Dr. John Kruse
Appearances
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Part of how the field actually in the 90s started becoming aware that adults could have ADHD is that all these clinicians who were having ADHD clinics for kids were starting to notice, wait a minute, this parent is showing up 20 minutes late to pick up his kid. Wait a minute, the parent didn't feel fine.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
the prescription, so the kid went for two weeks without the medication, they started becoming more aware of ADHD in adults by seeing that the adults who were parents of these kids, and again, there's a strong genetic connection, had ADHD. So there are certainly wonderful, loving, supportive, nurturing parents with ADHD, but studies that have looked at trying to find some objective measures are
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Things more likely to be forgotten, misplaced, mislaid, go off track with an ADHD family, absolutely. And one of the more powerful sets of interventions for kids with ADHD separate from medications is family-based training that helps get the whole family, one, to understand how the kid's brain is working differently, but actually it might not be that differently.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
It might be exactly how dad or mom's brain is working. but to help them function as more consistent parents. So the other bias, I'd say again, before identifying specific careers, is that as a society, we've long cherished or valued... The guy who worked 50 years for Eastman Kodak Company and got the gold watch at the end was sort of the... epitome of what you should strive for in a career.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
But if you're interest-driven and your interests change, so for many people with ADHD, the best career is actually not one 50-year career, it's 10 five-year careers or five 10-year careers. And part of it is the whole work world has become more fragmented and you know, upheaval is the name of the game and break things quickly is the motto of Silicon Valley.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I didn't phrase that quite right, but the message I think is still there. We're accepting more that many career trajectories are going to look not like just one beautiful arc, but I think there's a sort of a normocentric bias to that is what you should strive for. And if you are changing careers, that's a bad thing.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And yet lots of people who do worthwhile things in life and often because of their more varied experience are bringing more to what they're doing. So I think we need to... value that and embrace that as an option and accept that maybe for some people that is an optimal career path.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yeah, so I'd say there's a lot of good neuroscience research or neuropsychological data that the more time you spend immersed in social media, and it's the constant, it's the barrage of information and not just the volume of information, but that you are constantly being interrupted, and that most of these interruptions are intentionally designed to attract your attention. And
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
that the more people practice thinking that way or being in the world that way, yes, it's harder to sustain attention for long periods of time, that you train yourself to overreact to any new distractions. So the core elements of some of the executive functions that are impaired in ADHD, we are all becoming more ADHD-like. So that's the...
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
thesis of the book that I've been working on that's still several months from going anywhere, but I call it Attention Deficit World. And one of the things that's been frustrating is that there's been this huge disconnect.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
There have been people writing about, you know, the question you're asking, that the neuroscience, our brain's getting more distracted, or are we becoming, you know, it's not just distracted, you know, immersion in this media world or social media, cell phone, however you want to break it down, It's not all bad. It's not just that concentration's worse.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So detecting visual items in the environment, there's some things that people become more adept at. Whether that's actually a good thing to be more adept at, people do a multitask more quickly or switch in and out of it.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
They're still not doing as well on that task if they had no distractions and just focus solely, but they're multitasking better than people who don't immerse themselves a lot in the internet. So there's a whole literature and popular books and attention. We know everyone's getting a little more distracted. But all the books that talk about that say, well, this is just sort of everyday stuff.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
This has nothing to do with ADHD. And there's lots of wonderful ADHD books out there, and they say ADHD is this discrete condition, even if they acknowledge it's on a spectrum of severity, but that it's really serious stuff, and we don't, you know, Just because you forgot your homework or you left your car keys or you can't remember where you parked your car, everyone does that.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And we want to make sure that you respect that ADHD is a serious and potentially disruptive condition. And when I say serious, and I'm going to go on this tangent for a little bit, the caricatures of ADHD is, oh, there's the squirrel. It's silly. People are distracted, ditzy, late, doing things that we make fun of in society, and we ignore that
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
many of these things can have a more serious repercussions inside. So a kid who has ADHD, their life expectancy is about 10 years shorter than their non-ADHD peers. That is the same extent of cutting off life as having diabetes or having major depression. Is that because of accidents, addiction, injury? Almost all of it is two factors, and they're almost equally.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
One is accidents, so motor vehicle accidents, you know, if you're Driving distracted, you're more likely to be involved in accidents, but it's also, you know, the kid who's probably being more daring with the tractor on the farm or daring the bull. I mean, all sorts of accidents, not just motor vehicle accidents. And the other is suicide.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And some of the suicide is because there is an overlap with depression and anxiety and other factors. But I'm convinced, and not many people are looking at this angle, some are, with suicide we focus so much on the despair, the misery that someone hates their life. But there's lots and lots of depressed people who don't kill themselves. The other really important element to suicide is impulsivity.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
is lots of people feel really bad, but we know having guns in households increases the likelihood someone's going to shoot them. Accessibility to tools that you can quickly use to kill yourself, which shows if you slow down the thinking process, if you give people more time, if they are less impulsive, they are less likely to kill them. They still might be miserable.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And that's my explanation for why, even though during COVID lockdowns, we did see increases in depression, we did see increases in PTSD, we did see increases in domestic abuse and battering. And we saw actually a decrease in suicide during that time. How does that make any sense?
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And it wasn't huge, but since suicide's been going up every year prior to that, it's pretty clear and blatant in the data and remarkable. And my claim is so many more people were at home, you know, your kid's not around to play with the gun or find the gun or, you know, you know what's going on or poison or hanging themselves from the door or whatever else they might do.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I'll just start out by saying that like most things in neuroscience and psychiatry, we have some definitions and we have lots of different thoughts and frameworks to approach things. So I'll start with our diagnostic category or how we diagnose ADHD. And that is there are 18 different symptoms. Nine of them are hyperactive impulsive. Nine of them are inattentive.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
There's also the middle ground. So I sort of mentioned that the caricature is sort of the silliness and the trivial of being late for your friends at the restaurant or forgetting your car keys. And the extreme is death. But in between, we know ADHD measurably derails education, disrupts social relationships, impacts your likelihood of your earning potential.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I mean, ADHD isn't just an academic cognitive problem. It isn't just who's going to jump through the hoops and get through school. It isn't just who's turning in their reports or doing their work on time in the workforce. It's also having social implications. And in all those areas, it's having measurable, detrimental, significant impacts on people's lives.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yeah, so back up a little bit, and I maybe should have said this when we were talking about diagnosis and what is ADHD. And many people think it's a horrible title because it focuses on attention deficit hyperactivity disorder. And it's very clear, as you're enumerating here, It's not a deficit of attention. If it's a deficit at all, it's a deficit of control over attention.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And with attention, there's at least three different realms where we're controlling it. I mean, one is we direct attention. So if something's important going on over there, there, so we have to be able to shift it. Two, you have to be able to sustain it. So if it's a situation that's appropriate to be sustaining it. And three is you need to shift out of it if it's inappropriate to stay in it.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And in all three of those realms, people with ADHD have less volitional control over their attention. So many people in the ADHD who experience it describe hyperfocus as one of their superpowers. And that is where they're getting so absorbed in their work that they are
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
so busy coding that actually everyone else in the office has left and it's only when the janitor is coming and emptying the garbage cans at 11 p.m. that they say, oh my God, where is everyone? I'm still here. because I was so intently working on the project. Some people strongly resist the idea that flow... And I'm going to butcher the Czech... Csikszentmihalyi.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
My reading of... When I sort of delved into this, I think hyperfocus is exactly a flow state, because people are describing the same lack of awareness of time, and it's always... I mean, it's a task that's somewhat challenging and engaging and interesting. It's not just that, you know, if it were just about enjoyment or bliss, you could hyper-focus looking at a beautiful flower.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So the inattentive ones are things like forgetting to follow through on things, losing items, being easily distracted. The impulsive and hyperactive ones are cutting people off in conversations, blurting things out, running around, fidgeting. The definitions themselves were designed with a child
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
People don't describe that. So it needs the right amount of challenge. It can't be too easy. It can't be too hard. It has to be something important and interesting to you. It involves oblivion not just to time but also to lots of space going around you. So I think they are pretty close, if not the same, phenomena, flow and hyperfocus.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And some people with ADHD, and I think some are ones who learn what situational factors or what internal factors can help get them into that state, but many of them still struggle with showing up when they don't want to be hyper-focused on something or have trouble engaging it when it would be useful to.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So many people come to me as a psychiatrist for ADHD are primarily focused on medications, and we still know that the stimulants are the single most powerful, I mean, in terms of extent of symptom reduction overall and in terms of the percentage of people they help, they're our most potent tool.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I mean, the medicine's not going to change everything, and you need to be focusing on your life as well. And I always start with scheduling. And many people with ADHD find scheduling anathema, that that's like the slaves on the galley ship being told you have to row, stroke, stroke, stroke. And what I tell them is that the part of you that's going to help make the schedule that works for you
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
population in mind because until roughly the mid-90s, it was dogma that this was a neurodevelopmental disease of childhood and that every child who had it outgrew it. is dramatically wrong. Some kids do. Most kids don't. The latest work suggests that most adults fluctuate in time with the severity of their ADHD symptoms. So jumping back to the definition. So we have these 18 different symptoms.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
isn't some evil taskmaster trying to make you do what you don't want to do. It's actually the wisest, smartest, nicest, kindest part of you that's identified. What are your lifetime, what are your bigger goals? How are we going to match what you're doing in the minute to line up with those bigger goals? And this analogy isn't perfect, but the best one I've come up with.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So rather than the guy on the Viking ship, the person, you, the part of you that's making your schedule, is a mother hen who's sort of counting all the chicks and making things aligned and nestling down and hunkering around you and taking care of you and nurturing you.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And with scheduling, what I tell people is before you slide in your work or your homework or your school or externally derived tasks, I tell people you need to have the four basics. And sleep is far and away the biggest basic, particularly for, it's essential for all of us, but it's particularly critical for ADHD and there's particular reasons why it's a particular challenge for people with ADHD.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
But I'm trying to think if I can imagine a counterexample. I would say all the successful people I know with ADHD have found some way to try to regularize their sleep compared to what it would be if they were just... So the four essentials I say are sleep, eating, exercise, or some amount of movement.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Because again, with the hyperactivity, there's people who can sit at a desk for 12 hours, not even getting up to
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
a bathroom break or to eat or anything that's not just bad i mean that's bad for your brain bad for your body and then the fourth thing i put in is a miscellaneous category of me time relaxation meditation i put all those in the same slot maybe they shouldn't and all those need to be in place We can talk more about sleep, but I'll just say a little bit more about the eating component.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So we have our diagnostic criteria for ADHD, but I had, over the years, two different real-life tests. The office I had was in an old Victorian home, so it was a home office. The office itself, the entrance was at the end of a short but very steep driveway, so it was a separate door. And I would always explain to everyone new patient, the exact same thing. There's a house at 45 Hartford.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
The office is at 45A. The entrance is at the end of the driveway. And I actually did the data on it. The only people who ever showed up at the front door, the home door, were the people with ADHD. Now, everyone, it wasn't... It was specific for ADHD. It wasn't completely sensitive. So some of the ADHD people got it right.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
But never did anyone who was coming in for OCD or depression or PTSD show up at the front door. And I gave the instructions the same time. And sometimes I didn't know beforehand that the person was coming in for ADHD because they didn't know. But if they showed up at the front door, that always made me, you know, uh-oh, I better make sure I ask specific detailed questions.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
questions about the ADHD possible component. So the other sort of real life diagnostic test I had, if someone during the evaluation would say something like, or in a subsequent session, oh, it was four o'clock yesterday and I just realized I hadn't eaten all day. Ding, ding, ding, ding, ding.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I mean, I have people who diet, I have people who have fasting regimens or others, but they're not forgetting to eat. And it's not that everyone with ADHD does that, but either not getting the right interoceptive cues from your body or not paying attention to them is something that's been measurable in people with ADHD.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So having a regular meal schedule. And again, getting back to the COVID in workplace. I had lots of people in tech who really lamented, now I have to work from home. They were giving me lunch, a healthy, nice lunch each day at work. They're scrambling to even use the home meal delivery systems because getting that organized and set up is just too overwhelming for them.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And again, these are bright people who are succeeding in most parts of their life.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
That can be one variation. But it's often just completely forgetting or being oblivious to it. I mean, the other ways ADHD can play a role is I was meaning to have breakfast before I left the house, but always when it's time to leave the house, you forget that you hadn't done this, and the kids' shoes need to be tied, and oh... Do I need a new toothbrush?
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
As an adult, you need to have at least five of them. When we say have them, all of these are things that normal people can display at any time. So any of us might interrupt someone, might have trouble sitting, might have trouble attending to a task. But to meet the criteria, these have to be displayed
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I better go check upstairs before I go out because I'm going to the CVS store. I mean, time management is a problem with ADHD, an executive function problem. Interestingly, it's not one of the 18 symptoms in our official checklist. So our official checklist is... sort of a crude clinical attempt to map out a lot of the aspects of ADHD, but it misses a lot. So there's emotional regulation problems.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
We know something like 60% of people with ADHD acknowledge that emotions explode or come up bigger or stronger and are harder to regulate, and that's nowhere acknowledged in our official diagnostic symptomatology.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Matthew Walker in his great book on sleep, one of my favorite things about it is he really emphasizes this point that quality sleep isn't just about eight hours. It isn't just duration. It's getting quality sleep And the timing of your sleep is every bit as important as the duration. So if you're used to sleeping midnight to 8 a.m. and you're staying up dancing or partying until 4 a.m.,
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And you say, oh, it's a weekend. I can sleep until noon. You may still get those eight hours, but they're not restorative to the same extent as if you had slept at your regular time. And I mean, my PhD research was on circadian rhythms. We had realms of data back then. So this was 40, 30 plus years ago. We had every bit as much data then that
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
an excessive amount of time or to an excessive degree to the extent that they're causing some dysfunction or distress and that they have to be displayed in multiple realms of life. So if it's only at work that you have trouble completing your task, that might have something to do with your boss or an uncomfortable chair or something. So these have to be
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
that the timing of sleep is as important as the duration, and yet every public service announcement just says, get your eight hours of sleep. Why are we leaving out this other piece? We've known for decades that people with ADHD have a strong propensity to being night owls, to have a different chronotype where they're maybe more effective or functional later in the day, a tendency to stay up.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
For many years now, we've actually known that this is strongly genetically controlled. So we do have, you know, there are genetic markers affecting sleep timing that are overrepresented strongly in the ADHD community. So some of it is your push that way, but some of it is the nature of ADHD, that if you, you know, procrastinating is part of ADHD.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
If you procrastinate, you're gonna push things off till the end of the day. Some people, the end of the day is a better time to work because there's fewer distractions. You know, if everyone else is asleep finally, no one's gonna come in and interrupt your work or ask what your thoughts on this project are. But again, getting regular sleep, and regular and sufficient,
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
doesn't mean it has to be what I'd say normal. If it works for you, if you can build your career and your social life around sleeping from 2 a.m. till 10 a.m. every day, I'd say go for it if you can be consistent with it. So what are the things that help with getting regular sleep? One thing paradoxically for many people is actually being on stimulant medications.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So stimulants do have as a side effect, some people have insomnia, some people stay up later.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
But more people with ADHD tend to, either because the drug is wearing off at the end of the day and there's some crash in alertness or energy, or because they're being more productively expending energy and are more tired at the end of the day, or it's just helping synchronize circadian clocks by getting a consistent start early in the day. We don't know the mechanism by which it works.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
There's lots of plausible and overlapping ones, but Again, daytime alertness medications can help.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
traits that are displayed in multiple realms of life. They have to cause, again, distress or dysfunction. They have to be to an extent that's beyond what a normal person does. And what's strange is often ADHD has a stigma. It's not a real diagnosis, partly because There isn't some fancy word as pathognomonic, you know, some classic symptom that's characteristic exactly of that.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I was going to say, both of those have some science background, so I'd say I'm glad it works. And what's hard to sorting out is why it's working is one is, you know, potential placebo effect. You're doing it because you're thinking or hoping it works. Good. And two, I'd say maybe even more importantly than the placebo effect is the days that you're deciding to do this
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
There's something different about those days to begin with because they're not doing it every day. So those potential issues aside, I'll jump into insomnia. And Matthew Walker talks about some of this. To me, maybe the biggest finding in insomnia sleep medicine in the last 20 years is that almost everyone who has a problem with insomnia doesn't have a problem with sleep. Huh? What?
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
That sounds like I'm contradicting myself. What I mean is the sleep system's intact, it's there, it's waiting to arrive and put you to sleep each night. What the problem, and this is from the sleep researchers, with at least 90% or probably more of people who have insomnia problems, is the failure of the daytime arousal system to shut off properly.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So normally we have these two mutually inhibitory systems, wakefulness... arousal system and a sleep sedation system. And usually when one turns on, the other turns off. And with most people's problem with insomnia, it isn't that sleep is weak or insufficient or not there. It's sitting, it's waiting there. It just can't land on the landing pad because you're too aroused or too awake.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I mean, maybe that helps the arousal system to turn off better at the end of the day if it's gotten more fully engaged during the day. I don't know. But it feeds back more into some of the non-medication approaches to helping with sleep, and that is doing everything you can, again, not just to force sleep or push it because that doesn't work very well. It's getting rid of arousal.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
It's dampening arousal. So for people with ADHD, one is, you know, deciding on what's a reasonable bedtime you know having thinking about this ahead of time and two eliminating any stimulation or i mean once so exercise i'm a big fan of i'm a Marathon runner, I know you're heavily into exercise as well. Exercising too late in the evening can elevate body temperature, disrupt falling asleep.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So physical arousal, we don't want to be doing a lot of late in the day and emotional, intellectual, cognitive arousal. So the biggest single tool in modern life is do not have your phone in your bedroom. And that's hard for lots of people to do. But if it's there, you're going to be checking it.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I mean, studies have even shown even if you're not checking it, if it's there, you're thinking about it or looking at it. Just having it away out of sight is better than having it visible and turned off. Two is using, if you have someone you're sharing a bed with or family members, using them to help reinforce.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yes, and it's really helpful to talk about this ahead of time because the exact same words can either be sounding like a nag or someone trying to exert their power over you, rather than what people with ADHD, we know, need reminders. They know they need some of that external structure.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And if you are on the same page and can have a partner, your kid, or someone else present, hey, dad, shouldn't you be turning off the computer and heading to bed right now? That can be helpful. Again, it can be destructive if it's not done in a framework where both people are on board. And it's not fair to make the other person responsible for your own behavior. But lots of people are usually...
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
happy to help the person with ADHD be more organized in their life. So we were also talking a little bit before, one of my favorite tools for falling asleep is actually cyclic sighing. I mean, there are other box breathing and other techniques that help someone relax. So we know cyclic sighing engages the parasympathetic nervous system, our rest and digest system.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So with schizophrenia, we have hallucinations. Most people aren't having hallucinations. If you have those, you know, you might have schizophrenia or a drug effect, but that's unusual. Again, with ADHD, they're all usual behaviors. It's just to an unusual extent. So the diagnosis comes under a lot of stigma and questioning. Isn't this just normal behavior carried to a ridiculous extent?
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I mean, one of the things that happens normally in the transition every night when you fall asleep is you're going from primarily sympathetic tone to primarily parasympathetic tone. So anything that is strengthening or putting you there already makes it easier. I know you have videos about cyclic sighing and I do too.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I mean, my own experience which I was sharing with you before we started talking was Not only does cycloxying help me fall asleep better, it actually helped me stay asleep throughout the night better.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yeah, I mean some might. I mean some – it may be a prostate issue. Yeah. Clearly that isn't accounting for half the population, but I think it's much more the neurologic innervation of our bladder. All our nerves start functioning not quite as well, and they're just getting the signal that I really need to urinate right now when pretty clearly most of those people don't. They could wait, but...
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
the signal is arriving that says you have to and it's believable and you don't want to deal with it if it's, you know, you don't want to not listen to it if it is right, so.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So when I read your paper with Spiegel and others January, For years, I've said, I don't have a meditation practice. Most people think I'm sort of so chill or relaxed that I do. You seem like a pretty mellow dude. I haven't ever taken the time to do it, which I'm embarrassed by. So I said, read the paper. I can do five minutes a day of cyclic sighing. And I tried, and it was...
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Some days I was getting it in, and many days I wasn't getting it in until bedtime, which is that I slept really well until I was around 40 and not so well the next 20 years, mostly with the trouble of falling asleep, even though I knew of relaxation techniques and others. So I wound up just consistently doing it to do it more for the general health, and I do have slightly elevated blood pressure.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
and relaxation and to see what effect it would have. And it was clear. So I do about five minutes and much more than five minutes I tell people, and I might be doing it a little slower than most, count out about 20 or 25 reps of it. And if you lose track, it doesn't matter. Just go back to the lowest number. Because again, everything we're trying to do is decrease arousal.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
If you have a timer on it and you do it for five minutes and then you're woken up, you're reversing or mitigating some of the benefit of doing it. So my recommendation is do it for five minutes, about, but
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
do it by counting reps and don't focus or you know if it's six minutes if it's four i mean there's so many aspects of this and we know the exhalation has to be longer i was trying to find you know is anyone systematically you know as a four second exhalation better than ten versus six and those studies would be so simplistic and easy to do but you know there's lots of variables that we can play with to see what's optimal i don't think we know at all what's optimal but we know what's good enough
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
The data point that I shared with you is that prior to trying cyclic sighing at nighttime, So I was waking up virtually every single night, once a night, to urinate. And in the 18 months, 20 months since I've been doing it, I think it's been a total of four times that I've woken up during the night to urinate. Fantastic.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yeah, there's a few studies looking at acute aerobic exercise. Part of it is that it's hard to study people when they're exercising during many exercises. I mean, you're not going to wire someone up when they're swimming, for example. Right. So there's not a lot of studies in any one approach, and there's so much diversity that often it just gets lumped together.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So there do seem to be some acute effects of measurably improving some of the executive functions associated with better attention from acute exercise, and there seem to be some more general or longer-term benefits from people who are consistently actively exercising.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
having you know being able to concentrate longer being able to switch attention more appropriately or effectively and there's a huge body of sort of clinical literature of patients reporting you know i know i feel much more alert the day i get my workout in the gym in or i feel better or the week i took off from that was a big mistake.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
But I would say identifying at what's the most valuable or what's the best duration. I ran through the data about a year or two ago, and I would say that we can't make any conclusions. And I would say at some level, try it and see what works for you. And that's what's important. It isn't what works for everyone.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yes. And so the answer is, and these are really rough statistics. I actually, one of my pet peeves is people who quote, oh, the rate of this is 27.43%. Well, It might have been in that study, but that's looking at one population at one set. So I use ballpark figures.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
The ballpark figure is Americans in the last 20 years, more than that, about 20% of Americans run into some addiction, substance addiction problem, either alcohol or drugs. People with ADHD have a rate that's almost double that, and it's higher in men than in women. Double? Almost double, almost 40% risk.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yeah, that's substance abuse, and that's looking at abuse, and we can get into the related topic of what's misuse versus abuse, and I have pet peeves there. However, kids who are put on stimulant medications when they're young, and I should say the stimulants themselves do have a small potential for addiction, but putting kids on stimulants pretty much normalizes their rate of addiction problems.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So it protects them.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yeah, I can say not absolutely every study has found this, but several large meta-analyses have gone back, and most of them have found this fairly dramatic benefit to being on stimulants as a kid in terms of specifically reducing substance abuse risk. And some of them that have looked at this, when I said it was a yes and...
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
It seems to be that it's not just the impulsivity traits, but some of the inattentive ones too. You know, if you're teachers lecturing about the risks of alcohol or this and this, and you're zoning out the window and looking at the plane flying by, You have less pertinent information on the topics.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
You may be less attentive to the negative effects that other kids are seeing among the classmates who are stoners at this age or X, Y, or Z. So it seems that both inattentive sets of ADHD symptoms and the impulsive, thrill-seeking, not weighing the consequences as heavily are all contributing to this heightened risk.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So Ritalin is, or generic methylphenidate, and there's dozens now of slow release versions and there's even a patch, a skin patch instead of an oral version. Our definition of what a stimulant is is really squishy and vague. In its broadest sense, it's any drug that has an effect in the body, like the sympathetic nervous system, which is a norepinephrine-driven fight-or-flight arousal system.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yeah, so back up a little bit. Like all of our other mental health or psychiatric conditions, there's clearly both a biological component to ADHD and clearly a social environment. The nature and nurture question isn't which is it. It's always both. So with ADHD, we know there's a very strong genetic component. The heritability factor is around 0.8%.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So by the loosest criteria, caffeine's a stimulant. Well, butane's a stimulant, even though we classify it as an antidepressant. Some of the decongestants are stimulants. But more often when we're talking ADHD medicines, we're using stimulant more specifically for amphetamine-based products like Adderall and Vyvanse.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And again, there's a host now of newer branded extended release forms and methylphenidate. And we lump the two together, probably most ADHD experts agree with, and this is where I'm going to be disagreeing with most of them, I don't consider Ritalin a full stimulant. So the neuropharmacologists differ a little bit, but amphetamine... is a strong dopamine and norepinephrine reuptake blocker.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So it prevents what's already been released from being taken back up. So more is available longer. But in addition to that, amphetamine is a pretty potent, let's just say, vesicle manipulator. So it's actually forcing a bigger release from the vesicles when they're synaptically released. So it's not just that the signal lasts longer and is stronger because of that. It's a bigger signal.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Depending on what study you look at, most of the studies suggest that methylphenidate is actually a pretty weak vesicular manipulator, and some studies don't find any impact there at all. Which means if methylphenidate is basically a norepinephrine and dopamine reuptake inhibitor, That's what Welbutrin is. That's one of the components.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And so why I would further say, if you look at the efficacy data, how well do these work in resolving ADHD symptoms? All the meta-analyses lump Adderall products, amphetamine, and methylphenidate products here and say, you know, they're here because they work better. This is, you know, success in reducing ADHD symptoms.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And Alvar, Stratera, Adalmoxetine, Welbutrin, I use Cymbalta a lot, Modafinil, Guanfacine, all these other things are down here as less effective. But if you actually look at any of the plots that I've looked at and separate out, methylphenidate is actually closer to the pack below. It's the amphetamine products are head and shoulders above everything else.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Methylphenidate is usually at the top of the rest of the crowd. But if you're just looking at the data objectively, there's a clear decision point. So in terms of efficacy, Amphetamine products are stronger. But in terms of some of the side effect that I worry most about, it's not at all common, but it's one of the horrible ones is amphetamine-induced psychosis.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Now that we're finally looking at that a little more closely, because for years the ADHD experts have said, yeah, it's really rare, let's not look at it at all, let's not pay attention, move along, you know, don't look. With amphetamine, Adderall products, and that's probably dose dependent, but it's close to one out of 500 people.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
which is about as strong as the heritability factor for height or for schizophrenia.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And what's, I'm going off on a tangent here, but I'll keep following it because it's an important tangent. It's only one out of 500 people. That's uncommon. But this is a really bad condition because so amphetamine induced psychosis is a schizophrenic like picture. Usually someone is really paranoid, really worried that their friends are manipulating them or the police are spying on them.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I mean, if you drink too much alcohol, you can be batshit crazy, that's a highly technical term there. You can be out of touch with reality. You can be hallucinating. You can be saying all sorts of nasty things. But if it's alcohol-induced, you fall asleep at the end of that night, you wake up the next morning, you may feel horrible at the hangover, you're not hallucinating.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
You're not psychotic anymore. Hopefully you're regretting what you did, probably not remembering much of what you did. People will let you know. With amphetamine...
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Induced psychosis, on the other hand, classically and characteristically and what I've seen clinically, it continues for days, weeks, or months after stopping the medication, which means we've changed someone's brain and we don't have lots and lots of data and it's actually only come to us because people are concerned about marijuana causing a similar picture.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So now we're studying this a little more. Well, with amphetamine-induced psychosis, about, and these are again rounding from different studies, about 20%, if you look 20 years out, about 20% of those people are in a permanent psychotic state still. So again, it's uncommon, but it's such a bad outcome that we really should be alerting people to it.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And I've been, I saw a much higher risk of this for I can get into it if we need a reasons in my population in San Francisco. But I've had people coming from all the most prominent ADHD clinics over the years who just moved to the area.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And when I'd say this, give this as my introduction to, you know, I'm happy to continue on this, but are you aware, to a person they said, no one ever told me that. Now maybe they have ADHD and weren't listening, but it's so uniformly consistent that they didn't hear or know that that was a side effect. And one in 500 isn't a trivially small number. No, it's not trivial.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And I mean, why I got alerted to it is my rate in San Francisco is actually higher than one out of 100. And so I'll go into, I think, a couple different reasons. One is I worked with a lot of HIV positive men. And we know HIV, particularly in the days before we had effective antivirals, is a virus that goes to the brain and affect, you know, there's a, HIV-induced dementia.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So probably some of these people had brains that were compromised because of that and were vulnerable. Two, a high incidence of methamphetamine. So methamphetamine, street speed, is a chemically different molecule than amphetamine. It has an extra methyl group, and an extra methyl group can mean a lot.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So it's a cousin, but methamphetamine, we know, has higher rates of psychosis, higher rates of addiction. This tends to be more rewarding. But Again, in that population, and many of them would hide that history from me, but I think that the very first person I had with amphetamine-induced psychosis, a guy in his 40s, HIV positive for years. This was back in early, mid-90s.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
was able to finish school in his mid 40s, get a good paying job in two years on stimulants, and then had a full-blown psychotic episode where his dad had died of a heart attack 10 years earlier. He was threatening his mom because he believed his mom had poisoned her. He flew over to Rhode Island where she was living.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
But it's high likelihood. So this tends to run in families. But again, it has a social... You're not just a brain in the world, you're a brain interacting with the world. And with ADHD, we like to frame it as both structure is important and demands are important.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
He was making threats from a payphone and because Rhode Island's so small, he was actually calling from out of state, so it was a federal crime. He got thrown in federal prison for this. And he stayed psychotic for months after he wasn't using anything. But it later turned out he had had a psychotic episode 10 years earlier on street meth, which he lied about. when I did the evaluation.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So the other high risk group I had was I was known in San Francisco as someone who worked with adults with ADHD at the early stages of recognizing ADHD. So, and I was comfortable with the broader range of stimulant dosages and many providers are. So I had people who had, and they were all young white males, straight males who had
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I don't know how many of those demographics are relevant, but who had histories of taking stimulants, having a psychotic episode, again, being really paranoid. And again, the numbers aren't huge, but at least five people with this general profile.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
But even though they were paranoid, even though they were severely impaired enough that each of them wound up in a psychiatric inpatient hospital, which is pretty hard to get into in this day and age or even 20 years ago, they all liked something about the experience enough that they all wanted to get back on. And all of them knew enough to lie about this past.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So they didn't tell me about, you know, they presented. All of them also had ADHD. You know, they presented with ADHD. They'd say, I've been on stimulants before, and I'm not working with that doctor because my insurance changed or they had moved to the area. So they gave plausible histories, and most of those, within a month or two of restarting it, wound up back in the psychiatric hospital.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I had one guy, bright computer programmer, late 20s, calling me from inside the psychiatric hospital to try to get me to prescribe more Adderall to him. And not only that, he had convinced his inpatient psychiatrist that this was a good idea, that this was important to treating his ADHD and helping him retain his job. Wow.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yeah. And you put the word mania in there, manic, and lots of people define this as amphetamine induced mania rather than psychosis.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So one of the aspects of ADHD, separate from the official, how we categorize it or diagnose it in terms of symptoms, we most often are understanding it this way. day and age as a problem with executive functions of the brain, how the brain's working memory works, how selective attention works or doesn't work, how emotional regulation is working or not, how impulse control is working.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I don't because one is uniformly and maybe other people are seeing more that these people were paranoid, they were worried, they were anxious, they were delusional, but they weren't overtly enjoying it, they weren't having a great time, they weren't saying I'm gonna party with all you friends and I'm only worried about the people there.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And yes, they were talking more loudly, they were sleeping less, which could be characteristic of mania, but there was no positive affect that I or police reports or often families give you extensive history of everything that was going on, that there was nothing euphoric they were describing about it.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I mean, I think the second piece is how much of they... It's unclear how much they actually remember or recall or... either through psychological suppression of it or physiologic. They're in a different enough state that didn't register properly. It's not clear. But they tend not to recall the paranoia. And by paranoia, it's persecutory delusions. I have people who,
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
assaulted family members thinking that they were being spied on, manipulated when they were the parents trying to take care of their kids.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I mean, some of this is just individual style rather than intellectually thinking one is better or not. And my style is usually to listen as closely as I can to what the patient wants. That doesn't mean agree with them, but to... explain in as much detail as I can what I perceive the risks and the likelihood of those are and what I perceive the benefits to be.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
For years, just statistically, I had many more people who were on non-stimulants than stimulants compared to the general ADHD population. And that's even accounting for, by many variables, I've always worked with a lot of people who are on disability from Medicare. I also worked with people who are on Medicaid in the cities.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Essentially, the ADHD brain is less able to provide the structure it needs, so it's more reliant on an optimal structure in the outside world. So getting the home versus working in an office environment, part of the problem is if you're in a traditional office environment, you're starting a specific time. Everyone else is doing their work at a certain time. When you go to lunch is clear.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
insurance before Obamacare happened so I worked with not entirely but a skewed more dysfunctional more severely afflicted population which again you would think would be a better match for the more powerful drugs I'll jump back, but this actually is a situation where we have more powerful drugs.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So often when I treat people with depression, they'll try one or two or three antidepressants and say, well, give me something that's more powerful. And with depression, maybe we can put ketamine out of the picture. And I know this is a side issue, but all of our antidepressants seem to work equally well. We don't have potent antidepressants that got FDA approved.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
It works in a certain range of likelihood. But with the stimulants, amphetamine-based products really are more powerful and more so than with depression or many of our other conditions where it's more a categorical, this will help or not, as long as you're above a threshold, there's a more linear relationship. If a little bit of Welbutrin helps a lot, it's likely to help more.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I mean, you might start getting more side effect issues and there may be good reasons to not keep going up. But there's a more linear dosage results relationship.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
When you used that term, I was talking to Rob beforehand about running marathons. And when I ran the 100th anniversary of the Boston Marathon, they had some of the medical literature from the previous decades. And one of the Medical warnings was, you know, maybe you could do one or two marathons in your life, but don't do more than that because your heart will wear out.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And, you know, I've run 100 and my heart, I think, is still beating. So we know things we thought we know at one point.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Common cardiovascular effects of not just the stimulants, but the non-stimulants that are affecting norepinephrine, so Welbutrin, Cymbalta, Modafinil, it's less clear, and we can get into that when we talk about Modafinil, but clearly methylphenidate, amphetamine, on average increase, at therapeutic doses, increase Heart rate, a few points. Increased blood pressure, a few points.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
But part of that obscures that probably 80% of people don't have any change and maybe 20% have maybe a more slightly significant change. So we know that there's some impact there. We know there's some people with extremely rare genetic underlying conditions, usually related to the neurologic wiring of the heart, who are particularly vulnerable to dropping dead from a stimulant.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Almost every year there's a well-trained athlete, either a professional player or more often a high school or college player, who will take cocaine, take Ritalin, take prescription stimulant, and drop dead of a heart attack. The risk of that is so uncommon. This is 15 years ago. When Adderall XR came out, the Canadian government was worried enough about this risk
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
that they banned Adderall XR for almost a year, and because they have a comprehensive medical system that could look more extensively at the numbers, and this was looking at kids, the percentage of kids who dropped dead with Adderall was tiny, and not just tiny, it was lower than the kids who aren't on Adderall who dropped dead of a heart attack.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So part of it is, if you're in this rare genetic condition, Almost always there's family members or you've had some other near-death or syncopal episode where you passed out. So history taking of the individual and family history. And if you're at all worried or concerned, you can do EKGs, which detect most of those electrical abnormalities.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
But the cardiology, and lots of my colleagues practice maybe a more conservative cover-your-ass medicine approach where everyone has to have an EKG before they're on a stimulant. But even the cardiology associations have said that seems to be a waste of resources. Absolutely do a thorough history.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
You may have people checking in or seeing you in the hallway. Larry, how far along are you on this coding project? Are you going to be ready for it on time? When you're home, you don't get any of that reinforcement. You don't have any of that structure. So, I mean, structure is a Goldilocks issue.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Absolutely do a thorough family history if there's anything of concern or if the patient's anxious about it, get an EKG. But other than that, these should be generally safe for most people's hearts.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So there was a meta-analysis that came out earlier this year on, so most of the studies looking at more serious, other than just mild hypertension or mild elevation of heart rate, haven't found much, but most of them only look, you know, a year out or a year of treatment, do we see rates of heart attacks? Do we see rates of strokes? Do we see rates of dangerous arrhythmias?
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And in general, they're looking at a young population where these events are really uncommon anyway, and most of them didn't find any evidence of problems in a year or two out. The more recent study,
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
looked as long as 14 years out, and there they found measurable, statistically significant increase in risk that increased during the first three years of being on a stimulant and increased at a much lower rate for the next 10 years, sort of plateaued out, but still measurably higher than people with ADHD who weren't on a stimulant, but the absolute rate is still really, really low.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So for most people, it's not a risk. I mean, on the other hand, if you start these medicines when you're 10 or 20 and maybe on them for 60 years, we don't know whether potentially more people are getting into more trouble.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So thanks for bringing me back to your question. Sure. And I'm going to jump through in that sort of qualifying phrase, never been on any stimulant in their life or tried it or something. At least not consistently. What I would say is these drugs are fairly common in our society, both illicitly and I mean, we know lots of kids, lots of adults with ADHD share their medication.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Lots of people have tried these things, even if it's just once or twice. And that itself is valuable clinical data, you know, if they felt too revved up from it. So if they have, I try to find out what dose was it, what did it do for you, what good things did it do for you, what bad things did it do for you. So my presentation is usually, you know, Adderall is likely to be
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
the most strongly effective, or I more often are using Vyvanse. These are the other options, but Adderall also has, again, greater risk, rare, but risk for these bad problems. What, you know, does that scare you? Some people are petrified. They're not going to go anywhere near that. Some people say, yeah, I'm not that concerned about it. And most people do come in with some
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
It's not just more structure is always good because if you put or impose too much structure on someone, so most people with ADHD are really lousy assembly line workers. They don't want to be just Picking up one bolt, screwing it on the side of the Lexus or whatever and watching the car move down the line, that's too stultifying, too limiting, too structured.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
friends at work, family members, X, Y, or Z, you know, they think they know what the drug is likely to have as an effect on them. And I tend to, at least as a starting point, listen to that. And now, I mean, there are certain reasons I absolutely would not. I mean, my worry, again, I saw more of it than I think most people in a higher rate with amphetamine-induced psychosis. But
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
A friend from college was just trying to refer a friend's son who's 27 and had a psychotic episode on marijuana and does have ADHD and is in bed depressed and not going to work and is being evaluated by two New York City doctors. But the psychiatrist kept him on Adderall. I absolutely... Again, the...
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
The likelihood of recurrence seems so high that if you have a family history of schizophrenia or psychosis or you've had any experience of it, I would not prescribe a stimulant, an amphetamine-based stimulant.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yeah. I mean, you could actually play that both ways. I mean, you could claim that if they've already been on an agent without developing psychosis, then maybe they're more impervious to that as a potential side effect. Or where you were coming more from is if we're already on one agent that's pushing them that direction, why the heck would you ever add another that could also?
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I mean, my approach clinically would be more, what do you think the marijuana is doing for you? And Might it be more helpful to just clear that out of the picture before we add anything new onto it, but depending on what they say or don't say. So my reading of the data is very clear that there is some, I mean, even at low THC, there's some risk.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Is it reefer madness that everyone who puffs a joint is freaking out? Clearly not. But again, it's much more potent than it was 10 years ago. 70 years ago, I guess.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
One other big factor is that CBD actually seems in some studies to have an anti-psychotic effect. So maybe strains of marijuana... 50 years ago that had a, whatever nature thought was a more balanced view, had less of a risk.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
But now that you can get pure THC products, and I'm sure you've highlighted that a big problem with this whole industry is even in Colorado, which three years ago was the state with the most close regulation and inspection and almost a majority of what the labels say don't correlate with what you're really getting. So this is not a well-regulated industry, even though
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So you need the optimal amount of structure. And with COVID and working from home and kids... being at the home. So one thing it created is less structure for the day, but it also increased the demand side of the equation.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
States are trying to regulate their industries, so you may not know what you're getting. CBD, again, may have some protective effects, so getting pure and higher potency THC may be particularly undesirable. So in my own YouTube podcast series, I've researched lots of subjects, and most of them I wind up saying, we don't have a lot of data on it, and there's not a lot of data on marijuana.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
It's the one... subject I've actually changed my mind from reading what was out there. And for years, I would tell people, because being in San Francisco, even before the wave of legalization, lots of people were using it. Lots of people felt it helped them.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And what I would tell them is the data we have, and these are from everyday users, is that there are measurable, you know, that the characteristic of the classic stoner has a Grain of truth, though. So measurably lower motivation, poor organization of thought, lower energy are strongly correlated with daily marijuana use. Why would anyone with ADHD want any of that going on?
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
That seems like a perfect misfit or accentuating what's not working right. Over the years, though, I had a handful of people who would swear it worked better for them than stimulants, it worked better for them than the non-stimulant alternatives. clearly not everybody.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And when I looked at the data, there is actually some tiny studies, you know, there are some that are funded by marijuana organizations, so that doesn't mean they're wrong, but it's harder to evaluate how objective they were.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
But there's some research that suggests there is some sub-segment, and I don't think it's people with ADHD in general, but some subset of that population who may actually do better. And most of the time they were looking at marijuana rather than pure THC. And what I was going to say is there's probably at least 70 or 80 other psychoactive components to marijuana.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Not most of them is in a higher concentration as a THC or CBD, but They're out there. Maybe they are more important, even at lower concentrations.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So the cognitive demand, not only did you have to manage your own time and schedule now, in addition to doing your work, you had to schedule it, but you might have had screaming kids in the other room, or you might have had your partner who wants to use that room for their quiet meetings some of the time when you're trying to do it. So the demand's
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yeah, so there's some well-done research showing nicotine is helpful for improving some of the executive functions, sustained attention, and I'm not sure which of the executive functions, but they help people focus, be sharper, do better. There is actually a major pharmaceutical company who is developing a nicotine receptor product specifically for ADHD.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And they abandoned that several years ago, and I haven't been able to find word as to why that was abandoned, whether there was some other side effect. It's worth throwing out there that although nicotine in many ways acts like a stimulant, it actually is moderately unique. And I hate people who say unique means one of a kind, so I can't modify it in any way.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Unusual, maybe not the only one, unusual in that it both arouses people and reduces anxiety simultaneously. Most of our stimulants are again banging away at the sympathetic nervous system and that's banging away on good arousal and bad arousal. So nicotine again seems to be both calming and helping alert or focus people.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
increased for many people and the structure decreased and that was sort of a perfect storm for creating more ADHD and what's really Interesting from a mental health perspective, at the very start of the COVID epidemic, public mental health figures said, we know if this is a massive epidemic and we're going to have to do quarantine, we know depression is going to go up.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And as long as they're taking it in a way that's not clearly detrimental to their health, which smoking and vaping and probably chewing are, well, not probably, definitely are, and if it's affordable, because some of these products are pretty pricey, at least the chewing gums or the Nicorette that was used for helping people with smoking cessation, I have some people who feel that it's been an important and useful part of their regimen.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I have some people, small numbers who prefer it to any other medications. And almost no, again, other than sort of the basic neurophysiology showing that it can have beneficial effects on executive functions, there's no research, at least as of a year or two ago, whenever I dipped my toe, not my anything else, into the snuff, looked into it.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
There's no clinical research showing does this help or not help.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So epidemiologists say that the most widely used psychoactive substance on this planet, and I thought it was alcohol for years, but it's actually caffeine because lots of groups outlaw alcohol who won't outlaw caffeine. So lots and lots of people use it. And this is a gross oversimplification, but this is what I tell people.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Even though it's most widely used, if you used it as an equivalent dose to our stimulants, I mean, essentially we're using it at a lower dose level. It's a pretty lousy stimulant. I mean, separate from that it's working primarily on adenosine and indirectly working on dopamine.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
But associated with higher levels of anxiety, higher levels of jitteriness, higher levels of cardiac toxicity, if you were to use it at an equivalent dose. But most people are using it at a substantially lower dose. the ADHD experts sort of historically have fallen into two different camps. Some of them have said that It's going to interact with your stimulant or other medications.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
It's complicated. We don't want it messing up the picture. Stay off of it. And the other half say, it's a stimulant. Lots of people are using it with these other stimulants, both full-blown stimulants and non-stimulant ADHD medications. And as long as you know it's part of the picture and you're trying to be constant with your dosage or aware of it, then fine.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And maybe it helps you get away with a lower dose of the prescription. The one little piece I'd add in there is that often you don't know what dose you're getting. So people have the common experience. As I was saying earlier, I've only had three cups of coffee in my whole life. So this is all anecdotal or research, not personal experience data.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
But lots of people have the experience, go to their local Starbucks or something and say, whoa, that feels way stronger than usual. And then invariably they say, oh, that must just be me. I'm more anxious already. I'm jacked up or Because they think Starbucks, $7 billion Stores around the country, everything's automated and precise. They must be.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Starbucks isn't, you know, they control for the aromaticity, how many minutes each bean is cooked, which side it gets flipped over on. They're not controlling for caffeine intake, which is wild to you. So University of Florida study, and this is several years ago now, went into a Florida Starbucks, bought the same drink every day for three weeks.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And compared to the caffeine content, the highest A compared to the lowest A was a three-fold difference. Wow. And that's Starbucks. Who knows what smaller – so one is you may think you know what you're – and maybe the bane of coffee drinkers and maybe Sanka in a teaspoon that you're dissolving may be the most consistent there or –
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
But one of the risks with caffeine and with pretty much any over-the-counter drug is you may not know what dose you're getting.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
We know anxiety is going to go up. We know alcohol and substance abuse is going to go up. We know PTSD and domestic violence is going to go up. They claimed suicide would go up. That was incorrect, and we can get into that. But I think there's an ADHD reason why it didn't go up. Nobody that I heard was mentioning that ADHD would go up.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yeah, and there's also lots of cultural and habitual, you know, if it gives you your warm fuzzies or puts you in the right mode or you think you're more alert or you're listening to your favorites. newscast in the morning as you're drinking it, that all is adding to its effect.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
In terms of combining it with other over-the-counter things, there is some study looking at caffeine and L-theanine together and having some, at least in a tiny handful of studies, some measurable beneficial effect on, I think it's mostly kids that have been looked at, and nothing
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Dangerous found across a pretty broad range of L-theanine dosages, but I'm not aware of any good research done with adding all the other things that are currently being added to it. And some logically may be doing something, some may be irrelevant, some may be more detrimental.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yeah, there's a tiny bit of evidence that suggests it may both dampen down, help with anxiety, but it may directly have some beneficial cognitive executive function benefits itself.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So just as with the fish oil for cardiac benefits, there was a time period where the first few large, and they were pretty large, well-done studies showed benefits for cardiovascular health. The more recent studies with fish oil haven't shown an effect or benefit. And strangely to me, and not very scientifically,
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
The cardiology community sort of looks at the more recent ones and say, okay, that's what it is. Well, you have to reconcile all the data in the pool. ADHD fish oil story is a little the opposite. And it's almost everything with ADHD. It's been kids that have been most strongly looked at. The first few studies with fish oil in kids didn't show any benefits at all.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And part of it is because partly to hold on to its legitimacy as a real psychiatric diagnosis, both many patients and many researchers in the field hold so strongly to this is a biological condition. Why would it change, you know, I mean, we can understand why PTSD, more people are being traumatized. Uncle Joe just died from coughing his lungs out from COVID. You know, PTSD, it's easy to see.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And then subsequently, there have been several studies that looked at benefits. And again, in the field jumps to the second set without reconciling, well, how do we you know, do a good meta-analysis with everything in there. And I haven't looked closely enough to know, you know, were there methodological differences, dosage differences, population differences that matter.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I'd say unless you're taking so big a dose that you're probably at risk for heavy metal poisoning, which is a possible issue with big, big, big doses of fish oil. I mean, most of the recommendations are in the range that it seems. And I'd say that depression has been the most consistent field.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And that doesn't mean every study there has been positive either, but the most consistent field for a mental health benefit or a health benefit. And there the recommendation is usually target about 1,000 milligrams of EPA of eicosapentaenoic acid a day. If you're seeing some benefit, but it feels like that there's more room for improvement, so this is my model, I tell people then you could
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
probably double it reasonably. I mean, some of the dramatic studies looking at fish oil for mania, people hospitalized with it, and they used dosages as high as 7,000 milligrams a day. To treat mania? Yeah. And that study, I think it was a Harvard area clinic that was doing it,
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
The results were so dramatic that they ethically had to stop the study before its intended completion because the benefits seemed to be so robust in the fish oil group compared to that it was unethical to not put everyone on fish oil. That's a lot of fish oil.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So the other thing that I think is understudied with the fish oil issue is that and it's a Harvard guy who has a proprietary brand of purified EPA. that pushes it.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So in nature, whether you're a whale or a human or a butterfly or maybe not insects, I'm not sure, across the mammal, bird, reptile kingdom, the omega-3s are found in about a two-to-one ratio of EPA to DHA, eicosapenta-honoic acid to docosahexaenoic acid. And what I tell people is I think Mother Nature is probably smarter than any Harvard professor. And
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
The brain particularly is high in brain membranes of DHA. So I don't see, some people seek out EPA purified or sole, you know, only EPA brands. That to me doesn't make a lot of sense. So I would say we can still count or do the numbering based on about 1,000 milligrams of EPA, but don't worry that you're getting about 300, 400 milligrams of DHA and probably that's better for you.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Or depression, you've just lost your job and your whole industry, you know, you're a restaurant worker, that's not coming back.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So we could easily relate stories as to why these other conditions were going to go up, but there was no prediction, again, mostly because I think the defensiveness of the ADHD community and not wanting to acknowledge as much that there's a real nurture component and not just a nature component. And yet what we've seen, just looking at prescriptions, and the media has jumped all over this,
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I'm going to kind of pass on that by just saying it's complicated and probably important and so many variables that it's hard to know what's really valuable in a day-to-day real human living perspective.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yeah, only to the extent of trying to have a varied diet and eating at somewhat regular intervals, but not more specifically.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So by stepping back a little bit and broadening it, I'll get to the video game things. But one of the effective approaches that helps with symptomatic reduction with ADHD is cognitive behavioral therapy. So that's a form of talking therapy. And my quick overview of it is that it focuses on
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
actions, thoughts, and feelings, and that humans can have direct control of their actions and thoughts, not too much over their feelings, but all three are affecting each other. And the traditional CBT was developed by Aaron Beck to treat depression probably 50 years ago, maybe longer, 60s, I think, late 60s. Anyway, on the surface, it's a horrible match for
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
ADHD, because we know it requires lots of repetitive, boring homework, doing the same thing. It involves introspection of being aware of what you're doing already, looking at those patterns, looking at what the triggers are. to see if you can see triggers for them.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And then doing lots and lots of repetitive homework, and when it's successful for depression or PTSD or other venues, we know it actually changes brain wiring and brain chemistry. So lots of people still think talking therapies are sort of up here doing something and chemicals and medications are really changing the brain. If your thoughts are changing, if your behavior is changing,
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
your brain has changed. That's the only place that thoughts and behaviors come from. But there have been at least two groups, Mary Salanto's in New York and a Harvard group by, I'm blanking on his first, Saffron and some other, Ramsey at Pennsylvania, developed approaches using CBT techniques specifically designed for people with ADHD to help overcome some of those hurdles and barriers.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
not only have ADHD diagnosis gone up considerably, but also prescription stimulants have shot up dramatically in the last few years.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And both of them encourage actually the use of medications in combination with it. Because many people with ADHD are too unfocused, too unable to sit down and do it. But these are approaches, and both approaches are amazingly similar, although devised completely independently. At the core of both of those approaches is having a system of scheduling each day.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
That doesn't mean micromanaging each minute, but it's having the essentials in place, having blocks of time that you know what you're going to do. Um, and having a task list in combination with that and ways of learning to prioritize and move things up or down. And again, with ADHD being interest driven, rather importance driven, you may have a task. I mean, you probably have 17 task lists.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
One's New York coffee, one's At the grocery store, one, it's having one consolidated list because if it's everywhere, then it's nowhere. And two is the simplest triaging or organizing approach is having the things that are both urgent and important. So to happen today, those get in the A category. The things that are important but aren't as urgent are the B category.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And all the other things are the C. And one of the temptations that people with ADHD have is, oh, I need to be productive. you know, it's fun to go buy shoelaces and that's on my list. So I'll go to buy shoelaces because then I can cross something off my list, but I didn't move the car. I didn't do my taxes. I haven't done my homework and all the important things remain undone.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So it's a system for getting done what's really needed to be done. And, you know, eventually if, if, your shoes don't work, the shoelaces will move up to that A category, but for most people they're not really there and it's not a good use of your time to do them first. And there's much more to it.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So the CBT approach can work with decreasing procrastination, it can help with structuring your own workspace given that you probably have much more trouble doing that and not doing it spontaneously. It's how to eliminate distractions and modules on even extending your concentration time. So the answer with the video games, there is one product that's actually been FDA approved for use in ADHD.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And the really important thing to remember there is the FDA's system for addressing medications is much more rigorous, much more thorough. You have to demonstrate it really works and does something When the FDA approves devices, basically they're saying it's not going to kill anyone, it might help.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I mean, it might help tremendously, but having the FDA imprimatur for that doesn't guarantee that or mean that at all.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yeah. Yeah. So almost all of them have been run by the company. I mean, it's good people at UCSF who are at least partly involved in it. Oh, is this Adam Gazelli's group? I think so.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Their product and some of the others can clearly show you get better at their product and you get better at tests that look exactly like their product. But in terms of real world, how much is this really helping ADHD symptoms on a day-to-day basis? Not a lot of data at all. So again, that doesn't mean it doesn't work.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And I'm going to go sideways in talking about neurofeedback because there's lots and lots of neurofeedback companies across the country that are making Lots and lots of money. And there was an article in the American Journal of Psychiatry in the last year. I'm not remembering which group did it. And it was another failure to find a significant impact from neurofeedback.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And again, I'm not saying it doesn't have an effect, but I've had lots of people saying, writing me, should I keep spending hundreds of dollars each week because my insurance isn't covering this? And the doctor saying, oh, maybe 20 more episodes will retrain your brain. So this gets back to a topic you brought up earlier, how much are we retraining our brains with immersion in social media?
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And the evidence is we are rewiring our brains. So maybe anything pushing in an opposite direction or maybe this is reinforcing some of the bad things we don't want. We're in a messy world without clear answers yet.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yes. Getting back to the scheduling. I mean, what I recommend to people and one of my weakness, I don't know the specific apps, but there are apps that will help shut you out of. Facebook or Discord or TikTok or whatever it is, if you can't exert your own willpower, which again is harder to do if you have ADHD.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And if the app approach doesn't work, the next level up is there are all sorts of companies making lock boxes and physical devices where you can lock yourself out of your device for certain hours of the day. And I think that's a good idea for lots of people.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So guanfacine and a related drug called clonidine, which can be confused with Klonopin and others. So clonidine and guanfacine are both alpha-2 agonists. So they work on a subset of the norepinephrine system. They're both originally antihypertensive for lowering blood pressure. And it was actually studies first in clonidine that suggested this could be helpful with people with ADHD.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And I think it was just a serendipitous initial discovery. It wasn't seeking out its mode of action to see if that really worked. One difference between the two of them is clonidine jumps off the norepinephrine alpha-2 receptor really quickly. And for people who skip a dose with their blood pressure medication or stop abruptly, it's not uncommon to have rebound hypertension.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And not to smile, but way higher than what you're being originally treated for to dangerous levels. guanfacine leaves the receptors more slowly and there have been formal studies trying to see if this is a problem or issue there.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And particularly given that people with ADHD forget their medication or run out and don't fill it in time or just don't remember to take it, the rebound hypertension does not seem to be nearly as common with guanfacine and that's part of why the research has moved more towards the guanfacine. So there's extensive work by, I'm going to blank on her, Amy Arden, she's at Yale. Oh, Arnston.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Arnston, thank you. And her lab and related labs have shown that quamphicine's effects seem to deal with strengthening synaptic connections in prefrontal circuitry. So unlike most of our drugs that are just boosting norepinephrine and or quamphicine, dopamine and work quickly. And I'll throw in this because we didn't really touch this.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Most of the ADHD experts still say stimulants, amphetamine, Ritalin work quickly immediately because they boost dopamine right away. And our drugs like Stratera, which is atomoxetine or Cymbalta or Welbutrin, work slowly for ADHD because they're antidepressants and antidepressants work slowly. There's still people saying this.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And for 25 years, I've been saying this is just wrong from, one, a basic neuroscience point of view and wrong from don't you ever talk or listen to patients. So neuroscience view. How quickly does dopamine reuptake get blocked by Welbutrin or by Adamoxetine, Stratera, or by Cymbalta? Within minutes to hours of taking it.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So you would expect, if you're boosting norepinephrine or dopamine availability right away, you should see effects right away. And if you ask patients who these drugs work for, and they don't work for anybody, all the ones I've worked with say, It worked just like the stint. I could tell. I took it and I walked out of your office. One guy I have who loves Cymbalta...
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
said, I took it in your office, and I wasn't sure it was working, and I got downtown to work 15, 20, maybe a half hour later, and there was this guy coming at me on a skateboard on the sidewalk. And I know in my normal ADD state, I would have just been flooded and not be able to process, and I could just step out of the way. So it worked that quickly and dramatically. So that's the aside.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So jumping back, guanfacine seems to work slowly. So the synaptic strengthening building, and it seems to be the alpha-2 receptors that are on neurons that receive glutamate as their primary input. The alpha-2 receptor is modulating how glutamate is actually working, and it's actually the the NMDA glutamate receptors, not the more common in the brain AMPA glutamate receptors.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Yeah, so most often it takes two, three, four weeks. And because of it, I mean, with the stimulants, you see effects right away. It's reinforcing, and stimulants often... in addition to having effects on concentration, attention, other, you know, do boost energy for most people, do boost mood for most people. And can improve sleep, if they're not taken too close to sleep, yeah.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Guanfacine's most common side effect tends to be sedating. So most people take it at nighttime, which is like, why are you taking a sedating nighttime medication for your ADHD? It's because it helps, it works slowly, indirectly.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So Intuniv, the brand name extended release guanfacine, was approved in kids, because again, most of the research on ADHD is still in kids, for treating ADHD as a solo agent. It clearly works in adults as well. And even before Intuniv was approved, there were a handful of studies with either immediate-release guanfacine or extended-release guanfacine.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
In the studies so far, the results aren't distinguishable. They both seem to work. So clinically, because it's much cheaper, I actually use... immediately release form, and all at bedtime. And again, because my impression, and I probably don't have an end that's big enough to do a rigorous study, is the sedating effects are relegated to the nighttime and people are feeling okay during the daytime.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I mean, some of the rationale with the extended release is you're sort of smearing it over a longer time, so it should be less sedating. But depending on the time curve and how it works, you could actually wind up with being more uniformly sedated day and night with the extended release. So I've seen good results in some people.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I've had many who either didn't work or they didn't perceive a result because, again, some part for some people of the stimulant benefit is... I can feel it. I know it's working.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So the majority, at least in terms of prescription searches and what clinics tend to be, it looks like most people who are on guanofacine are on it in combination with either a stimulant or a norepinephrine or dopamine-promoting agent.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So we're going to jump back to your issue with the recency in science and how to incorporate things. When some Modafinil was a drug developed by a French company and approved there and used for decades, for maybe a decade before it came to the U.S. 25, maybe 35 years ago. And at the time, all the research showed that it was an orexin receptor that antagonist. Antagonist, agonist.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Works on the orexin system. The hypocretin orexin system, right. So boosting activity, but not working like all of our stimulant alerting drugs, which are working on primarily norepinephrine systems. So it was called the non-stimulant stimulant. Now most of the
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Pharmacology literature refers to it as a dopamine-acting drug, and some people are debating whether it's orexin that it's working via or dopamine. I haven't seen anything that to me gives a clear consensus. So I stick with the orexin because that's where I was taught.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So orexin, getting back to the sleep-wake and the brain and arousal, as I described it, there's two ways to wake up in the morning. One way is the normal way that you just wake up and the other is being alarmed by an alarm clock, your neighbor starting their lawnmower, someone snoring, an earthquake if you're in LA or Hawaii, being startled out of sleep.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
That wakefulness system is a sympathetic nervous system. The erection system is a more natural, normal waking system and it isn't arousing you, isn't, It's waking you, but it's not agitating you. Again, the claims originally was that this is how Modafinil worked. It was waking you up, but not overstimulating overrevenue.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So other than being developed by this French company, the entity that spent most research funds looking into what this does or doesn't do was the U.S. military. Because they have a big investment in wanting people to be alert and ready to kill 24-7, but not being hyperactive, trigger-happy jittery like stimulants can do.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And particularly in the early days, this is really dating me of the Afghan war, we dropped bombs on Canadian troops by accident, friendly fire scenario things. And the investigation, the pilot and the crew there blamed their trigger happiness on being revved up by methylphenidate. So for years, the military has relied on traditional stimulants to keep people able to fight around the clock.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And they wanted an agent that would keep you alert, awake, but not revved up, not agitated. And I'd say there's some good evidence that that's really sort of how modafinil works or performs. So modafinil is called provigil for provigilance. And then when they were losing their U.S. patent,
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Like many drugs, the Provigil is a racemic mixture of left-handed and right-handed versions of the same modafinil molecule. They found that the R-modafinil, the right-handed version, was the one that's doing most of the good stuff and has a longer half-life than the combined version. So they got a new patent for R-modafinil, which is NuVigil. So that's the only difference between the two.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
They're the same active ingredients as far as we can tell. And when it got approval in the U.S., it was approved for narcolepsy, where people are falling abruptly asleep during the day, so it keeps them alert and awake there. It also got approval for circadian sleep shift work disorder, where because you're on a shift schedule, you're sleeping weirdly.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And it got approval for daytime sleepiness from sleep apnea. But even at that time when it was approved, there were dozens of studies that showed, regardless of why you're sleepy, whether it was sedating medication, whether you had lupus or MS, whether you had some other condition, it works pretty well for keeping people alert and awake.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So more than keeping alert and awake, there does seem to be evidence that it helps with some of the executive functions of attention, concentration. My clinical experience with it, it tends to be, again, with the amphetamine on top, Many fewer people describe it as being helpful or as helpful.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
On the other hand, there's one study, and I'm forgetting the principal investigators, it was at Brown University, where they used some very clever, sophisticated approach to try to sort out motivation versus pure cognitive functioning. And their claim, and it was a very well done study, they were comparing it directly to an amphetamine product. Their claim
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
was that modafinil was the one that was actually boosting cognitive functions and not just boosting motivation, whereas that most of... amphetamines benefit for ADHD. When we say it helps me concentrate, it helps me sustain focus, it makes me less distracted, their feeling, their analysis was that stimulant was mostly working on motivation.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
It's a controlled substance, but not nearly, not the same schedule as amphetamine and Ritalin. So it's easier for some prescribers to prescribe.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Even though it's the non-stimulant stimulant, and I'd say most people do experience, you know, I feel more alert or awake or better, but I don't feel revved up, about 10% to 15% of people that I've worked with and others have written about it, so I don't think it's unique, will feel revved up when they take it the first few times.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And invariably, the people I've worked with have said, this feels like bad speed, including people who haven't too, who never even took speed. So I don't know why they came up. I mean, it's just weird that people come up with the same terms. But it's, I mean, my interpretation is that for some people,
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
this novel substance primarily maybe attacking into the orexin system is serving as a signal, kind of like a panic attack does, that there's something weird, something different, we're being revved up, and that it's, I think, secondarily triggering the sympathetic system. Because for most of those people, within a few trials, within a few days, they no longer had that over-revved effect.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And again, the important piece for... Alerting people to that is if they're expecting taking this, I'm not going to feel over-aroused and over-agitated. And they do, then they're even less prepared and more freaked out.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I mean, it is a – controlled substance because some people are worried about the potential. And there was a woman Olympic athlete 20, 15 years ago who was and said she had narcolepsy. I don't know, but was disqualified from the Olympics because of it. Whether it has any real performance-enhancing effects is not clear.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
You know, it was available in France for a decade, at least, before it came to the U.S., and they didn't see any rates of substance abuse or problems. I mean, it clearly does not have the—on any tests or animal studies— the propensity that the amphetamines do. And I'd say it's to me not to conclude its subject, whether there's any potential for addiction with it.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Maybe I'll start with that. So for decades, particularly starting with kids, the dogma has been taking breaks from stimulants is a good idea because it will decrease the likelihood of developing addictions, it will decrease tolerance, and... Not a lot of rigorous research, but one of the known side effects of stimulants for kids is growth suppression.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So height winds up being about two centimeters, not big, but measurably and consistently found there for kids who are routinely on the stimulants for their growth years. And taking breaks that last for several months, like taking it off during the summer, result in overcoming that decrement in height.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I looked, and I still haven't, whether there's any lower rate of addiction, whether there's any lower rate of developing tolerance. There's nothing that shows clinically. I mean, it may be true. The other recommendation when I started out was, and this was before the internet, before constant plugged into everything, and before kids had...
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
soccer practice and violin lessons and 400 activities is that kids should take it during the work days and not take it during the weekends and not take it during the summers. And now, and for many years, we've lived in a world where little Johnny has soccer practice and ballet and piano and has 42 things to get to where he's supposed to be performing and focused and behaving.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So the sort of excuse you could have downtime has diminished in many communities. And again, whether there's actual benefits to that or not, other than for the height decrement, which again, there is evidence that taking long breaks, but probably not short breaks, mitigates that. I haven't seen any evidence clearly showing a benefit. That doesn't mean it's not there.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Nobody has really studied it rigorously. Sort of related to that, you asked the question about short-acting versus long-acting, and there's differences in the realm of what's clinically helpful or useful, and then there's the issue of risks or side effects. So again, one of the claims is that
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Part of what makes a drug more addictive is not just the level it reaches, but how quickly it's going in and out, and that the short-acting drugs may predispose someone to higher rates of addiction.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
at least occasionally, some people arguing on the other side, that saturating the receptors for longer periods of time with high doses, with a long extended release version, that may actually be more of a risk. But I'd say there's more concern, I think, in the basic science community from the immediate release.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And there's a tiny bit of data, but part of it overall is that we talked earlier about global rates of addiction to any substance. That we have fairly good data on because the CDC tracks it. But in terms of very specifically, who gets addicted to Adderall? Who gets addicted to Ritalin?
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
There's so little data and most people just sort the same numbers that, oh, maybe 2% to 3% of kids run into trouble and it's not common and that's it. Or they study a much broader question, and that's the issue of misuse combined with abuse.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And misuse, by the research definitions, means anyone who didn't use their drug exactly as prescribed, which means if you're taking a short-acting Ritalin and it says take it one every six hours apart during the day, and you acknowledge taking it on one day, eight hours difference, you're classified as a misuser by those studies.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I mean, I'm being maybe a little ridiculous because most of the exceptions aren't that narrow. But there's a big blurring in the research, particularly coming from the people who are worried about addiction. I mean, we should be worried about addiction, but we shouldn't be overreacting or creating, pretending it's a problem among those where that, I would say, is not addiction. That's not abuse.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
That's not using it as directed. But people with ADHD, by their very nature, are not going to use things as directed, either because they forgot or weren't organized enough to get it on time, or forgot what you said in the office, even though you wrote it down because they lost a sheet of paper it's written down on. So getting back to patient's experience of it.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
So the advantages of the immediate release is they tend to work quickly. You can feel it going in. It's easily most people, there's a lot of individual variability, but let's say in the six to eight hour range, we'll get benefit. Some shorter, some immediate release lasts all day. But you know when it's on, you know when it's off.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
If you forget to take your medicines in the morning, but you know you have a presentation at three that afternoon, you could take it and still be able to sleep that night. So it allows more flexibility, it allows more pinpointing of optimizing it for points the day you want to be using it.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Some people philosophically say that in itself is wrong or bad, that you should be absolutely steady and constant because what we're trying to do is be consistent and reproducible. And others would say we're trying to treat individuals who have different demands on them and have different patterns during their day. So there are different philosophies about what's better or worse.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
One of the big downsides of the immediate release though is not only does it go in quickly, it tends to go off quickly. And most people, not all, but most experience some withdrawal as it's going off. And although when we're using this for ADHD, we focus on the cognitive executive function benefits, the focus, the attention, the concentration, and people can experience that.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Many people who weren't even aware of it increasing their energy feel my energy is crashing as I go off of it. Or many people who weren't aware that it was actually elevating mood to any extent feel, oh my God, I'm crashing and I'm crying and cranky and miserable now. And with the extended release versions, most of them go in more gradually so it can be harder to detect.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
They last a longer period of the day. And most of them go out much more gradually at the end of the day. The one I like the most for a long-acting amphetamine product is Vyvanse. And Vyvanse was designed as a slow-release product. It was designed specifically to be unattractive to drug abusers. So Vyvanse chemically links the dexramphetamine molecule to lysine, one of the amino acids.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
It's a basic component of proteins and 20 essential amino acids. And if you snort it or inject it, you have an inactive prodrug. You have the list dexamphetamine. Your red blood cells actually have an enzyme that cleaves the lysine and leaves you with free active dextroamphetamine. And that's the slow release mechanism is how quickly your red blood cells can do it.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And they have limited capacity to do that. So although they designed it... to be a anti-drug abuse drug, it actually turns out to be one of the sort of most consistently evenly entering the body. For some people it goes in so slowly that they say, I don't feel it. And also towards the end of the day one of the best in terms of not falling off abruptly.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
The potential downside is again that the capacity of the red blood cells is limited so at some point For most people, because that's a rate-limiting step, when you're adding more and more, you're actually extending the duration of time more than you're getting a bigger peak because your red blood cells just aren't cleaving it fast enough to make more dextroamphetamine available.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Almost invariably when I'll ask, you know, how did this compare to your Adderall XR or to a Hansi, they'll say smooth. Smooth. They're getting it.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Good question. So I'd say there's two different angles. And I think, I mean, the one that's easier to objectively measure is putting people in a lab and there's a simple test, a time perception test, and you interrupt them after a certain period. I mean, say you're going to be estimating how long you're left without interruption. And People with ADHD, they're inconsistently inconsistent.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Consistently inconsistent. So it's not that they perpetually underestimate or overestimate, but they are estimating incorrectly much more often than people without ADHD. So there's something at a basic time processing level that's aberrant there.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
But there's also getting, you know, the real world aspect of not paying attention to cues or not noticing other people left the room or not being distracted, which compounds the situation. And I mean, it's also interesting to the extent to which many people aren't. So I often ask, even though it's not one of the 18 symptoms, are you chronically late?
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And particularly people who show up late to my office time after time. So one of my favorite quotes is, this person who the session before we had been talking that her boss was giving her threatening notices because she had come in two hours late one day and she had all sorts of good excuses of why she couldn't get out the door. And we were talking, you know, are you regularly late? No, no, no.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
And I said, well, why was the boss so upset? And then I asked, well, when is the expectation? This was pre-COVID, pre-working. When is the expectation you're there? When do you usually show up? Oh, well, office starts at 9, and I'm usually there by 9.15, 9.20. That's not late. In her mind, it wasn't late. So when you ask a question, are you routinely late?
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
You're going to get meaningless information on your little checklist unless you know what that means to the individual. So the second part of the question, I'm sure it's been done and I don't have the answer, whether stimulants or other drugs measurably improve time perception in that you know, laboratory situation of just, can you estimate how much time has elapsed?
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I should know that, but I don't have that on top of my... And the more global question of how central that's sort of the time aspect of organization of thoughts and attention is to the content of disorganization. I mean, there are some research groups, I think it's mainly a Danish group,
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
who's feeling that ADHD is primarily a circadian rhythm disruption, that that's the central neurologic issue at play. And there's interesting, I got to do work in the early 80s on bright light therapy for winter depression, which has a measurable impact as strong as medication, but there is one or two studies done on individuals with ADHD
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
without any seasonal depression, without any depression at all, and just those same bright lights, showing them a dose of bright lights early in the morning, measurably improved a broad range of ADHD symptoms And the claim was that that was working because it was helping resynchronize internal rhythms, which are out of sync in ADHD.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Whether that's exactly the same thing you were getting at, but certainly if you have, I mean, even though we have a sort of master clock in the suprachiasmatic nucleus, we also have clocks throughout our body and they're talking and interacting and ostensibly synchronized and working with each other. But it could well be that for many people they're not, and that getting that to work is essential.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
I'm going to step back and answer. I'll get to your answer, but I'm going to frame it two different ways first. One is, and I didn't come up with this, but I think it's one of the most insightful quips about ADHD, is that non-ADHD brains are importance-driven. If you know you have to move your car because you'll get a parking ticket, you go out and move it.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
If you know taxes need to be paid in April, it's a boring, thankless job. Nobody... Maybe a few people enjoy it, but most of us aren't. CPAs are. You take care of it. The ADHD brain, in contrast, is an interest-driven brain. So they know, yeah, yeah, yeah, I should be doing my taxes, but hey, look at how the Warriors are doing in their basketball playoff game. Look at... this cool cat video.
Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Oh, I'd rather do something else. So regarding career or work, I think the most important thing is that it's interesting to you. So we can talk about realms of work or certain career paths, but if it's not compelling to you, if it's not interesting to you, it's going to be hard to work at it, even if it's structurally maybe a better support.