 Hi, welcome to Ask an Expert, an interview series where we chat about topics around mental health with experts ranging from those with clinical experiences to those with lived expertise. My name is Monica, and I'm a medical student with interests in psychiatry and neuroscience. I created this series, Ask an Expert, to give a platform to those who have lived expertise and also clinical experiences to really share their stories. So if you're interested in being featured in the next episode of Ask an Expert, then consider to fill out the recruitment form in the description box below. Or if you know of a friend or family member who might want to join, you could also forward them the link. I think it's a really great way to really shed light on important mental health challenges that are especially increasingly prevalent. And speaking of really prevalent experiences, I've oftentimes heard of people just say that, you know, their attention span is getting shorter and shorter with the rise of shorts and the rise of TikTok and that they're becoming quite restless or impulsive. And that leads me and a couple of potentially other people to wonder at what point does that actually become something like ADHD. And so I'm really delighted to talk about ADHD today with the wonderful Tracey Marks. Welcome, Dr. Marks. Hey, Monica. Yay, we're here together. I am so excited for this. I know lots of people from the Psych2Go community have been waiting for this to happen. So it's amazing. It's great to have you. This is amazing. Thanks for inviting me over. Thank you so much for being here. Shall we start by, would you like to share some of your experiences and the kind of things that you do? Sure. So I'm a psychiatrist and I am, I work in a private practice, my own practice in Atlanta, Georgia. And then since about 2018, I've been consistently producing mental health education content on YouTube here under my name, Dr. Tracey Marks. Amazing. So for any of you who are curious or who might not know, the channel is going to be linked in the description box below. So do check it out. There's amazing content also about also some mental health disorders, ADHD, which is what we're going to dive into today. So I thought maybe we can start by just defining what exactly is ADHD and at what point does it become more than just being distracted? Sure. So ADHD is listed actually as a neurodevelopmental disorder and the diagnostic manual, which is the book. I wish I had one here with me to show you. But it's a book that we clinicians use to establish or understand what, how to diagnose something. So you have all of these disorders and a list of criteria for someone to meet to be considered to have that disorder. So and their categorized under mood disorders, et cetera. So here neurodevelopmental disorders are disorders that predominantly start in childhood and thought to be a product of your brain development. So the reason I mentioned that is because ADHD, I actually feel very, I have a personal interest in this disorder as well as a lot of compassion for people who suffer with it. Because it's so easy for people to think that they're stupid or just misbehaved, lazy and not see it as something legitimate. And here it is. It's actually a brain development problem. It's a little, some people argue that there is an adult version of it and that's still kind of up for debate. But nonetheless, generally speaking, the symptoms developed in childhood, they may not be severe enough say for you to get treatment. But it's not, it is more than say trouble paying attention because you've got a lot of balls in the air, a whole lot of stuff going on. It really goes a lot deeper than that. So what kind of things are we thinking if we're thinking beyond just the problems focusing? OK, so there's if you can divide it kind of into two sections. One is trouble with inattention or trouble with attention. And then the second part is hyperactivity and impulsivity. So that's where you get the ADHD or attention hyperactivity deficit disorder. Some people will just shorten it and say ADD. It's the same thing. There is no separate ADD. It's just termed ADHD inattentive type if all, if your main symptoms are inattention and you don't have the hyperactivity, which is pretty common. Not everyone's hyperactive. So the inattentive symptoms can look like not trouble paying attention, but also very poor attention to detail. You can just completely miss stuff and someone's like, it's right there. You didn't see it and it's like, you didn't see it. It's almost like you're blind to it. If there's just too much information in front of you, you may only see one thing. Losing things, can't ever find your keys, always misplacing stuff. That's all part of the poor attention to detail. Then and focus. And then also with concentration as far as how it affects your concentration. You may have a lot of trouble getting motivated to do work and stick with it being easily distracted. So you sit down and do something and then you're paying attention to this other thing. So then as a result of that, you can leave a lot of things unfinished. And then the second half, the hyperactivity and pulsivity symptoms would be. Being like it'll usually this tends, you tend to see it more in children with the inability to sit in their seat. They can't blurting out stuff in class. They just cannot wait to finish for someone to finish talking before they're saying something, running around with lots of energy. Fidgetiness in an adult, it may look more like being able to just kind of not stay settled, always kind of messing around. You always got to stay busy, that kind of thing. And it's not a good busyness. Like I got a whole bunch of stuff done. It's like, I did a little bit over here, a little bit over there and the person can even I have some adult ADHD. patients who have the hyperactivity component. And it's almost like you can just feel the energy hitting you when they're talking. They're like, you know, real animated and stuff. And that's, you know, more well beyond what you would expect for someone that age. I see. So you alluded kind of to childhood versus adult ADHD. The criteria is the same, is it? But is it just the diagnosis process? It's a bit different then. Yeah. So the criteria is the same. It's just the way that it manifests can look different. So in children, you can get more of the hyperactivity running around poor impulse control, trouble getting in trouble in school, discipline, problem, that kind of thing. Whereas the adult, actually, there's been more research showing kind of attaching emotional discontrol to ADHD as well. And that tends to be a more of an adult manifestation as well of having trouble controlling your emotions. So there are some people who may be misdiagnosed as having bipolar disorder because their moods are up and down or they're very labile, very emotional when it's really actually part of their ADHD of trouble being able to contain how they express themselves emotionally. So you mentioned the process of the potential of potential misdiagnosis with bipolar. Are there any other things that are commonly kind of confused with ADHD? Yeah, so I would say so there's bipolar disorder, number one, number two, probably would be anxiety. And interestingly enough, it can get kind of complicated. So anxiety can interfere with your attention. So sometimes a person can have trouble focusing or staying at a task and it's more because their anxiety makes them too unsettled to be able to just kind of have the thoughts flow. So then they may start to question, do I have ADHD because I have trouble focusing and then a mistake that can happen then is to be put on, say, a stimulant, and I know we'll talk about treatment later, but put on a stimulant and then that just totally takes their anxiety to another level, like they're totally out of control and having more anxiety. So anxiety and ADHD can look somewhat similar, not entirely, but anxiety can certainly interfere with your ability to pay attention and focus and concentrate. So those are probably the two main ones. I've had some people ask me like in comments, well, can you do ADHD versus autism spectrum? And my thought about that is it's not really a versus because it's not as though those two things look so much the same. They're both neurodevelopmental disorders and that autism spectrum is a problem with slower development in certain parts of your brain. And a lot of people with autism spectrum can also have ADHD, but they're two separate illnesses or two separate disorders. So if someone comes in or someone suspects that they have potentially ADHD, anxiety, bipolar, you name it, what does the diagnosis process look like? So the diagnosis process process. I'm copying you. I'm talking like that process. The process, I'm going to do that, can look different depending on what you're trying to get out of it. So if you were going to see someone mostly for treatment and you're seeing either a pediatrician, so if you're under 18 more than likely the diagnosis will come from your pediatrician or if you're really advanced child psychiatrist or if you were going to see a psychiatrist for treatment, really the diagnosis is based on a clinical assessment. So, you know, we have a list of criteria, some of which I went through and you listen to the person's story. You see when their symptoms started, how it impacts their lives. Do they have other things that could be causing inattention? Let's say if their main complaint is I'm having trouble focusing and getting my work done, you know, depression can also be a reason you could have trouble focusing and getting your work done. So you're eliminating other problems, other disorders that could be causing the same symptoms. And so it's a clinical interview and, you know, in an evaluation by a clinician. If you are trying to get accommodations, like for college or school to be able to get extended time for test taking or be allowed to be put in a separate room for testing or extension on assignments. They usually, they, the schools usually require formal psychological testing. So in that case, you may go through a battery of testing from a psychologist that could take several hours and, you know, they do a write up and everything. So that kind of extensive evaluation usually is not required. If your only, only thing you're trying to get out of it is treatment. If you want accommodations, it kind of needs to be something more formal. OK, so going into more of the big package of potential extra tests that you have to do. Do some of them really include kind of electrophysiological things or what kind of things can someone expect? So I don't, I don't do the testing. So I don't know exactly. I have seen testing results and it's more. It's a lot of, I don't know about, you know, I've never seen anyone hooked up to do some electrophysiological type of assessment. It's more answering questions and the testing is set up in a way that when you answer these kind of questions, it shows it's testing this part of your brain. And when you do this type of exercise or answer this, it's showing that you're able to do this or that and this other part of your brain. So ecological testing is a whole thing. And psychologists are trained to be able to do that kind of testing. But it's answering questions. It's not being hooked up with electrodes and things. Yeah. So it would kind of be like the structured clinical, the skid, right? So if someone were to come in, they would just be skid, skidded. Is that the word? Skidded essentially? Yeah. So if you came to see me as a psychiatrist, you'd get skidded even though I don't use the skid, but you'd be asked questions and I would determine, you know, what I think your diagnosis is and maybe prescribed, maybe not. But if you went to see a psychologist, it would probably be hours of answering a whole bunch of questions, bubble sheets and maybe even doing calculations. I mean, it's it's yeah, it's a lot of questions and you're writing things down. And then is this usually done in one single session or is there kind of multiple kind of things that people can expect before getting that diagnosis? So if you're doing the psychological testing for for accommodations type thing or just to have it be official kind of thing. Usually it's several hours. It doesn't have to be more than one day. Just kind of depends on how much time you got kind of thing. But I think some people probably prefer just kind of do it all in one shot rather than have someone come back. OK, I see. So now that let's say someone has a diagnosis, what's next? What can that person expect? So from a treatment standpoint, they the main first line treatment, meaning the first thing that we go to for adults are stimulants. And those stimulants, there's two main ones. There's the the methylphenidate category of stimulants, Ritalin, Opalin, et cetera, Conserta. And then there's the amphetamine group, Adderall being the most common one, Bivance, another one. And I will say that for adults, the amphetamine products tend to work better or be more potent than the methylphenidate products. Some pediatricians may prescribe other things like clonidine, especially if it's a really young child, it may not it's supposed to going straight to the stimulants. And then there are some non stimulant medications like Stratera is one. I tend to use that as a second choice because the stimulants just work better and they work quicker. If I have someone say with a lot of anxiety or psychosis, if you have a psychotic illness, you should not take stimulants. It can take your psychosis to the next level. So when you that's usually contraindicated are not recommended if you have a psychotic illness. So that person that might get Stratera, there's a new kid on the block that's a non stimulant treatment. And I'm blanking on the name because it just came out. That's another option. And then well, I'm anti-depressant like well, butron could also be kind of a third line because it also increases dopamine, which is one of the main brain chemicals that's affected with ADHD is low levels of dopamine in certain parts of the brain that affect your attention and motivation and all of that. I see. OK. And so in terms of that decision making process of deciding which kind of drugs to get which categories you mentioned, if there are any contraindications, are there any other factors that you might want to consider when trying to decide which kind of drugs to give a person because you mentioned so many. Give me hard. Yeah. So if someone had because of stimulates, stimulate you for lack of a better way to put it, but or kind of like turn the dial up on your internal motor. If you have any kind of medical problem that would not be good if you had your dial turned up like a heart problem or something or high blood pressure, for those people, stimulants may not be a good idea. The people with anxiety stimulants may not be a good idea. Some can take them. So like medical there can be medical reasons not to take stimulants also. And some people just don't tolerate them well. If you can make they can make you lose your appetite. So there are some people they're already thin and like now they're not eating at all and like bone skinny. And I don't want to take stimulants because of that. So another downside, though, is that the stimulants are habit forming or can be misused by people. And so they're in the same DEA category or controlled substance category as opioids. And they're treated just as seriously. So you have to have official prescription and you can't get refills. You got to get a new script for everyone. And so it can be a bit of a hassle getting stimulants. If you lose your pills, your doctor may not give you anymore until the next month because of the abuse potential. And then the last thing is even abuse aside, you can develop a tolerance to them. So they stop working. You've got to go up to the next dose and then finally you max out and it's like, OK, well, what do I do now? You can't go up any higher and then you've got to start changing pills around. So it's not a perfect system. But an advantage of them, advantage of them over some like something like Stratera is they work very quickly. So you can kind of for the person who may not want to take them every single day, like, you know, I only need it on days where I have meetings or on on, you know, before test days or something, then you can just kind of pick and choose when you want to be on, so to speak. And the short acting ones tend to last about three to five hours. The long acting ones tend to last more six to eight hours, nine or ten hours. So you could say, I only want to take it on Saturdays. Another downside and I want to go too long on this issue, but I even have this experience with my son, who, you know, some people can crash to have this like crashing feeling after they take them where, you know, they they're they're on, they're going to move in with the work. And then the medicine wears off and it's like they almost feel depressed. Or I've heard people say, I feel like I can't speak when I'm on the medicine. I'm just not myself and I feel like people can tell. So for people like that, sometimes it's just a trial and error. And unlike antidepressants, where you've got to take them every day to see the effect or Stratera, you got to take it every day to see the effect. These, it's like, are like pain pills. You take it, it works for a little bit, the effect goes away and you're done. So it's easy to know. Is this a good fit for you or if it's not a good fit for you? And so that kind of makes them easy to be the first choice. Wow. OK, I've got a couple of follow up questions. So because they're so fast acting, it's not it's so different from SSRIs, right? Like whereas you have to take it and then wait, what, like six weeks? Sometimes I think that was the mean kind of time according to the Sardi trial. It just works a few hours. Is that kind of? Yeah, I mean, you could some people, you could see an effect within 15 minutes even. I mean, yeah, they're fast acting. And so, you know what what it's going to do or what it's not going to do. And some people will say, well, you know, unfortunately, some people can kind of get used to this, like, turn on effective. Like I take it and OK, now I know it's working, it kicked in. And then because these medicines can you can develop a tolerance after a while. You may not get that kicked in feeling, but you still may be working more efficiently. And that can make some people, I think, look to take too much of it because they're like waiting for that kick in thing. And I'll tell my patients, I'm like, so people who don't have ADHD don't have to kick anything in. They just like get up and start working. And so, ideally, that's what you want to experience that you take it. You may feel more focused, but you don't necessarily feel like like like an engine turned on like you would maybe if you drank a whole bunch of caffeine, you know, you can tell when it kicked in. But I went down around the hole. Would you ask me? No, yeah, I think that's that's definitely it. And is this not this is not a long term like solution, is it? So I wish I wish we had better options, actually, because of the fact that so I have some some patients, adult patients who've been taking them for years have never needed to increase their dose. And they're usually people who end up skipping doses, because I usually encourage people if you're going on vacation, don't take Adderall so you can sit on by the beach with a cocktail in your hand and be on your Adderall. So, you know, try and take a break from it to give your mind a break. And then that that slows down the tolerance process. But there are people who just, you know, if they they they can't function that well without them, they may get in a car accident because they're not paying attention well enough when they're driving and things. And that's pretty serious. So for that person, when they max out, you kind of don't we don't have a whole lot of other options other than to play what I call musical pills. OK, you were taking Adderall that you're out of that one now. Let's go to Vi-vans. OK, now let's let's switch over and try concerta. I mean, it's so sadly we don't have a lot. Once you start developing tolerance, we don't have a lot of other options. And it's easier to develop tolerance when you have to take it every single day versus when you can take breaks from it. Right, yeah, it must be extremely more complicated with people who experience anxiety, as you mentioned, because at this point it might not be the best kind of way forward, especially because they're already so anxious. So, I don't know, for someone who is experiencing ADHD and anxiety, what kind of solutions can they expect? Yeah, so here's the thing. It's almost like you've got to pick a problem. Which one are we going to address? Well, what's the bigger problem? Oftentimes with anxiety, anxiety is the bigger problem. And since anxiety can interfere with your focus and attention, what I found that is that with the person with really severe anxiety, we can get the anxiety under control. The attention is OK. You know, it's not perfect. They may not be able to read a book in a day or do other things that people who don't have attention problems can do. But they're not like falling behind on their work and they're or they're not, you know, losing their keys. And they may be losing their keys, but they can find them because now we have, you know, the Apple find me thing, you know, stuff like that. They use things to get by and they do without the stimulant. So, but that said, yes, there are because. And ADHD can produce anxiety. You know, I've had some patients who we were addressing their anxiety first. And then it turns out it was really the attention all along that was generating all of this anxiety and worry. And as soon as we addressed the attention problems, it's like the anxiety just melts it away. So sometimes it does become a trial and error thing. The again, we pick a problem. Let's go with anxiety first, let's treat that first. And we start there. And if we're still having a lot of problems over here, let's focus on this over here first and then see what happens to your anxiety. So really trying to understand the root cause, whether it's anxiety, whether it's ADHD, whatever mental health condition there is. And yeah. OK. So speaking of perhaps addressing anxiety, I know that you have recently published a new book, which is very exciting. Yes. Yes. It's Why Am I So Anxious? And I still got a whole bunch of my little sticky notes in there. And yeah, it just published last month, mid August. It's jam packed with solutions, not only like a bunch of what you can do about anxiety, but when to do things about anxiety. Because one of the frustrations I've had over the years with treating anxiety is, you know, I would bring up natural solutions, of course, usually when people come to see me, they're already wanting to take medication. If I just say, oh, go go change your diet and come back, you'll be good. They're like, what did I come to you for? I could have saw that on the Internet. But anyway, so what the frustration that I would have would be, you know, I would say, what about this breathing and meditation and people would say, well, I tried that, it doesn't work. None of that, none of that stuff works. I hear that all the time. And then I started believing that too. Like less stuff doesn't work. People need medicine, that stuff doesn't work. Well, what the issue is, is that none of the solutions for anxiety work for every part of your anxiety. There's not a one stop shop solution that's going to take care of all of your symptoms. You've got to layer the solutions, layer things. So what I aim to do in the book is give people a collection of tools that they can use and layer to address their anxiety for various situations. And even someone who ends up needing medication, because for some people, that is the answer for them. But even so, on top of that, you can still have your collection of tools in your toolbox to be able to use at a point where maybe you don't need, you can get off the medication and just rely on your tools or stay on your medication. And when things still go up and down, you still bring out these tools to manage things. I'm definitely very keen to have a chat about some of these tools and perhaps share it with the Psych2Go community. So we'd love to have you do it again. I'll come back. Amazing. So if anyone in the Psych2Go community has any particular questions or is keen to hear about the book, then please leave in the comments section below. Otherwise, I would like to thank you so much, Dr. Marks, for joining me on this episode of Ask an Expert. Thank you so, so much. You're welcome. This felt like it was two minutes. It was such a great chat. I learned so much. And I really hope that to those watching, you guys also learned a lot. Let me know in the description box. No, in the comment box, actually, your thoughts, your comments, what you'd like to see next. Otherwise, you can follow Dr. Marks' very own channel. Amazing. Read or fuck. Follow us on Discord. Link is also in the description box. And yeah, see you in the next episode. Bye. Yeah, I'll see you again. Bye-bye. Bye.