Adult Executive ADHD: “Those Wrecked by Success”

Pristiq For Major Depression – Clinical Details on CorePsych Radio
July 8, 2009
Intuniv for ADHD: Understanding Tenex, Guanfacine and Alpha 2
July 20, 2009
Climb Carefully

ADHD Can Easily Ruin A Career Any Level
At CorePsych Radio this PM I will spend an hour on this painful, too frequently witnessed phenomena: Good grades through school, excellent work ethic, driven to perfection and wrecked by their own success.

Program Outline: See Ya There –
at CorePsych Radio: link to Internet program and pdf outline there as well.

This particular subset of ADHD is late onset Adult ADHD, and if you don’t know about it, you simply won’t see it. The original observation was by Freud in the 1916 [Freud, Sigmund: The Complete Works]

  1. The Context: ADHD is Contextual Diagnosis not 24×7
  • Freud brought this character problem up in a paper in 1916
  • His solution was unconscious Oedipal conflict
  • Saw deterioration in context of employment advancement
  • Many who do well academically appreciate and benefit from the context of academic life.
  • We’re now beyond all ADHD being only 4 year old children
  • This appreciation of structure can last long into adult life
  • These folks do not have the typical ADHD history
  • School history does not have the bumps
    2. The Correction:
  • Approach is ‘cognitive issue,' not “job issue”
  • They are worse at home – less structure more variables
  • They are worse anywhere they don’t have control – they must determine the structure.
  • Many are medication resistant, and Neurotransmitter testing is remarkably helpful to begin the process.

This is Brief Review, Full Program Outline at CorePsych Radio – please join me for the full show this PM at 4 EDT, 1PDT

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  1. Owen says:

    This is me to a T, unfortunately. Came home to my wife last week with my second manager job loss three years. Prior to that, I had five great years as a lower-level associate (apologies for being purposefully vague for anonymity reasons). This is despite successfully managing my AD/HD with medication management and therapy (am planning on bringing this up at next appt.).

    Managing the multiple personalities at the office is my kryptonite, especially when interacting with the “difficult” ones. Then something goes awry somewhere along the line and I’m eventually told I don’t sync with the culture/am not a “good fit” and out the door I go.

    Is this podcast still available? I’ve read this chapter in your book, but I’d like to know a few strategies for addressing this problem. Thanks, Dr. Parker.

    • Owen,
      Beyond the ADHD meds you likely need some coaching for over-thinking and balanced management skills, protocols. Management needs an internal structure and I do recommend several coaches that can help over the phone. I have a super self management coach here at CorePsych if you would like to consider her, she’s outstanding, or these other coaches I’ve trained around the country on applied neuroscience:

      If you wish to work w our office, call Desiree at Services:

  2. Elizabeth says:

    I’m 24 and take Adderall. However, I still find myself unable to concentrate a lot of the time, and seem to lack any sort of ambition. If I take my medication late or not at all I’m very tired, lazy, impulsive and I crash HARD. I just want to live a normal life without having to worry about taking my medication, whether or not the damn pharmacy will have the stuff to fill my prescription. I would like to have children but I’m so scared about not taking my meds for 9months. I’m constantly told “well this guy learned to live with it and manage it without medication.” WHY CAN’T I! It makes me feel stupid and like a freak. Then you have all those young kids out there selling their RX with no repercussion which leads me to wonder, do they really even have it? It makes those of us who struggle with it, look like we are merely faking it just to take drugs. It has ruined any ambition I might have had since I was very little. It ruined any ability I might have
    had to stay focused which is why I struggled so much in high school and never went to college.

    • Elizabeth,
      Take some time and shop for a doc who really understands and can work with ADHD. So many don’t get it, don’t know how to work the meds that many folks go untreated. The hard crash sounds like possible associated serotonin issues: see my video on ADHD and depression for some hints on that one at YouTube drcharlesparker – hope that helps! Hang tough!

  3. Josh P. says:

    Dr. Parker,
    First off, thank you so much for these resources and YouTube videos. I am finally finding quality information about ADHD from a very respectable perspective. In fact, reading Dr. Amen’s Sex on The Brain and learning about SPECT imaging this past summer is what lead to me getting help. I am 20 years old, and a college student at a competitive 4-year university. As I stated before I just recently got help for my ADD/ADHD, I am seeing a psychiatrist and am currently prescribed 50mg of Vyvanse. I have a question about Vyvanse dosing, and am also curious about some of the things your YouTube videos and various articles on here are talking about because the more I read and listen to, the more they seem to describe me but I don’t think my Psychiatrist has your perspective or necessarily understands how to help me besides writing scripts. This will probably be a somewhat long post, I apologize in advance I try to be thorough.

    I am trying to figure out my DOE for Vyvanse and have had difficulty with side effects. I sought treatment because of reading Dr. Amen’s book and because I was fed up with how I acted and felt every day. I didn’t feel like I had any control over my life, I couldn’t wake up when I wanted to, I couldn’t plan a days activities, I couldn’t do homework or practice guitar when I wanted to. For instance: I make store shopping lists then get to the store and buy maybe half the things on the list and then 10 things that weren’t on the list and then get home and wonder why I didn’t buy the other things when I needed them later. I was constantly having the same fights with my girlfriend and while I usually get into long term relationships things were usually only good for the first 3-4months (I get bored, lose interest, or things start getting serious and I want to back up to when things weren’t serious which leads to problems) and then it’s an uphill battle for the remainder of the year until we break up. I began to get depressed because I felt like I was a slave to my incoherent nonsensical whims. I would try really hard to do assignments or papers early or study for tests early but ended up cramming and panicking the night before. Whenever I had some homework, a paper, some social function, a public speech or presentation, or a CPR test for example, I would get really really tired, lethargic and cranky and try to get out of doing it and in regards to school work would usually choose to do something like play video games or watch movies/tv shows or just play on my computer/roam the internet aimlessly. Then when the deadline came I would be a mess because I never prepared (In the case of the CPR test I snapped at my girlfriend, yelled at my parents, and drove too fast to get to the appointment, as soon as I took the test and did well I felt 100% fine, I didn’t understand why I was so rude to people I cared about and I was no longer tired and lethargic and there was no anxiety. This is common with all these “episodes” I get all worked up dread something the entire day which makes me inable to do anything and then the event comes and I feel fine after it). I never had the focus or energy to do anything, when I sat down to read a text book I instantly felt tired or I would glaze over the reading without comprehending anything. I felt like a slave to my mind I couldn’t do any of the things I wanted to do. I would make lists and then I’d just have piles of them and nothing would get accomplished, so needless to say I was unhappy with who I was and what I accomplished (never felt like I lived up to my potential, dissappointed in myself) and was getting depressed and just wanted to stay in all the time. I also suffer from performance anxiety, in sports I always enjoy practice and scrimmages but I never liked the pressure of actual games and I end up performing below my abilities. (I.e. when playing basketball I make excuses to never shoot the ball and always pass it off even though I really can play well, this doesn’t occur when I play with friends, but when we play a pcik up game I start to feel this way. I also resist hanging out with new people keeping to a small group of friends and resist social events when I’ll have to meet new people, I also do no enjoy large crowds). So I was tired all the time, unhappy, unfocused, and really really guilty and confused. There was this person I wanted to be who accomplished things and was more outgoing and friendly and who maximized his potential, then there was me… the person I actually was.

    So I read the book, figured I had ADD and got help. I was started on 30mg of Vyvanse, and the first 4 days were absolutely great! I stopped having sugar cravings, I only had desires to drink alcohol socially and responsibly, I became more realistic about expectations(of myself and people), I stopped feeling guilty because I understood their were limitations about what I could accomplish (before I thought when I made a list I was supposed to do 100% of it before going to bed and felt guilty and upset with myself when I didn’t), I had energy I got things done (My room was finally clean!) I was more friendly at work, at home, and a better friend. I was better with time management, I used free time more effectively, and no longer had anxiety problems. I felt like I had finally found what I was missing, I felt like things finally clicked into place for me, it was this feeling of “This is what I’ve been missing all this time!” I was very happy and positive (I’ve always been pessimistic) I wasn’t even rushing to take my pill in the morning I knew I needed it but I was so happy with who I was that I would wake up on time feeling refreshed, shower eat some breakfast and then take it, no worries, not a big deal just happy and normal. Unfortunately though, the medication began to wear off before I got off of work so I would get home from work and the old me began to return, I was cranky and tired, and I started to get depressed again but this time even worse, because I started to worry that the medication would not work for me and I had this taste of the sweet life and now I was supposed to just go back to who I was before. I started to lose faith in the medication. I had called my psychiatrist… but the only person who would talk to me was the medical assistant who just read me a contraindications pamphlets and told me that I needed to evaluate the medication for 2 more weeks and that it was not an important enough of a situation to see the doctor until my appointment in 2 weeks. Ouch… I got even more depressed because I basically got told that my quality of life wasn’t important enough to be dealt with in a timely manner (I just wanted to get in and talk to my Doc, I figured an increase in medication was necessary but I just wanted him to talk to me so I could see if this was normal and restore my faith in the medication). I kept taking the meds, and eventually got in the see him and he prescribed me 50mgs. I was taking that for a while and it was better (though not nearly as good as the first 4 days of 30mg…).

    Then I went back to school and I began to notice what you write about ADD being context dependent, and ruining myself with success. I am taking a heavy class load, am a leading member of our schools biofeedback research team, and just got a puppy before I went back to school, as well as holding a leadership position in my fraternity, of course there’s my girlfriend, and I manage the landlord affairs for my father up here (he owns a house in my school town that myself and some buddies live in). I always got overwhelmed pretty easy in the past (nagging thoughts, guilty feelings about not accomplishing things, these went away when the meds were effective, felt like I wasletting everyone down, unable to fulfill my duties to anything, or anybody, felt like there were a billion things I was supposed to be doing and I wasn’t doing any of them so I would just sit there or play video games or watch a movie etc.). So basically I have alot on my plate and I’m still taking the 50mgs. It works extremely well in the classroom, I enjoy learning I pay attention understand things and take good notes. In the classroom I plan on things to do when I get out of class but when I get home I just put things off and become the old me. I’ve also realized I’m experienceing some obnoxious side effects. I take the pill around 8:45 a.m. with a good protein breakfast go to class until 1 p.m. and am usually good for that period. When I get out of class though and get home I realize all I have eaten was breakfast and I’m not remotely hungry but know I need to eat (I have to force myself and it’s really hard to eat). Around two when I plan to do homework, I get extremely volatile, I have an extremely low frustration tolerance (I yell at my puppy and come close to hitting him I really don’t want to but find I just lose it when he won’t comply with me yelling at him. This is scary to me and not at all how I want to raise him), I want to break things when they don’t work right (I was going to transplant my computer from one case to another but the new one shipped broken and I had half of my stuff out of the old one and had to put it all back, I started to sweat, got really hot, extremely irritable and wanted to throw my entire computer on the ground and yell. My friend was talking to me and I wanted to yell at him and tell him off for something he did a long time ago), I also get tired and restless, and I just don’t feel good/right, I feel like I have tunnel vision it’s like I’m staring at things intently but can’t understand them… I think this is hyperfocus, I also get hot and sweat alot when no one else is got. So basically I think I’m hitting the top of the window but for some reason since I get tired and don’t feel good I keep thinking that I’m not taking enough meds but I have so many side effects that I know I’m probably over the limit. So finally my first question is, would this be typical of the dose being too high? From like 2-6 or 7 I feel terrible and then I perk back up and feel better after (feel kind of confused at why I was so angry before etc.), so I go from doing really well in the classroom, to feeling bad and angry, to feeling better than the middle period but not as good as when it works right.

    The problem with this is that my psychiatrist doesn’t like to do phone alterations… which is frustrating because I am 3 hours away and he only has appointments monday-thursday so with my class schedule it’s impossible for me to get back for an appointment. So I don’t really feel like I have any flexibility with him which is frustrating. I found a friend at school here here who takes Vyvanse and this is what he does: He cracks a 70mg pill into a bottle of water (like 17oz of water), he shakes it up drinks about 2.5oz, then takes the bottle with him and takes a sip inbetween classes and drinks about 5-6oz total (He stops drinking by noon) and thats all he takes for the day. He maintains that works better for him and is convinced that downregulation occurs when he takes a full dose in the morning (even though I understand vyvanse has a slow delivery, he still maintains it causes downregulation…). So he ends up only taking about a 25-30mg dose over a 3-4 hours period and this works really well for him. He finishes the water bottle the next day. Since I have to wait until thanksgiving to get into to see my doctor I was thinking about doing this with my 50mg pill and finding the sweet spot… What do you think of this method I understand it’s not very accurate at all but seems it could work. (I forgot to mention I also tried 60mg for about a 5 day period, but I was a mess with side effects so I went back to 50mgs so I am quite sure I don’t need to go higher).

    My other question would be, what can I do about the context dependent stuff as soon as I get home I fall apart and can’t focus and don’t accomplish anything (of course this could also have something to do with being on too high of a dose). I just don’t really know what to do about my current situation, I don’t know how to explain to my psychiatrist what I’m going through cause I’m worried he’ll diagnose me as bipolar or try to put me some anxiety meds or try to call what I’m going through something other than ADD/ADHD (I’m really sure it’s not… I’ve never presented any symptoms of those things while not the meds other than ADD/ADHD). I am trying to be patient but my life flies by while I’m living with this and trying to figure it out and it’s just a matter of time before I get behind in my classes and continue to miss out on opportunities. I just feel like life is too short and my life is too important to me to to just wait around for Dr’s appointments so I am looking for the right dosage asap and if this isn’t the medication for me then so be it but I want to fully and correctly evaluate this medication to know for sure.

    I apologize again for the length and any irrelevent information, thanks again for all your resource and time that has lead me to better understand ADD/ADHD.


    • Josh,
      First of all thanks for your remarks, using specific guidelines [DOE and Context] will ultimately get you out of the difficulties you are experiencing.

      As you know, it would be quite inappropriate for me to sub for your doc over the Internet, and I don’t want to lead you to making any adjustments without his approval, – all concerned would frown on my directing you specifically, even with these clear details. A further conundrum appears with your reaction to 60 mg, as increasing would be one way of approaching these challenges. Sounds, from that detail that you have a very narrow therapeutic window, – likely a result of metabolic challenge, from [as you note] protein breakfast to bowel transit time.

      What I can say is that several items do come to mind for your collective consideration [with your doc]:
      1. The moods – dropping hard when Vyvanse wears off – sound like serotonin down regulation [to quote your friend]. If you had a bit of Clint in Gran Torino on the front end you might need a small dose of antidepressant to keep from hitting the deck so hard in the PM – take a look at this old post from Dec 06. – Stims make an associated mild depression worse in the PM.
      2. I sounds like your DOE is firmly about 6 hr, and my guess is that you are simply still too low – I would have to hear more about what happened at 60, something to tell your doc.
      3. I also hesitate to make phone adjustments. I appreciate your pressure, but even with this long post the details just don’t go down as well on the phone or in a note – patience – you sound like you are on the right path.
      4. If all else fails don’t take Vyvanse. You may simply have a problem metabolizing that one, and could go over to an MPH product.

      Hope this helps, stay strong, – it’s often a bumpy path at the outset with any stimulant.
      And stay with that big breakfast!

      • Josh P. says:

        Thanks Dr. Parker.,

        I obviously need to work to improve the relationship with my doctor (and fully understand that I need to be a little more realistic of my expectations of my doctor). I was however curious if you had any thoughts or any special insight and appreciate what you did say.
        I think you’re right about me having a narrow therapeutic window and I just need to keep evaluating Vyvanse as effectively as I can, and if it doesn’t cut it then I will need to try something else. I’ll try to keep my head level, be patient, and improve communication with my current doctor.


        Thanks again.

        • Josh,
          Excellent attitude, good perspective, and insight that will take you exactly where you need to go. Tough getting started with so much pressure, but building the team will get the job done.
          Well done, be well,

  4. Carla Larson says:

    YES. Thank you. I was one of these. I had a Bay St career at more than six figures that imploded. Or I did. Whatever. Almost 15 years later, I’ve been diagnosed with adult ADHD. I could truly write a book about Dr. Charles’ topic today, and maybe now that I am medicated, I will. Great to see that it is getting attention. I hope it gets a great deal more…

    • Carla,
      Please write the book,- so many look for more responsibility, thinking the pressure will solve the inefficiency, and the money will drive the incentive. It’s the reality that will spin the outcome.

  5. David says:

    Love your blog, especially videos. The context/increasing variables rings very true. When is your guide to ADHD meds coming out? Very soon I hope!!

    I wonder if you could give an armchair opinion on this tragic, very high profile case that culminated in a major public inquiry in Canada last year. Lawsuits are still going on. I believe that, in concert with the profound institutional failure, ADHD could be the hidden culprit in this case.

    While the inquiry looked at the whole system of pathology in Ontario, the centrepiece was Dr. Charles Smith and especially his profound disorganization, poor memory and tardiness, coupled with a certain dogmatism in going after convictions. Words like – sloppy, slovenly, inconsistent, disorganized appear often the testimony. If you google “Charles smith pathology” you will get scores of media and legal reports. Many people were wrongfully convicted and spent years in jail as a result of this man’s incompetence and the system that allowed him to continue.

    I was astonished that possible ADHD never came up, either in the proceedings or some psychiatrist writing to the press. Also, the fact he worked in a medical environment, located in the same complex as a leading ADHD clinic for over a decade is ironic. I guess he kept his office door closed.

    When I saw a photo of his office in a newspaper, along with some of the descriptions, ADHD sprang instantly to mind. It was not just the usual piles of papers that one expects – pathology samples were part of the mix. Here are some snippets. (I can send it if you want.)

    Examples raised at the inquiry about Dr. Charles Smith’s competency:

    The Hospital for Sick Children temporarily cut Smith off from doing any surgical pathology in 1997 because other doctors were complaining about “diagnostic inconsistencies.” The coroner’s office wasn’t made aware of these concerns, even though it was well known that Smith was splitting his time between the two institutions.

    He was tardy in producing autopsy reports. At one point he had 60 outstanding, one for two years. He was often subpoenaed by court to produce these reports.

    He was extremely unorganized. In a crucial case, Smith didn’t recall having worked on it and he was unable to find required slides

    The first in a series of complaints about Smith was sent to the College of Physicians and Surgeons of Ontario in 1994. The coroner’s office blocked the college from investigating, arguing that it wasn’t their jurisdiction.

    In 1994, defence lawyers were circulating court transcripts of testimony from Smith, showing inconsistencies in evidence.

    A Crown attorney complained that Smith had altered his views on the cause of a child’s death when he took the stand on a case in 1995, making the Crown “look like a total fool.”

    In 1997, Smith took a hair, a crucial piece of evidence in a criminal case, and held on to it for five years until police discovered he had it.

    At a 1996 trial involving the death of a 3-year-old girl, Smith showed he didn’t understand how rigor mortis affects the body.

    In 2001, James Lockyer, president of the Association in Defence of the Wrongly Convicted, wrote to Young, saying he had concerns about Smith’s past cases and felt a “thorough review” was

    During his remarkably candid testimony, the disgraced Dr. Smith provided a checklist of the reasons he “fell victim to [his] tendency to become dogmatic, adversarial, too defensive, and to speak in black and white terms” – with disastrous results.



    • David-

      Once someone thinks it’s a ‘personality disorder’ there is no mandate for medical intervention, as the most commonly recommended intervention for personality disorder is either psychoanalysis or psychodynamic psychotherapy, – neither of which would have a turn-around impact on his apparent PFC dysfunction.

      Very characteristic of ADHD is the process of overlooking boundaries in the context of changing reality. If reality changes, pressures mount, the mind changes it’s response to the reality bringing marked inconsistency based upon that person’s perception of reality. Again, as I have said many times, ADHD is a contextual problem, likely worsened by increasing responsibilities – Wrecked by Success.

      ADHD can then become an excuse [and often is attempted], because treatments are so mercurial and unpredictable with few objective standards for recovery as hyperactivity and inattention are themselves so amorphous – vapors in the wind.

      My own view: Treatments are quite predictable with specific outcome objectives that should be expected, and then psychotherapy/coaching regarding boundaries is essential anyway. First the mind is set through medical intervention to use the therapy by correcting the brain condition at the outset, then the therapy will either correct the way they consider reality, or that person needs a change in their level of responsibilities.
      Thanks for your interesting comments!

  6. Gina Pera says:

    Great, great angle, Dr. Parker.

    I see what you describe so often. In fact, it seems the bulk of people who write to me (beyond the partners of adults with ADHD) are 50-something men who are recently diagnosed. Their ADHD was never caught because they were high-functioning in certain settings and because their spouses (usually a husband) accepted much of the blame for not being able to keep the person organized, etc. It took several decades for them to admit to themselves that ADHD might just be holding them back — or had knocked them down. Especially in this economy.


    • Yes Gina,
      Appreciate your confirmation from your street perspective – it’s interesting to see what a difference it makes accepting the fact that ADHD with almost anyone over 7-8 years old is so often seen in context. Too many variables, too little structure, a sudden, though not emergent [’emergent’ is too stimulating] change in the complexity of reality, and an implosion – major destructive life change: Look for ADHD as a foundation.

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