Meds: The New Frontier…? (This One Is Loooong. Also: Explicit Lyrics Warning, Because Apparently I Haz A Feelz)
Yesterday, after an entire adventure that should’ve had its own laugh track, I finally picked up my new (generic) Adderall* prescription. As I said to WeDoBallet, it sometimes seems like they specifically design the ADHD-Rx pickup process to be as difficult as possible for people with ADHD!
Yeah, my imagination is a weird place to live.
Getting back on meds for ADHD has been a tough decision for me — less because I wanted to prove I Can Do It My Own Self! (seriously, I really kind of hit rock bottom with that once I started dancing again; more on that in a sec) than because I’m an old-fashioned Yankee, and we’re all about Independence and Self-Reliance (and also about frugally recycling our neighbors’ discarded Windsor chairs) and it’s just a knee-jerk habit. It persists long after we realize it’s not rational.
Also a little bit because there’s a risk of ADHD meds (which are stimulants) kicking off manic episodes and because I have a history of anorexia and I wasn’t sure I trusted myself (more on those in a sec, too). And also, also because I’m just plain paranoid about meds. I’ve had bad, bad experiences with side effects, you guys.
WRT mania: I have a really good doctor, Dr. B: I feel like I can talk to her, she “gets” me, etc. She’s been Denis’ doc for years, and I’ve been seeing her since 201…3? I think? Anyway, for a while.
I started seeing Dr. B during my most recent IM’MA GO TO MED SCHOOL AND SAVE DA WORLD! phase, and she knows that I know what I’m about (and also knows when I don’t know what I’m about but think I do), so we have a really good working relationship.
She also knows that I know how to do research and have access to scads of peer-reviewed research resources through school**, so she expects me to come in well-briefed on everything and acts accordingly. She also doesn’t freak out when I, say, stop taking a daily allergy medication and switch to only taking it on the days I need it the most: in short, she trusts me to generally make pretty good decisions, and knows Denis will steer me right if I don’t.
Likewise, Dr. B hasn’t steered me wrong yet in terms of medication options. So, basically, I trust her to make sound calls when prescribing. She’s starting me off at an Adderall dose that’s on the lower end of the middle of the dosage spectrum. I’m cool with that.
Which brings me to the bit about mania: stimulants can tip off manic episodes in people with bipolar disorder.
Look, a header!
The whole stimulants-kicking-off-manic-episodes thing has certainly happened to me, though normally it happens as a result of a sort of insomnia cascade effect, which goes like this:
- I decide to chug a little coffee or Coke Zero to help me focus on something (or just because I’m out for dinner; I’m dumb like that)
- The focusing effect wears off too quickly so I chug a little more.
- Later I can’t sleep because my brain won’t STFU, but I still have to get up in the morning, so I wind up sleeping for 2 or 4 hours or whatever.
- The next day I have to function (seriously, if you think I’m distractible and impulsive on a normal day, you should see me when I’m sleep-deprived! … so I suck down more caffeine.
- Then I can’t sleep again.
- The next day, EVEN MOAR CAFFEINE!!!
…and then BOOM! I’m in ManicLand, because (for me) lack of sleep is like an express train to Electric City.
So I was worried about that, but it Dr. B prescribed the short-acting version of Adderall, which should help reduce the likelihood of sleep disturbances.
For what it’s worth, this might be an upside of the whole Insurance Disaster related to acquiring my meds.
Here’s how that went down:
First, Dr. B prescribed Concerta, a long-acting methylphenidate formulation.
For whatever reason, my insurance plan only covers short-acting methylphenidate. You have to take it, like, four times a day.
Dr. B and I agreed that four pills per day is probably more than I can remember to take (and definitely more than I want to carry around with me). Likewise, a longer-acting agent is less likely to wear off just when I need it.
I hunted through Humana’s formulary to see what was covered, and it turns out that Adderall is, and that the generic form — while shorter-acting — is only $20/month (the longer-acting form is still under patent, and thus would run me $200/month for the first three months).
Dr. B felt that this would be a reasonable choice, and we swapped out the prescriptions (further hilarity ensued as I learned that my local CVS pharmacy doesn’t keep my prescription in stock, though — thankfully — the one near ballet class does).
At this juncture, I’m thinking that the short-acting version might actually be a better fit for me: I’ll still only have to take it twice per day, and I suspect it will be less likely to lead to insomnia … which, in turn, will reduce the likelihood of going Full Manic Jacket or what have you.
Likewise, while it’s called “instant release,” the effective half-life is much longer than that of caffeine — so I won’t be constantly topping-up over the course of the day (though I will either have to get used to drinking plain water at restaurants that don’t have seltzer/soda water/club soda — I like plain, still water fine, but not so much with food). In short, I will be adding a lot less stimulants to my system and doing so in a way that will be more even-handed and consistent, which should help ward off the danger of the manic spiral.
Obviously, careful symptom-monitoring is still called for, especially since I really can’t take most of the mood stabilizers currently on the market (that’s a post for another time). I’m willing to try one of the newer ones if push comes to shove, but given my history of serious side-effects, I’m really hoping it won’t. Fortunately, Denis is an exceptional spouse — very able to help me monitor my moods, and both willing and able to notify me when I’m heading for a derailment.
So, in short, with good monitoring and some help from Denis, I’m actually pretty optimistic about avoiding Adderall-induced mania.
I am, however, a touch more worried about (oh, look, another header!)…
I don’t talk about my history with anorexia all that often. There are any number of reasons for that: it’s sort of a Forbidden Topic for dancers; it’s an ongoing struggle that I’m not sure will ever end; sometimes it’s just One More Thing***. I mention it in passing from time to time, usually when I’m touching on points about what it’s like to have lived all over the BMI spectrum. But I rarely discuss it depth.
I guess the other thing about anorexia is that it doesn’t stay contained. It touches every single corner of my life, and sometimes that frankly pisses me off.
And, then, there’s the fact that I’ve had good treatment and I largely have the behavioral end of things basically under control (I don’t starve myself anymore, generally speaking, though I do still do some of the other behavioral things that are associated with anorexia. It’s been a long time since my BMI was <18.
None of this means that the thought process is gone. It just means that I have tools to fight it.
Ballet, curiously enough, is one of those tools — and yet, at the same time, it’s a complicating factor.
On one hand, you can starve yourself and dance — but not for very long, and especially not as a male dancer who is expected to command explosive jumps and sooner or later pick up other dancers and haul them around and stuff. You can only perform so long before your body just says, “Fuck you, no.”
On the other hand, as a dancer, you spend a lot of time looking at yourself in mirrors, and a lot of time looking at other dancers. Even if you don’t already have serious body-image problems, you’re going to wind up thinking about your body, comparing it other bodies, and so forth. If you do have serious body-image problems, chances are good that sometimes that’s going to exacerbate them.
I’m walking a fine line, right now, between performance and obsession. In short, my leg muscles are pretty hypertrophic, so extra fat on my legs can interfere; likewise, while my legs are very capable of adapting to the load required of them, weighing less makes their job easier — it’s easier to launch 160 pounds than it was to launch 174, which means higher, cleaner jumps****.
The thoughts that could lead to excessive restriction are still there. Fortunately, dancing is hungry work; so is cycling. I’ve pretty much managed to stay on top of maintaining a balance, but there’s a part of me that wants to obsess, that wants to restrict.
There’s a voice in my brain that argues against the rational, sane one that tells me to eat enough to sustain my strength and so forth; that voice still tells me I’m weak and undisciplined when I don’t do all the behavioral stuff I used to do when I was surviving on 600 calories a day (which was my target for several months when I was 19) and you could count every rib and vertebra in my body.
Here’s the thing: stimulants are appetite-killers, and I’m a tad concerned that it’s going to be too easy to take advantage of that. Like, “Oh, I’m not hungry, I don’t really have to eat.”
Denis doesn’t think I’ll fall prey to that: he trusts me to be rational about it and remain cognizant of the fact that ballet requires fuel.
I hope he’s right.
I think the problem is subtler than that, because I know myself pretty well. In the past, my pursuits always required fuel: but I would do this thing where I would figure up what the daily caloric requirements were, then shave it back a little, then (when, inevitably, my body didn’t immediately implode) I’d shave it back a little more, and so forth. It was an insidious process.
I realize that by saying all this I’m kind of building a framework for letting myself off the hook if this does go down: but I’m also making an effort to be frank about this and sort of keep it in front of my own face.
Like, I’m saying, “I know this is a Thing. I know I need to pay attention to it.”
And, honestly, I’ve figured out at this point that between dancing, school, my household responsibilities, and work, I really, really do need help. My coping mechanisms are awesome, but they only let me handle a very limited amount of responsibility at a time — and that’s kind of how I got here.
(Look, one more header!)
About Hitting The Bottom
I’m gonna go ahead and admit it: I’ve trotted out my ADHD high horse once or twice in the past (though not in a long time).
I struggled unsuccessfully through most of my primary and secondary education, then I figured out how to be a good student in the last two years of high school. (I’ve written a bit about this before.)
Somehow, I thought that meant I had ADHD licked: like, I had it all figured out.
Never mind that once I left home, unless I was living alone in an environment I could completely control, my house was always in chaos. Never mind that I had terrible trouble making appointments and dealing with the vagaries of Grown-Up Life. Never mind that I couldn’t handle having more than three or four bills. Never mind that planning things like shopping and budgets was, like, completely beyond me, or that I would completely lose all the important stuff I needed to keep track of (wallet, keys, phone) if I didn’t set it down in Exactly. The. Same. Place. every time I came home.
I was able to remain in denial pretty well because I did fine when I lived alone and lived very simply — but that’s the thing. When I lived alone, I could choose to live as simply as I wanted — so I had almost no furniture, minimal clothing, minimal dishes, and so forth. I had only one income stream.
I even kept the bills to a minimum — I had one credit card for things that might require such a thing, and other than that it was just rent (which, happily, included water), gas/electric, a pre-paid phone, and cable internet (but not cable TV). My ideal apartment would’ve included all utilities in the rent, just to make things even simpler. I used cash for most purchases, so I was able to track my finances in my head: I just kept a running total, subtracting as needed, and checked my balance online once a day to make sure I was on track.
Grocery shopping for myself was easy: I know what I like, and I don’t mind eating the same thing day after day. $50 was more than enough to feed me very well for a week, and (unless I felt like going on a shopping adventure) I could do my marketing on the way home from work.
Once a week, I’d treat myself to a dinner out, and going home was always nice because my apartment was always impeccable. When you live alone, you don’t watch TV, and you don’t have a lot of furniture to navigate around, it’s actually pretty fun to sweep and mop and so forth. I didn’t have any carpet or a lawn to worry about. I did have a nice, deep bath tub and my own water heater so I could read in the bath all I wanted.
All of that made it possible for me to manage. It was actually a really nice way to live, and it’s totally how I’d choose to live now if the choice was mine alone — but living with other people, even one other much-adored person, really complicates things unless that person is willing to live the same way.
Predictably, as someone who needs to live an incredibly minimalist lifestyle in order to maintain, well, order, I married a self-professed slob with mild hoarding tendencies and complicated finances (as a self-employed healthcare professional, he has a zillion income streams; you guys, that turns budgeting into a straight-up nightmare). Said self-professed slob had also already been living in the same house for twenty years, so he’d had time to accrue lots of stuff.
Suddenly, there were tchotchkes, nicknacks, and bills (oh, my!). Turns out I hate tchotchkes, and I really hate having to move them to clean around them. But it would take me a while to figure that out.
In my naievete, I offered to take over managing the finances, because Denis hated doing it. I also naively assumed that because I’d been great at managing my apartment by myself, I’d be great at managing the housekeeping around here.
It turns out that clutter fills me with nerve-shattering despair. It also turns out that I find it distracting as hell. It turns out that people with ADHD have trouble tidying up after self-professed slobs. It turns out that I have trouble putting stuff away when I have to move other stuff to do so, partly because WTF, but also partly because that involves more working-memory resources than I normally have for that kind of thing.
In short, it turns out that I’m, like, horrible at everything I signed up for.
And then I added school.
There was chaos. The bills got paid on time, the finances got reconciled (eventually), and the house stayed … well, sanitary, more or less, and would get de-cluttered a couple times each semester.
And then I added ballet.
And then I stepped up the ballet schedule.
And then everything went to hell in a hack (though I was much, much happier than I’d been for a while, because, hello, ballet!).
Then I realized I wasn’t managing anymore. Not even close.
I’ve been making noises for a while about needing meds for ADHD before — there’ve been a number of times that I felt like I was hanging on by the skin of my teeth.
Last semester, I managed to totally screw up the paying-the-bills, tracking-the-finances, keeping-the-house-livable part of my job.
I also accrued the first non-A grade I’ve taken in my post-secondary education: a B- in precalc. I could have done much better, but I had a hard time focusing, getting the homework started when I should have, getting in enough practice, and keeping my head together on exams. It was like grade school all over again (I didn’t wind up with a D because at least I have coping mechanisms now).
I did, at least, succeed in pulling down an A+ in senior seminar, which is kind of a big deal — and at the time I sort of took that as evidence that maybe, somehow, I could still arrange my waterfowls in a linear array under my own power.
You guys, I tried hard. I really did. Sometimes you try all you can, and you still find out that you just can’t. Sometimes the best coping mechanism in the world, applied with discipline and diligence, only gets you so far.
Enter the meds.
Medication isn’t going to make my ADHD magically go away. Nor will it solve all my problems by itself. I still need my coping mechanisms. Medication isn’t magic.
It is, however, a tool. It’s like having a little electric assist for your bike if you have some kind of condition that means your legs can’t build strength very well: you want to be able to ride with your friends, so your electric-assist bike lets that happen. It doesn’t ride the bike for you. You still have to pedal; you still have to steer; you still have to think about what you’re doing. It just lets you keep up with your friends.
I am hoping the meds will help me handle all the stuff I’ve got on my plate right now.
Having taken my first dose this morning, I do feel like my mind feels more settled; more able to focus on the task at hand. I don’t feel like all of the WARNING! klaxons are constantly going off because of the clutter around me (which will really help when I get to work de-cluttering). I feel more able to, you know, keep a thought in my head (working memory is a huge, huge problem for me).
Edit: I’m also much, much more able to sit still. I learned last Friday that the uncomfortable, dysphoric feeling I get when I have to sit down for more than ten minutes a time is, in fact, a symptom of ADHD. I knew I was way out there on the hyperactivity scale, don’t get me wrong, but I always assumed everyone experienced that sensation.
Task-switching is easier (also a huge, huge problem for me): Denis came home to take care of a fashion emergency; a tech from the utility company came over to re-light all our pilot lights after doing some work that required them to shut off the gas to the neighborhood; I got up to do some laundry — I was able to do all of these things without enormous difficulties in returning to the main task I’m doing right now (which is writing this post).
These might seem like minor things, but the time I lose switching tasks adds up enormously over the course of any given day (especially since I sometimes lose the narrative thread entirely while doing so).
So, basically, my “mixed amphetamine salts” aren’t going to magically make everything okay for me. The house is still in chaos; the finances are still a mess. (Amazingly, when I took my first dose this morning, Disney Spirits did not appear and fix all that for me! THE MOVIES LIE, YOU GUYS.)
The difference is, I feel like the meds might actually help me both get caught up — which is literally impossible for me, otherwise: that was the first lesson I learned about how to be a student with ADHD — never get behind. EVER. They should also help me keep on top of things once I’m caught up, even though there’s a lot going on in my life right now, and even though there’s going to be even more going on in the near future (ballet! work! grad school!).
Speaking of which: this post is now officially long enough.
In future posts, I intend to write about:
- Treatment decisions (why we’re treating ADHD as the primary disorder, rather than bipolar, even though bipolar is arguably the more dangerous of the two)
- Mechanisms of action
- Anorexia (because I suppose eventually I do need to get around to that)
- How my ADHD meds impact ballet
…and similar related stuff.
I’ll also keep you posted on how the meds are working — in other words, not mechanism of action (literally how the meds work), but what kind of differences they’re making in my life, both the good and the bad (because it’s unrealistic to expect a medication to be perfect).
That’s it for now.
Today’s to-do list (I guess I’ll strike these off as I complete them; I’ve also added a few that I forgot before):
Entomology homework. Clean catbox. Take out trash. Fold ballet laundry. Wash andfold other ballet laundry. Invite Eric and Larry to Commencement. Create a resource to use for SI tomorrow.
- Reconcile the November bank statement (yeah, I told you it was bad).
Start sorting the dining room. Make dinner.
- Work on choreography.
- Watch that one Sergei Polunin video 6,000 more times. Oh wait, did I say that out loud?
…Not necessarily in that order.
Posted on 2015/03/03, in adhd, balllet, life, life management and tagged adderall ir, ADHD, ballet, medication. Bookmark the permalink. 12 Comments.
You mean this PAST November though, right? haha
Yes! AT least it’s not, like, November 2013. Or 2012. That would be … eeeeee.
Apart from switching, stimulant drugs are also strongly implicated in rapid cycling. In fact there’s some prominent mainstream psychiatrists who now suggest rapid cycling is only caused by stimulant drugs, particularly anti-depressants.
Yeah, I’ve fallen for that with regards to my bipolar.
I don’t think we ever get any aspect of ourselves licked. It’s like body weight and dancing. We adapt more as we stick with it longer but then something comes along to disrupt the balance we’ve been carefully maintaining and the old problem returns, sometimes in a different form.
Meds are tools and ones I’ve used to great effect in the past (usually illegal ones). But where I’ve come unstuck bigtime is when I’ve tried to use them in an ongoing way to improve my whole life rather than sparingly to deal with particular short term circumstances.
The human mind/body is pretty big on homeostasis. Anything that changes the way it functions kicks in systems that try to push it back to where it was. Eventually you end up taking drugs not to improve your performance but just to maintain the situation you were in before you started the drugs. Then you’ve got the choice of escalating the dose – along with the damage – or putting yourself through nasty withdrawals so the drug will become effective again.
Cabro, you touch on the two things I am worried about here. I’m hoping careful management will help to avoid the development of tolerance, and thus of dosage-spirals and so forth, but the rapid-cycling thing is more complicated. By the textbook definition (>4 cycles/year) I’m a rapid cycler, and I’m not sure of the role of stimulants in that tendency. I avoided stimulants almost entirely for a couple years at one point, but I didn’t keep good mood records, so I can’t really make a sound comparison. It’s possible that I didn’t rapid-cycle during that period.
I’m hoping the slower, steadier release rate of the Adderall will be less likely than that of caffeine (which, admittedly, I tend to overuse) to induce mania. We’ll see, though. I am kind of lacking in insight sometimes.
I love your comparison of meds to an electric assist bike – that’s pretty brilliant. That gives me another tool for explaining on those occasions I’m willing to do so. Thanks for that. 🙂
Thanks! I love analogies for explaining this like this. They really seem to help people “get it.”
Thank you for sharing this! Best of luck on this journey (cause it totally is one).
Do pay attention to the appetite thing, especially with your history. I find I rely on a scheduled lunch because without a plan I could go all day without a bite… You also may find that you BURN calories differently. I have accidentally lost weight and had to gain it back on purpose… which is a hard thing for my particular psyche, rational or not.
Here’s a little early-med anecdote for you: When BoyMowgli first started taking medication (he was much younger than I’d generally support but it was right for him) we got up to the first dose that actually worked and he said “It just quiets my body and my mind so I can make choices!” JACKPOT! That was AdderallIR actually, but we’re both on Concerta now.
Ha, funny! BoyMowgli’s description of the effect is almost word-for-word what I said to Denis yesterday. I hadn’t realized how much of the problem was simply not being able to make decisions (also didn’t realize how high I scored on the impulsiveness scale until I filled out the little sympotatic questionnaire).
Thank you much fit the thoughts on appetite and eating. I have definitely noticed a significant impact on my appetite — I think I’ll borrow your scheduled lunch approach! That should help keep me on the straight and narrow (and from passing out in class :P). I’ll also keep tracking my food to make sure I’m taking in enough calories and nutrients on average. I hear you about having to regain weight: definitely no fun!
Thank you again for your thoughts!
I could not even begin to handle your list even on a good day. I work, feed myself, do some school work and if I am lucky get some exercise in. There has to be at least a couple of hours of just being able to think in my own space time as well or I start to feel out of control and begin the insomniac cycle which I have had under control for the last two years. I feel good that I am able to manage my schedule with only a large cup of coffee in the morning, but I can only accomplish half of what I would like to. I know my limits finally and stay well within them. I have to because every time I try to medicate any problem there are more unwanted effects than intended effects, that cause more harm the latter help. As I read your posts I am filled with admiration and anxiety for you. You are truly running on a razor’s edge, but you also only get one life. As long as you remember what you have learned from past experience and pay attention you are doing as well as anyone I have known. I appreciate being able to read about your experience. Thanks for writing well and thoughtfully about it.
I am bipolar one, so when my doctor started me on this process of ADD meds, he started me with a non-stimulant one first. That did nothing for me so we gradually tried the stimulant ones very slowly so not to risk mania. I have not had mania since the summer of 2004 and never before. So far after two months of my stimulant med, I do not have mania. Of course, everyone’s chemistry is different, no med reacts the same for each and every person.
My doc is taking a similar approach to dosing for the same reasons. So far, things are still looking good (and the Adderall leaves me so tired when it wears off at the end of the day that I’m sleeping better than I ever imagined possible, which – if it continues – might greatly reduce one of my biggest mania triggers). OTOH, I’m just finishing my second week in the meds, so I’m tempering my optimism with a hearty dose of caution!
Excellent point about the complexity of individual chemistry! It will be interesting to see how the science of neurophysiology develops as we go forward.
Pingback: Meds: Yup, Still No Disney Spirits, But I Think I’m Okay With That | my beautiful machine / danseur ignoble