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ADHD Medication Insights – Fix The PM Drop 1
NPH Brain Evidence: ADHD At 76 Needs SPECT Review
December 28, 2013ADHD Medications – Fix The PM Drop-2 The What Drop
January 19, 2014Turn ADHD Medication Side Effects Into Learning Opportunities – #1 The Teaching Drop
ADHD Meds Can Drop You
“Intolerable” PM Crash Details Can Become “Instructive”
If you watch more carefully, and truly understand the side effect challenges with stimulant medications, you can help correct your entire treatment protocol.
The only thing more expensive than education is ignorance. [Tweet This]
Ben Franklin
First
#1 This PM Drop Teaches – [this video] – Afternoon ADHD Medication Drop is the single most commonplace resistance and difficulty found in taking ADHD medication. In spite of admonitions here at CorePsych about not paying attention to metabolism or dosage strategies, very few either pay attention or attempt to clinically address these several essential PM Stimulant Drop patterns. Even fewer see through this “PM Stimulant Drop” as useful, indeed instructive. This video series will help correct that treatment failure challenge.
Then
Stay tuned for these next six PM Stimulant Drop videos: If you look forward to the schedule for Stimulant Drop videos – SUBSCRIBE on this video: Remember: you can't treat the specific comorbid ADHD condition unless you recognize it!
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Get Started: Learn From The ADHD Medication PM Drop – 2.32 min Overview
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The Next Topics – Contained In The Playlist here
http://www.corepsych.com/7videosPMDrop
#2: The What Drop: Stimulant Meds simply stop working, Whaaaa??? Back to the same ol' straightforward inability to concentrate
#3: The Sad Drop: Most common emotional crash – Whining, crying and depression, feeling blue, out of it emotionally on the sad side
#4: The Mad Drop: Next most common emotional crash – Anger, rage, exceeding sensitivity to small insults, kick the wall, throw a chair
#5: The Whatever Drop: Less frequent but often seen as apathetic in association – Who cares? – not me, whatever, I'm gone…
#6: The Energy Drop: I simply can't move. I'm not able to do anything but sleep. Without a stimulant I can't move
#7: The Combo Drop: Puzzling mixed symptoms ask for a more comprehensive perspective that combines these provocative insights. Each of these drops reveals a specific underlying challenge that can be addressed if correctly recognized and assessed. Stay tuned and like this page below so your friends can review this very brief video on the details that really matter.
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Dr Charles Parker
Author: New ADHD Medication Rules – Brain Science & Common Sense
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38 Comments
[…] ADHD Medication Insights – Fix The PM Drop 1 […]
Dr. Parker,
First of all thank you so much for your work. I have read your book and watched many videos and have learned so much. You really are helping me to change my life!
A very brief history…It was suspected that I had ADD my whole life however it was never diagnosed or treated. In my 20s I was diagnosed with GAD and began treatment. I tried many different medications, had a horrible relationship with Ativan and finally settled on Cymbalta which I have been taking for about 8 years now. It MIGHT take the edge off of the anxiety but nothing wonderful or life changing. Not long ago (I am 38 now) I decided to get testing for ADD. Sure enough was diagnosed and started treatment right away. I have been taking Vyvanse for about a month and it has done amazing things for me. My anxiety levels are lower than they have been in my entire life as well as great symptom relief for my inattention.
The problem/question:
I was feeling so good regarding my anxiety that I wanted to try and wean off of Cymbalta and see if perhaps my anxiety was caused by the ADD the whole time. I never felt the Cymbalta did anything for me anyways.
I spoke to my Doctor and we had a plan the slowly taper down. I lasted 3 days and can honestly say that they were 3 of the worst days I have ever had. Anxiety through the roof, depression(which was never an issue) angry etc. Maybe Cymbalta is doing more than I thought? Maybe withdrawal? I don’t know. I went back to my 90mg dose of Cymbalta along with my 40mg of Vyvanse and have been feeling pretty good…until the PM drop!
I have a combination of the What drop and the sad,mad and whatever as well. Have been taking a booster in the afternoon which helps with the “what”. But I am already taking a serotonin medication and it is not helping the sad, mad or whatever. Could it be that I am on the wrong serotonin med? not enough? I am deathly afraid to try and come off of the Cymbalta but something is obviously not working right.
Sorry to be so long winded!!!
Any thoughts on how I can make my treatment more effective would be welcomed and SO appreciated.
Thank-you again for your work. You are making life a lot easier for many people.
Robyn
Robyn,
1. Take a look at the Energy Drop too, as your PM drop is likely hooked up with an underlying metabolic challenge. The Energy Drop can feel like depression and can certainly manifest cognitive slowing as well – it it looks like a mysterious Combo Drop. Sometimes it is a pure Energy Drop, thus my separate vid, but more often than not it’s that mix of several clinical parameters. Also check on your DOE as a 10mg increase with the Vyvanse may give you 2 more hours.
2. Having said all of that: Cymbalta is on my third tier combo list as it clearly inhibits 2D6 [Vid: http://corepsych.com/2d6 ] – especially when it’s up to 90-120mg. This second strong possibility is that you are slightly OD on the Cymbalta, thus backing up and causing a ‘toxic’ reaction to the Vyvanse. That unhappy circumstance will create complex counterproductive outcomes with weird discontinuation effects as well.
3. Your doc can switch you to Lexapro or Pristiq [clean on 2D6] – slowly going up with the new whist the Cymbalta goes down, and that will clear the air on the moderate inhibition of 2D6 with Cymbalta. Then work on your DOE, with a possible Adderall chaser at the end of the day… not needed if the 12 DOE works with Vyvanse.
4. If none of those machinations work you do need to go to Plan B: Biomedical Testing – http://corepsych.com/tests14 This link will take you to much more info than I have time for here.
You’re close, but no cigar.
cp
Wow! Thanks for the quick response!
I did read about Cymbalta and 2d6 and was thinking of switching to Effexor however, I am open to trying the two you mentioned if you have seen more success. I do worry about side effects(weight gain, sex drive) but am assuming they can’t be any worse than with Cymbalta?
I am scheduled to move from 40mg Vyvanse to 50mg tomorrow. Have been going up very slowly from 20mg over the last month.
I currently take 5mg of Dex in the afternoon which is working ok. Do you find people have more success with Adderall IR?
Seeing my Doctor tomorrow and will share all of this with her. Where I live (Ontario, Canada) it is SO hard to find an expert who deals with adults and ADD. I thankfully have a wonderful family Doctor who admits she knows very little and is willing to learn, be flexible and work with me. Your insights and suggestions will be of great help to her and I both.
Thank-you so much for taking the time to respond to these comments. You truly go above and beyond.
Robyn
Robyn,
You’re very kind – glad I could pitch in. Seems like Family Docs in Canada win the award for open minded, thoughtful considerations. After many consults up there, I’ve found repeated value in working with them.
Dex very well might be better than Adderall, as Adderall had a more NE Norepinephrine effect. Effexor is the mother of Pristiq – I do try Effexor often, but if they have a metabolic slowing from genetic 2D6 polymorphism, then Pristiq will pass through unhampered.
Sounds like you’re very much on the right path – hang tough. Many more answers are out there.
cp
[…] ADHD Medication Insights – Fix The PM Drop 1 […]
[…] Vyvanse: Fix The PM Drop […]
Hi Dr. Parker,
My husband has ADHD and was prescribed Amphetamine Salts by his general practitioner. i think we need an ADHD specialist and different medication? I don’t think it’s working as he continues to be disorganized, has no clarity of thought, angers easily, and has continuing racing thoughts and can not quiet his mind. I feel so bad for him and want to get him some relief. It’s exhausting. He self medicates with chewing tobacco and has told me often that Percocet quiets his mind and takes away the “fog”. He’s very intelligent, an inventor and an amazing person. Over the past 10 years of our marriage I have seen ADHD swallow him up. It makes me furious and sad. I have an insatiable quest for information about ADHD to be able to understand and help my husband.
Is there a medication used to treat ADHD with properties similar to Percocet?
Thank you SO much for your time…
Laurie
Laurie,
Opiates carry far more negative consequences with the challenge of tachyphylaxis [see this link for many more video details] – and the fact that even at the usual medical doses opiates are seriously physiologically addictive.
My conservative recommendation: get an expert on the situation immediately – one who understands titration and DOE as discussed in detail in this video playlist from here at CorePsych: ADHD Meds Dosage: http://bit.ly/dosevids – Metabolism matters, dosage matters, and with a clear understanding of expectations the medical team will help create more predictable outcomes.
cp
I just watched your videos on the pm drop. OMGosh! My husband lives on adrenaline! I am so excited and hopeful to find him a doctor who understands the nuances of ADHD.
Thank you so much!!!
Laurie
Laurie,
Glad to pitch in, thanks!
cp
Is there a resource to find a doctor who knows about titration and DOE? I live an hour from Baltimore MD.
Thanks!
Laurie,
Sorry, no – none at the moment. Working on it.
cp
Hi Dr. Parker,
I have watched a number of your videos on ADHD and have found them to be very informative and helpful. I am a 25 year old male currently being prescribed Vyvanse (70 mg). I’ve been taking the medicine for about 9 months (6-7 months at my current dosage level). Like Sepand, I too have been experiencing a crash from Vyvanse and overall I would say that the medicine’s effects are somewhat inconsistent from day to day. I have talked about it with my neurologist and he looked at it more as a DOE issue and responded by increasing the dosage in steps, ultimately to where it is now. I haven’t taken any additional medications. I am thinking that there may be more to the issue than just the dosage, however and want to make sure that I ask the right questions the next time I see my doctor.
Just to provide a very brief diagnostic picture, my ADHD diagnosis originally dates back to 1st grade (I went a lot of years without taking any sort of medicine), but more recently I have also been diagnosed with Asperger’s as a comorbid condition. The latter diagnosis came about as a result of neuropsych testing I went through when I was seeking accommodations on a standardized exam.
Getting back to the crash I’m experiencing, I’m not sure which of the PM drop categories mine would fall under. However, I would describe it primarily as a loss of motivation and interest in the world around me. I can become withdrawn and sometimes mildly irritable as well. As for the latter, it’s not so much feelings of anger, or rage. Rather it’s more of an increased proneness to becoming annoyed. It’s a somewhat paradoxical state because even though my “energy level” is lower, my mind is often racing with thoughts and I can still focus intently on a subject or project of interest (almost obsessively so), although I may feel like I’m in a bit of a mental fog or be slightly less sharp than usual. The PM drops became less frequent after switching to 70 mg but I do still experience them on some days.
There seems to be a strong connection between how much I consciously “feel” the medicine and whether or not I experience a drop in the PM. On some days, I hardly “feel,” or notice the medicine even though it is still helping me focus. On other days, though, I do get a very noticeable stimulant “buzz” (for lack of a better term) from the medication where I feel energetic for a few hours and am grinding my teeth on the insides of my cheeks all day. These are the days where I tend to experience the PM drop the most (the crash generally starts to set in at around 5 or 6 pm).
I’m not really sure what determines what sort of “medicine day” that I have. I am more likely to “feel” the Vyvanse more strongly if I haven’t taken it for a couple days but this seems to be more of a contributing factor than a driving force. Aside not being on a 7 day-a-week dosing schedule (I don’t take it over the weekend), I’m generally pretty consistent in how I take it. I eat a good, protein-laden breakfast every day, usually around 9:00-9:30am and take the medication at some point between 11:00am and 12:00pm before I start studying or whatever else I’m doing that day. I have also significantly cut back my caffeine intake on medicine days. I still have 8-12 oz coffee at breakfast but generally avoid all other sources of caffeine at least until the medicine is starting to wear off or on the downside of its apparent DOE curve.
I know that you wouldn’t be able to determine exactly what’s going or provide specific recommendations without examining me in person, but do you have any insights on what may be affecting how my body is responding to the Vyvanse, or based on what I described, are there any tests or screenings you would recommend that I should discuss with my doctor? Also, in light of my recent Asperger’s diagnosis, what impact, if any, could this disorder be having on how I am responding to the medicine (I read somewhere that Aspies don’t always respond to stimulant medications quite as well as people who only have ADHD); are there any specific issues that frequently come up with Aspies undergoing treatment for ADHD symptoms?
(I apologize for the lengthy post. I just wanted to make sure I gave you enough information to provide context to my questions)
Thanks,
Dan
Dan,
Even though “Aspie by psych testing” I still view that diagnosis as predominantly a descriptive diagnosis, rather than more neuroscientifically, neurobiologically based, as you correctly guessed. What you describe is a combo of drops, two related to serotonin, and one possibly related to energy [adrenal/thyroid?], and one likely simply due to DOE and the need for slight additional dose for studies in the PM.
1. Discuss w your doc the latter first: discuss trim with dexedrine or adderall IR in the pm. I would work to start your AM earlier, not so close to noon, as that process for some reason creates more DOE unpredictability + taking it on the weekends, as that also creates metabolic imprecision. Shoot for a 10 AM regularity for that aspect to work more often.
2. Consider augment w your doc low dose of clean “anti-touchy” med at a low dose to start in the AM: Like Celexa 10mg to eval the pm drop in that serotonin context.
3. Consider more testing for the pm energy aspect. Most docs are fine w customary thyroid, but also need to hit the TPO, rT3, Ferritin, D3, and B12 as well. Then Adrenal slowing: that’s more difficult – several labs available on this pdf sheet, none on the LabCorp, Quest – http://corepsych.com/tests/14 – For you I would definitely rec the IgG food and OATS w Great Plains – see these vids as well as those linked at each test for more explanation: ADHD Meds Problems – Mind and Gut: http://bit.ly/mindgut | ADHD Meds & Allergies – Milk and Wheat: http://bit.ly/mawimmun
More data for a guy like you will very likely provide more consistent treatment outcomes. Hang in there, trimming is nuanced, and always based on accurate clinical/lab assessments.
cp
Hi Dr. Parker,
I really appreciate you taking the time to write such a detailed and thoughtful response. My next neurologist appointment is in a little over a month so I’ll be sure bring up the tests and possible med adjustments you recommended. In one of my previous visits, we had discussed the possibility of an afternoon dose with an IR product but haven’t tried it yet. In the mean time, I’ll implement the dosing schedule changes you suggested and take my medicine earlier in the day and also 7 days a week.
The issue I’m having now with the PM crash is a problem that I also had when I took stimulant medication as a kid (as a child, I often complained that Adderall and Ritalin made me feel like a “zombie”) and is one of the two main reasons why I convinced my parents to take me off the medicine after 6th grade. The appetite suppression and overall effects on my enjoyment of food was the other problem that bothered me the most at that time.
Needless to say, it’s a pretty longstanding issue. The only thing that’s different this time around is that as a kid, I don’t remember getting that overly “charged-up” feeling from the medicine the way I do now on some days. After going without the medicine for 12 or 13 years and taking it again now though, I can definitely see its positive effects on my attentional problems so I really want to make it work with more consistency and stability.
On that note, I have one final question that is related to one of your recommendations. Do you see my caffeine consumption as something I need to cut back even more than I already have? There were two reasons why I had been taking the medicine 2+ hours after breakfast. The first is that I was trying to line the DOE window up with my study schedule. The other is that I was afraid that the the Vyvanse dose and the caffeine from the coffee would be too much stimulant at one time so I thought that I needed to space them out a bit.
As I said before, I have significantly cut back on my caffeine consumption, which I quickly realized I needed to do after my Vyvanse was bumped up to 70 mg. Instead of iced tea and other caffeinated cold drinks, I now drink plain water and unsweetened seltzer water. I still have one 8-12 oz cup of relatively strong coffee each morning with breakfast, though. After years of drinking coffee to semi-consciously self-medicate (and also because I enjoy coffee), I have developed a bit caffeine tolerance so one cup doesn’t affect me as much as it would some other people but at the same time, I don’t want to create a potentially synergistic effect with the Vyvanse, which is a pretty powerful stimulant by itself, or add any other complications to my medication response.
Dan,
Best of luck w the changes. RE: coffee – one size doesn’t fit all. Some have a prob w over stimulation, some don’t. It my experience that coffee doesn’t’ diminish effectiveness over time – it’s those pesky metabolic problems that impede predictable progress.
cp
Hi Dr. Parker,
Just wanted to put up a quick follow up post to say thanks again for your suggestions a little while back. After my last post, I read “New ADHD Medication Rules,” which was very interesting and informative. You really do an excellent job of breaking down the science in a way that was accessible to someone like me who doesn’t have an extensive educational background in neuroscience or physiology. I will be sure to recommend the book to my neurologist when I see him as he works with a lot of ADHD patients.
I haven’t seen my neurologist yet to discuss the possible med adjustments you suggested (ie, adding an IR booster in the PM and a low dose of an antidepressant), but my appointment is finally coming up this week and I will go over it with him then. In the mean time, I saw my family doctor and he ordered some blood work for me (everything came back normal).
Also, I started seeing a psychologist to explore some possible co-morbid anxiety issues. The psychologist hasn’t given me any sort of official diagnosis yet (she might still be in the process of assessing me as I’ve only seen her twice so far) but she has started some therapy in the last visit (ie. relaxation techniques). When I was choosing a psychologist, I made sure that I selected one who had experience working with ADHD and Aspergers in addition to anxiety. She will be keeping my neurologist and family doctor in the loop on any diagnosis/treatment.
Thanks again for your help,
Dan
Thank you Dan, for your kind remarks. Fair winds and following seas as you sail to new ports.
cp
[…] I’ve discussed these interactions in hundreds of presentations since 1996 when I first discovered how these challenges impede metabolism and create significant ADHD Medication problems. […]
[…] ADHD Medication Insights – Fix The PM Drop 1 […]
[…] ADHD Medication Insights – Fix The PM Drop 1 […]
[…] ADHD Medication Insights – Fix The PM Drop 1 […]
[…] ADHD Medication Insights – Fix The PM Drop 1 […]
[…] ADHD Medication Insights – Fix The PM Drop 1 […]
[…] ADHD Medication Insights – Fix The PM Drop 1 […]
A combination of the energy drop and the whatever drop describes me very well.
After doing the IgG testing and finding out that I have a reaction to dairy, eggs, gluten, pinto beans and yeast respectively, I thought that eliminating them would fix it but it has been a couple of months and hasn’t really done much.
I know I have a metabolic challenge cause I need to titrate my Vyvanse to 10 mg for me to not reach the top but I’d love to have this handled as I feel like I cannot get up without Vyvanse and then later feel apathetic after taking it. It’s very unusual and you have helped me out a lot and I hope to find the answer to it on your site. Thanks for all the great value you provide to us!
I tried adding Wellbutrin 150 mg to help me deal with the sleeping and fatigue issue but it has made me more obsessive and I felt really stupid cause my memory was just horrible on it. After stopping it and thinking I may have a serotonin imbalance, I tried out 25 mg of Zoloft and while it helped in reducing my anxiety, it made me sleep half the day.
The metals RBC testing shows that I am a little higher on chromium and selenium but they are not high enough to seem significant so I’m rather confused on what’s going on and when I’m going to get better.
Sepand,
Seeing this note encourages an even more specific process, as your liver sounds “constipated” from the burden for years. Do schedule a Brief Chat w Desiree at Services. A 15 min explanation will be helpful.
cp
Hi Dr.Parker,
Thank you for the quick reply. I have scheduled a Brief Chat with Desiree. I hope to talk to you soon!
Super, looking forward,
cp
Sepand,
Sounds like you’re significantly on that Path of increased awareness.
The absolutely most challenging part of recovery from these issues is the time it takes for the adrenals to come back around. Your best bet – two items:
1. a serious bowel restorative plan + added probiotics [e.g. GI Repair], and
2. adrenal support – we have several adrenal supports including an Adrenal Complex thru Desiree at Services.
No guarantees, but attention to those details often proves useful,
cp
[…] ADHD Medication Insights – Fix The PM Drop 1 […]
[…] ADHD Medication Insights – Fix The PM Drop 1 […]
Good video! I’m looking forward to learning how the PM drop side effects can give us clues to other contributory problems!
This site is great! I’ve learned sooooo much in the last month through your site and the links it provides. I’ve learned tons through your links to Tom O’Bryan, Sean Croxton, Peter Osborne and the whole “Trifecta” sensitivity issue (milk,eggs,wheat). I’m continuing to educate myself so when I finally do make an appointment with you, I won’t be scattered in complete “ADD” confusion. I don’t want to get off the phone and say, “What did he say? Huh? What am I suppose to do?” It’s like I will have the map and you can just guide me through it!
Talk to you soon!
Mike
Many thanks Mike, it always takes a team. – And when the team knows the plays, the ball hits the target.
Yes…., I am aware of a pm drop. However, I see it as part of a process….. For years I knew I was depressed; sometimes suicidal….(thanks to a canine friend, I didn’t do it on a particularly bleak day.) Now they say I have ADD with secondary depression. According to Dr. Amen’s profile….Limbic ADD? I am also retired with disabilities, (an accident at work), on a fixed income, and on Medicare. Most of what I have learned has been from reading and the internet…., thank you, Dr. Parker….Currently, I am on Vyvanse. I set an alarm clock for 8am to take my medication, (by nature I am NOT a morning person), and start the physical stretching necessary to meet the day. (I am still in bed with one of the dogs by my side.) I know exactly when the medication ‘kicks in.’ I get up, get a nourishing breakfast, and meet the day.
This, the beginning of 2014, finds me more capable than I have ever been in working with the situations I find myself with….; many as a result of ADD. Keeping to my morning regimen, I’m able to chip away, and work toward creating a more normal environment. I know I have a severe hearing loss and I’m reclusive….., but the internet has kept me connected with people.
Yes….., I am aware of a pm drop…., but I continue to experiment with schedules and specific activity structure. AND I have my tablet by my bed to follow the latest You-Tube segments from Dr. Parker!
So right Pam,
The process of understanding evolves with the kind of careful observations you are making about burn rate, metabolism and correctly dialing in the meds in a way that will help understand the comorbidities… those pesky guys that haunt the halls of Treatment Failure.
Sounds like you’re well on the Path, but will nevertheless appreciate these next vids in the series. Will turn out another one not this weekend, but the following. This next one is, in a way, self explanatory, but odd as it may seem so completely overlooked by those thinking ADHD medications are only for school.
Thanks for your kind remarks!! Have a great year.
cp