kaigou: life is a banquet, and some poor suckers are starving to death. (3 life is a banquet)
[personal profile] kaigou
I'm getting the impression that some of what I've figured out over the years either isn't as widespread knowledge as I thought, or maybe it's just not something most therapists/doctors explain to user-satisfaction. This ties into the issue of medication for ADD/ADHD, because one of the biggest issues about medication for that specific cognitive issue is that it's, well, pretty freaking illogical. I mean, honestly, my reaction the very first time a doctor suggested a specific medication was, and I quote: "Wait, my brain fires off in every direction at top speed, so you want to give me a stimulant? Are you people on drugs?"

So here's a really really simplified, only barely marginally scientific, explanation of one of the major theories about why stimulants work for ADD/ADHD. Keep in mind that when I say "marginally scientific," I mean that this is an extremely generalized version of something that seems to be how it (generally) works, but the brain is a damn complex organism. The how's and why's of ADD/ADHD (and related cognitive disorders) remain murky and new things are being discovered all the time, as our technology gets better and better at tracking brain processes.

In general, though, I'm told this is the basic gist of how doctors/researchers are somewhat sure (as sure as anyone can be, which is "kind of" and "maybe on days it's not raining" and "ask again tomorrow" styles of 'sure').

First, let's look at a brain that doesn't have a chemical imbalance.

The term "chemical imbalance" is actually pretty literal, if you think of your brain (and your body overall, for the most part) as containing a whole lot of checks and balances. The little receptor points and controllers and whatever else in the brain, the nerves, the cells, so on and so on, don't work in a straight line. Instead, a lot of them work by affecting something else, and making sure that "something else" is balanced properly.

In the image above, the big blue-bordered box is a controller-type of receptor. (I say "receptor" since I think that's the term -- it receives incoming stuff -- but the term may be different now; for simplicity, let's just go with 'receptor' and consider it a general label, not a perfectly scientifically accurate label, just in case.) Anyway, this receptor is in charge of Keeping Things Calm.

It produces and distributes the proper chemicals, which are routed to the pink boxes, which are in charge of sending out chemicals that juice you up. Obviously, you can't operate if you're too juiced -- too anxious, jittery, rapid-thoughts, much like a sort of constant flight-or-fight mode. Sometimes, of course, you need that juice, but most of the time, if you get too much, your chemistry's imbalanced. It's the job of the big blue controller to distribute a proper amount of Calm It Down Over There.

When the Controller can't operate at full capacity, you get the ADD/ADHD brain (or at least one with very similar symptoms, even if the original cause is different).

You could think of it as this: the pink boxes control, say, an electrical fence that keeps in a bunch of rowdy dogs. When the Controller (your local electrical line) drops in power, the pink-box-electrical-fences are turned off, and the dogs will all get out and run around the neighborhood and dig up your neighbors' peonies. I tried to make the fuschia-colored arrows thicker, to indicate that the amount going out has increased, because the Controller isn't doing its job of producing enough Calm It Down Over There.

There are two ways to handle this: either you find something that can replace the Controller, and send the proper chemical (or close enough) directly to the pink boxes, or you give the Controller something that will encourage it to get up to capacity.

The fact that the blue-box controller operates at a certain capacity is why stimulants (and related, like caffeine) hit unaffected (non-ADD/ADHD) brains in a different way. Their blue-boxes just aren't going to accept any additional fuel.

The extra fuel bounces off the full box. Nothing's breaking it down or processing it, though, so it has to find something that'll accept it as fuel. The green boxes are stand-ins for "something else in the brain that reacts to stimulants, caffeine, or similar".

Anyway, somewhere back in the earliest days of ADHD research/patient-work, someone realized that hyperactive kids calmed down considerably when they were put on stimulant-containing medications (usually for something else entirely), and that was the key to figuring out that it's the Controller that's easiest to deal with, instead of affecting the pink boxes directly. Something in the average stimulant doesn't aim for the pink boxes; it aims for the Controller. That's how you get this, which is a properly medicated ADD/ADHD brain.

Houston, we have chemical balance!

The yellow lines are the additional chemical. That chemical isn't tripping off your pink boxes, because they don't respond very well to that kind of chemical (not to say they won't, I gather, only that the pink boxes are wired in your brain to want the blue-box's version first and foremost). Meanwhile, the blue-box is very sensitive to even a minute amount of extra energy from stimulants. Just the right amount to fill it up, and the blue-box Controller is raring and ready to go, able to pick up production.

Now we have proper levels of 'chemical balance' because there's enough Keep It Calm going out... and suddenly, thanks to the right level of stimulant medication, the patient does the seemingly illogical and actually calms down.

This is ignoring the fact that getting that precise balance is in itself pretty damn hard. People talk about Ritalin, but there are actually closer to about seven or eight different stimulant-variations that can be used, and even more off-label medications as back-up. Sometimes what works is a different class of medications when ADD/ADHD isn't the only thing triggering an imbalance, so you can't just use only stimulants but have to find something else that also compensates for whatever else is going on... and on top of that, people's brains are highly unique to minute degrees, but when we're talking medication, those minute degrees can be of massive import.

In general, yes, the "chemical balance" is what everyone's aiming for, except that it's sort of like aiming to hit the back half of a flea on the side of a barn -- when you're on the other side of the barn. And it's night time. In a raging thunderstorm. And you have to do the hitting with a kidney bean and a slingshot.

Part of that crazy analogy is that you can't just shoot straight through the barn, even though you know for certain the targeted flea is right there! If only you could get to it! Unfortunately, sometimes you clip the barn anyway, or you (the patient) ends up dealing with a less conservative doctor who wants to push things a little too hard. You don't get a calmer patient. You get something that looks like this:

Over a certain level, the blue-box controller doesn't need any more stimulation. This is anthropomorphizing, and the exact explanation is probably way way above my grade, but generally speaking you could say the Controller-receptor here is like someone who stops eating when he's full. No, thanks, he says, and passes on the extra chemicals. But those chemicals have to go somewhere, so after bouncing off the saturated blue-box, they'll head to whatever spot in the brain will have 'em.

Result: the previously calm person is now chemically imbalanced in the opposite direction, and being stimulated -- just like any other chemically-balanced person would be -- and having the same reaction. Jittery, anxious, restless, heart beating too fast, can't concentrate, all that good stuff that was supposed to be resolved.

Which is what makes medicating for ADD/ADHD a really complex dance: too little, and there's little to no effect; too much, and, well, there's little to no effect. Or more precisely, there's an effect and it's too much, but the behavioral change appears, at least, to have been nullified.

The danger there is that sometimes, the Controller decides it's fed up, and -- this is even more unscientific, since again, it's mostly theory on how some medications for ADD/ADHD will fail after X length of time -- the Controller develops a bizarre kind of immunity. It simply refuses to recognize that peculiar blend of medication.

Again back to Ritalin: as much as unaffected people believe that Ritalin is the be-all and end-all of ADD/ADHD medication, they seem to be ignorant in even greater amounts that Ritalin can max out. And it's possibly one of the least-fun things you can imagine, because what happens, roughly, is that the Ritalin over-excited the Controller. For a little bit, the Keep It Calm was coming at maximum volume, until one day the Controller says, "holy crap, we can not keep this up. Screw this! We're going on vacation!"

And the Controller just quits. It won't react to Ritalin, and until it recovers, it might not even react to anything. Its warehouse of Calm It Down has been completely depleted. Wiped out! And in turn, now the pink boxes are suddenly without a controller and going haywire.

Obviously this kind of result is Very Bad, and it's a big reason doctors prefer to sneak up on that flea, instead of just throwing a whole combination of things. (Well, the good doctors. The less ethical ones will do a cocktail, sometimes a little too gleefully, and sometimes out of sheer desperation, and sometimes -- let's be honest -- because they're overworked and underlistening and thus aren't aware of other influences that may impact the medications' efficacy.)

As I understand it, this is how a lot of brain-receptors work. They can be tapped out and lose balance, just like we do as an overall organism. It's not all that different from working really hard all day without enough sleep and one minute you're fine and the next minute you're out, sound asleep and even blasting caps don't wake you. Or people in accidents who hit a certain threshold and pass out from the pain. Body says it's shutting down here, everyone out of the damn car, and there you go. Parts of the body can do the same.

And since the brain-parts of the body are hugely sensitive to chemicals -- and the whys and wherefors of a lot of chemicals are still not precisely known, along with what happens when you mix this with that and let's not forget about the issue of physical and psychological side-effects -- and you can see that the only reasonable way to hit that damn flea is to be very, very, very sneaky. Because you don't want the flea backlashing on you and taking out the entire barn for the hell of it.

I should also note: it is possible that in some cases, if the medication dosage is too high, that the over-extended parts of the brain will die. I am not making that up. I am not exaggerating, either. (I wish to heaven I were, because I've observed the aftermath, and it's not pretty.)

I may not have the scientific lengthy specifics to give you, but it does happen. You can see it in junkies and drug addicts who've been long-time over-users. The brain has a marvelous and amazing capacity for rewiring itself and creating work-arounds when a part of it atrophies, but that doesn't change the fact that there is atrophy, and not all brains can rewire (or can't rewire very fast, and age/health has a lot to do with it, too). In the end, a drug is a drug, and long-term misuse of too-high medication can eventually do just as much damage as any illegal drug, and the last thing a good doctor wants is to take out the entire barn enroute to smacking a flea with a kidney bean.

Once the blue-box controller has recharged/healed, there's a chance it'll refuse to ever recognize that particular mix of chemicals again, which means trying something else. Fortunately, these days, there are a lot of 'something-else' for ADD/ADHD. Some are wacky (at least in origin) and less well-known, but you never know what'll get the kidney bean to fly around the barn at the exact angle to hit the flea.

And when it does hit the flea, you aren't really "adding a drug" to your brain, not when you look at it this way. You're balancing what had been, for whatever reason, imbalanced. You're not becoming not-you, you're becoming the you that you would've been had the little blue-box controller been able to do its job.

One way to consider it: unaffected brains have blue-box fuel-tanks that can hold however many gallons, while ADD/ADHD reduces the blue-box capacity and production. Your car would run just fine, and so would your brain, with the right kind of fuel and enough of it. You hardly kick your car because it only has a ten-gallon tank and only takes premium, do you? You accept that it's not a twenty-gallon tank that does okay with regular unleaded, and you put in the effort to get your car -- and your brain -- that extra bit it needs to run smoothly.

Along the way, you may realize that you also need to adjust the way you drive to best fit the car you've got (behavioral patterns and coping mechanisms for ADD/ADHD), any maybe get yourself a mechanic who can help you keep the car in top shape (emotional/psychological component of therapy). Those also have their place and value, and do best used alongside careful adjusting and readjusting to find the best ratio of fuel quality and quantity (medication levels).

One may work for you, or all three, but the goal is the same: reaching for the day you'll go just as far as anyone else and then some, thinking clearly and calmly, leaving that stupid barn-clinging flea eating your kidney-bean slinging dust.

Date: 13 Jun 2010 11:17 pm (UTC)
chibidrunksanzo: Can you tell me again for exposition's sake? (Default)
From: [personal profile] chibidrunksanzo
I have a off-hand remark to a doctor story, myself. Months of not being able to breathe right, and several pulmonologists telling me that they can't find anything in my lungs so it must be in my head (Tangent: If you've ever had anxiety or depression, doctors are very, very, annoyingly quick to call anything they can't recognize in two minutes as in your head, even faster than for regular people), a comment about being tired and lethargic also lead a new pulmonologist to say, "Hmm, let me check your vitamin levels." One severe Vitamin D deficiency and a few weeks of supplements later, and I could breathe again.

I'll also note that not every female doctor I've had has been good, but every good MD I've had has been female. I specify MD because I've had good male chiropractors, who are doctors just not MDs.

Date: 14 Jun 2010 01:30 am (UTC)
chibidrunksanzo: Can you tell me again for exposition's sake? (Default)
From: [personal profile] chibidrunksanzo
My mom goes to an osteopath back in Virginia. She loooooooooves him. He finally figured out that her shoulder pain was because of a rib out of place in her back.

Of course, ERs and insta-cares are their own special brand of, "Let's get this person out." My back went out on a Friday after doctor's office hours, to the point I could barely walk. They gave me Flexeril for a muscle relaxant and Tramadol for pain. I just went to my doctor for a refill after about two years (it lasts awhile for me). First thing that pops up is don't take Flexeril with Cymbalta, which I've been on for more than two years. *rolls eyes* Just glad I didn't have the reaction.

Date: 13 Jun 2010 11:25 pm (UTC)
branchandroot: oak against sky (Default)
From: [personal profile] branchandroot
*nods* As one of my better therapists pointed out, when you've paid for something, it's yours; might as well use it. Even if you'd really, really, really have preferred never to have been in a position to get it.

And the brain itself can be so damn conservative! Even when the "motor" is repaired and you've gotten yourself some "gas", trying to put it in gear hits the big red button marked "last time this happened the whole system fried, do not respond".

One of the reasons I want so much to claw that harpy's face off is that she was /able/ to get off the medication merry-go-round and then has the unmitigated brass ass to stand there tsking at those of us who /can't/ despite the fact that every damn one of us would really, really like to! *starts frothing at the mouth and goes away to calm down; again*

Date: 14 Jun 2010 10:01 am (UTC)
From: [personal profile] maire
Really illuminating, and useful. I wish I'd read this ten years ago when I was crying my eyes out over needing medication, too. Thank you!

Date: 18 Jun 2010 08:34 am (UTC)
From: [personal profile] maire
Go, first doctor!

The doctor who first diagnosed my depression and anxiety as what they were did pretty well on the medication side of things, with good explanations of what they did, and on the exercise, diet, meditation-lessons, and sleep front.

Not so well on the 'Wait, you've been in pain for most of the last two years? That might be a factor!' front, sadly, but at least the meds she gave me made the pain go away as a side effect, even if that did leave me thinking the pain was psychosomatic for a few more years.

Doctors have odd 'blind spots' sometimes. Good ones seem to me to be the ones who know this and are willing to learn as well as advise.

Date: 14 Jun 2010 06:45 pm (UTC)
From: [personal profile] back_in_black
Absolutely fascinating. You have a unique way of putting things that really gets the idea across!

Date: 24 Jun 2010 04:27 am (UTC)
lo_rez: green-on-black classic radar circular grid (Default)
From: [personal profile] lo_rez
I am more grateful than I can say for this post. (via the network)

Date: 15 Aug 2010 09:41 am (UTC)
pierreuse: (Default)
From: [personal profile] pierreuse
Here via [profile] p_zeitgeist. Mind if I add you over on Livejournal? :)