associate it with AD/HD.

The nature of the change required to bring about such an event is far more unassuming than you might expect. We hypothesize that a small, slow shift in brain chemistry over the last five thousand years or so is responsible, with the magnitude currently of about the same order as the normal variation among individuals.

But emergent events of this sort are neither small nor slow, and the nature of the change in ourselves is anything but unassuming. Every ADDer sooner or later is faced with the fact that we have accumulated a body of knowledge about ourselves and our experiential context that sets us apart from the ordinary in very fundamental ways.

This realization can come gradually, or like a bolt from the blue. We suspect that this is strongly related to the fact that females have tended to be diagnosed late, in their 40ís or even early 50ís, often after seeking medical help for sudden radical changes in their lives.
In the not so distant past, this was usually attributed to menopause, leaving the woman feeling angry and ignored. But the trend seems to be reversing, and lately there has been a burst of males being diagnosed late, and many more females diagnosed in their teens, 20ís and 30ís.

Itís going to be interesting in a few years to go back and look at the statistics on the homeless over about a fifty year period.

We believe dealing with that epiphany is the last and biggest chapter of the story of our drugs and therapies losing effectiveness. Thereís not yet much written about this particular issue, but the undercurrent is there if you look for it.

Itís riddled with stories of failed marriages and relationships, repeated obsessive self-destructive behaviors, and drastically diminished expectations. But Kay and I have been through the experience of dealing with it directly, and we know itís possible to transcend the potential for disaster.

We were fortunate to already have a long committed course of study in several related areas, and specific experiences that offered us unimpeachable evidence that we werenít imagining the things that we were feeling.

I donít think thatís required, though; Kay often says we went through it the way we did so that others donít have to. I believe forums like this one are a part of that, and questions like yours are a sign that we are beginning to prevail.

I donít know the age stats on this group, or your age, but it doesnít really matter. The message is this: the experience youíre asking about can be best described as being due to a series of related periodic effects with different frequencies, maybe even varying frequencies.

Sometimes they sum constructively, and sometimes they interfere. We go up, and we go down, and the only thing you can do in our experience is expect it, donít blame the drugs or yourself, and be ready to adjust your strategies for dealing with it. And someday, when youíve done it for long enough, the whole thing might just blow up.

But we think you can handle it. We all can, with a little help from our friends.

And thatís it, really. I didnít cover as much as I thought we would, but more than Kay probably expected. Thereís a lot about AD/HD that should really capture your interest, given what you do during the day. If thereís anything specific that caught your attention, please feel free to ask about it.

Or feel free to pass it all off as the ranting of two harmless wingnuts, if that suits you. (big grins) Weíve been there.

Weíve got ADD, you knowÖ
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