Why ADHD is Linked with Addiction

so this paper came out um about a month ago so half of adults with adhd have had a substance use disorder alcohol use disorder is the most common among adults age 20 to 39 with adhd followed by cannabis use disorder and other drug disorders more than one quarter of those with adhd had major major depression so what i want to share with you all today is um something that i think is really important which is understanding why people with adhd are actually prone to substance use disorders so in order to kind of explore that with y'all today here's what we're going to do we're going to explain first of all what adhd is a disease of we're going to talk a little bit about like you know what is really wrong in adhd what is wrong in substance use disorders we're going to sort of explore the overlap between those two things and kind of the neuroscientific vulnerabilities of both of these disorders and once we understand the neuroscientific vulnerabilities and processes we'll start to develop an understanding of like how we can fix it right and so this is going to be really tricky because i'm going to try to send you all some pretty complicated neuroscience that first of all i don't fully understand because it's so incredibly complicated but secondly it's going to be very simplified um and then you know really ask you all to sort of apply that understanding to like what you can do if you have adhd and a substance use disorder so to begin with let's start talking a little bit about you know what is adhd so if i had to summarize i'd say that adhd is first and foremost a disease of executive dysfunction and so what does executive dysfunction mean executive dysfunction is so our executive function is our brain's capacity to plan and execute tasks so for example if i want to like study for a test there are many things that go into studying for a test and one of the key things that i have to do when studying for a test first of all is behavioral inhibition so i sit down to study uh for a test and in order to study for the test i have to stop myself from like doing other things like pulling out my phone you know logging on to reddit like watching twitch playing video games like going to get a snack so there's a part of my brain that when i focus it in one direction like prevents me from doing all the others all those other things i may have um you know impulses to do those things but essentially my brain is like no we're not going to do that now like we'll check the phone later so the first thing that happens in people with adhd is that they're they have deficiencies in their behavioral inhibition circuitry that kind of comes from the frontal lobe okay we'll talk about that in a second the second thing is that people with adhd have altered sensitivity to reinforcement and so what that means is that things that are low hanging fruit and easily enjoyable are far much more enjoyable to people with adhd so if you look at like delayed gratification studies and people with adhd where you ask someone with adhd hey i'll give you a dollar now or i'll give you five dollars in five minutes which one do you want literally the brain of someone in adhd is gonna pick the dollar now as opposed to the dollar and five five dollars in five minutes so compared to the neurotypical brain the sensitivity to reward and reinforcement is altered in adhd the third thing that that happens in adhd is a high amount of impulsivity so people may say like is decreased inhibition the same as impulsivity and it turns out that neuroscientifically they're actually like discrete mechanisms so people with adhd tend to be like a lot more impulsive so when they have like an impulse they're much more likely to act on it that may correlate with decreased inhibition may also correlate with reward sensitivity right so if i have an impulse to like eat chocolate and i enjoy chocolate more than the neurotypical person it'll be hard for me to diet in a healthy way okay so when we kind of summarize i kind of think about executive dysfunction and adhd as having three major components the first is deficient behavioral inhibition so it's hard for me to inhibit behaviors the second is an altered sensitivity to reinforcement so things that are fun for other people are actually like way more fun for me if i have an adhd brain and we'll get to the neuroscience of this because it involves dopamine reinforcement circuitries and things like that and the third is a as a certain amount of inhibit i mean impulsivity which is and that impulsivity has a lot to do with intolerance to delayed gratification okay so these are the three things that we're going to kind of talk about when it comes to what adhd is so the next thing that we're going to kind of touch on is that um so substance use is actually like very the adhd brain is very vulnerable to substance use because of these three things so if we think about like substance use you know it involves restraining our ability to like get high for example it could be hard enough on its own right but when i've got an adhd brain that has like a deficiency in behavioral inhibition has an altered sensation of reward and has like more impulsive kind of behaviors it makes it really easy for me to use substances so i think if we kind of look at what gets people to use substances and what protects people from using substances the way that our brains protect us from using substances are kind of handicapped in the adhd brain so it makes us much more prone to using substances so this is where if we kind of look at the kind the mechanisms of um [Music] adhd and if we look at kind of the mechanisms of adhd it'll what we'll kind of see is we'll map these mechanisms onto a few different parts of our brain okay so what we're going to now do is take a quick look at the brain and so let's take let's understand the neuroscience of this okay so we have a couple of different parts of our brain so the first is going to be the prefrontal cortex so the prefrontal cortex is responsible for inhibition so there's also another part of our brain called the anterior cingulate cortex which is kind of back here in the anterior cingulate cortex or results in poor selective attention and poor inhibitory control so the frontal lobes are responsible for inhibition but the anterior cingulate cortexes as well and what we know in people with adhd is that they've got like basically like a reduced activity in the anterior cingulate cortex okay and the third thing that we're going to kind of talk about and this is important for drug use is impair dopamine activity across the brain so this may sound kind of weird but you guys know that like with adhd we actually give people stimulant medication right so this is going to sound kind of weird but if you look at the per the brain of someone with adhd what essentially happens is that like they're getting too many thoughts too fast and if you look at that what that really is is not it's not that their brain is actually moving too quickly it's that their brain is not able to turn down the volume of some thoughts so when you give someone with adhd stimulant medication what you're actually stimulating is the pfc so stimulant medication increases the activity of stimul of the pfc and allows you to actually focus on one thing so it doesn't actually speed up the brain it actually boosts your pfc function which in turn will allow you to negatively inhibit like other thoughts and impulses does that make sense um okay so the next thing to understand is that people with adhd have impaired dopamine activity and so part of the problem is that we we know that in the pfc in the anterior cingulate cortex and we'll get to the striatum in a second we know that we have low dopamine or some kind of dopamine dysfunction in the brain of adhd and so if you kind of look at it like what drug use will actually do is increase your dopamine levels so one of the reasons that people with adhd will use substances is to almost self-medicate so they have a baseline low dopamine activity which results in adhd symptoms and when i add drugs i'm gonna boost oh add drugs when i add drugs it's actually gonna increase my dopamine activity which will result in almost like some amount of self medication the problem is that this effect is temporary so over time when i use drugs at the very beginning it'll stimulate parts like the pfc um it'll and that but it'll also kind of have some effects on kind of the amygdala over here in the hippocampus so like you'll get stimulation here by drugs okay but the problem is that over time is you use drugs they stop increasing dopamine over here and let me know if this is too much okay and what actually happens is they start to like affect this part of our brain called the striatum so drug use when i use drugs temporarily it sort of has effects let's say over here and over here but over time it'll start to activate a different part of my brain called the striatum and then what happens once it starts acting in the striatum what it actually does is decrease dopamine so then when i increase my drug use it actually has a paradoxical effect to decrease dopamine and then makes the adhd worse this has to do with the way that our brain actually like acclimatizes to drug drug use so um just to kind of recap and apologies if i'm saying this over and over again so in the beginning we have dopamine deficiency here and not a good amount of activity in our pfc if i use certain drugs i can actually boost the dopamine over here and it creates a self-medicating effect this will sort of explain to you why people with adhd may be vulnerable to substance use because it's almost self-medicating in some way then what happens through chronic drug use is that the parts of my brain that get affected change and once we get to the striatum what we actually see is a decrease in dopamine activity and then adhd worsens and there's some interesting evidence for this so if you look at the d2 receptor so i don't know if you guys kind of know this but you know like um so if i have a molecule of dopamine the number of receptors i have will kind of increase the signal so if i have like three receptors in one molecule of dopamine and this molecule of dopamine is kind of floating around it has a very high chance of like increasing the dopamine signal i can also increase the dopamine signal by increasing the molecules of dopamine right because then i can go over here i can go over here i can go over here so what we actually see in people who are abstinent i know this is going to sound kind of weird but what we see in people who are abstinent is a lower number of dopamine receptors and so if you have a lower number of dopamine receptors shouldn't that mean that you will get less dopaminergic activity and the answer paradoxically is no because the reason you have a lower number of receptors is because you're not bombarding yourself with dopamine so over time what happens i know this sounds kind of weird but over time what happens is we develop tolerance and so as we develop tolerance it can kind of make some weird changes to our dopamine receptor circuitry and actually like alter our sensitivity to dopamine so when people actually become abstinent it's the reason that their dopamine receptors kind of go down is actually results in them not being bombar or sorry i just got confused there um but as as you sort of decrease the number of dopamine receptors within abstinence it sort of signals a resetting of your dopamine system the other thing that we sort of uh seem to understand is that dopamine blockade in this part of your black brain if you block dopamine it reduces adhd symptoms and reduces substance use symptoms so this is what's kind of interesting here is that like once we move from this part of our brain to this part of our brain we start to like alter our dopamine metabolism in some way that's honestly like pretty complicated and and is hard to follow but the end result is that once we're acting from the striatum we we see increased negative increased impacts of dopamine and adhd symptoms worsen okay that's kind of the key takeaway and i apologize if i confused you all there for a few seconds the key takeaway here though is that if we look at the different regions of our our brain what we can sort of start to see is first of all why dopamine increase originally helps people with adhd and as our brain adapts and we start to see dopaminergic changes over here we'll see an increa a decreased dopamine response and adhd actually worsening over time and so this is and then what happens with this this person once we have like striatal activity of substance use in substance use or prolonged substance use is that not only they kind of addicted to the substance but the adhd actually gets worse okay so next thing med school ptsd so next thing to kind of explore is like let's talk a little bit about the mechanisms of adhd okay and um let's talk about some of the mechanisms of adhd and understand why people with adhd are prone to substance use so we reviewed a little bit of the neuroscience but the first reason that people do it is to self-medicate right and this is essentially what i was explaining earlier which is that people are dopamine deficient in adhd this may be part of the reason why they're sensitive to rewards and so as we increase dopamine through substances for some amount of time it may actually improve the adhd and this is also why we'll use you know stimulants which can be substances of abuse to treat adhd so it kind of makes sense okay so the first reason is self-medication the second reason is a little bit psychological okay so this isn't something that we really understand the neuroscience well uh very well but this is something i've observed as a clinician and we'll talk about this maybe in a future lecture so adhd is associated with a lot of shame okay so this is what happens in people with adhd like you're smart you know you're smart you look around and there are other people that are able to do normal things people that are stupider than you are that are able to do normal things and you can't do those things despite your iq you can't do those things despite all of your potential you can't do those things despite being in gifted and talented classes when you were in the third grade you can't seem to focus your mind and pass a single exam in high school so what happens in adhd is people don't understand that they've got adhd so what what happens is that they just feel like they're busted in some way and they feel like they suck at life they don't really understand because the other problem that we see in adhd is oftentimes people have high iqs and they develop compensatory mechanisms so what that means is that despite your adhd you you basically use like some kind of weird iq compensation to make it so that you can function semi-normally but this iq compensation it's sort of like i have a flat tire but i'm so strong that i can just push the car which like allows you to go 15 miles an hour when everyone else is going like super slow so you're like doing exerting a ton of effort to ultimately get something that's kind of normal despite a very heavy handicap and over time these compensatory mechanisms no longer work and so you used to be able to do what other people could do and despite your high iq now you suddenly suck at life which deals which results in a bunch of shame and the more shame you have the more you need coping mechanisms and then generally speaking because your brain is remember sensitive to reward because you've got an adhd brain the kinds of coping mechanisms you end up with are maladaptive ones so it's hard for you to sit there and meditate if you've got adhd so instead what you're going to turn to is drugs and video games and social media right because you're so ashamed of yourself so this is kind of the second place where drug use comes in where generally speaking what i what drugs do i kind of think about them like clinically as an escape and so adhd gives people's minds things to escape from right because in my mind like i'm an idiot like i should be able to do it but i can't do it so i need to run away from that so i get prone to drugs and so the third thing uh which i'm sort of separating out even though it's kind of you know maybe under self-medication is that i do think that there's a neuro vulnerability here which is important so like i've kind of outlined there are a lot of things about the brains of people with adhd that are a little bit different their sensitivity to reward their inability to inhibit impulses and so what this kind of results in is um you know like a vulnerability to substance use so vulnerability to substance use disorders so if we kind of look at like you know why these things correlate there's definitely like this self-medication kind of hypothesis there's a psychological component and basically like your brain has substance use if we kind of think about it in video game terms you know like you've got fire resist and ice resistant lightning resist and like substance use disorder or addiction resist for adhd people is like minus 50 so you're kind of born with this inherent trait of like having minus 50 addiction resist and so this is why people with substance use disorders and people with adhd while like half of them have substance use disorders so then the natural question is okay okay dr k what do we do about it okay so now i think i can just kind of say this to y'all so this is going to be tricky so this is going to be one of the parts of when we talk on stream where i'm going to say particular things and they're going to be hard to implement but i'm still gonna go ahead and do this okay so a lot of times here on stream what we try to do is give you guys easily accessible solutions that like you can do it in five minutes or ten minutes this is one of the cases where actually what i really want to do is not give you all an easily accessible solution but a plan of attack that unfortunately is quite difficult the first thing that you've got to do is stop separating out substance use from adhd and this is really important so a lot of people that i work with who have adhd will say oh dr k i have you know like i have trouble with motivation right like i'm so adhd like i have trouble in school i have trouble in motivation with motivation how do i get motivated how do i find out what i want to do in my life and they mentally separate out the fact that they smoke pot every day from like these problems they're like oh no i'm lazy it's not like the pot like i'm lazy it's not the alcohol it's not the video games they're not a causative factor they aren't the reason i'm lazy they are the result of my laziness right so it's kind of interesting but if you have a motivational problem if you have adhd and you use any kind of substance okay marijuana alcohol stimulants even video games you have to understand that as long as you're using that substance all of this cycle is going to be going on in your brain and you're really not helping your brain to achieve motivation so anytime you have a comorbid disorder so this gets into the idea of dual diagnosis so when you've got depression and alcohol addiction you can't deal with either of them on their own because if you've got depression and you're depressed it's going to make it far easier for you to reach for like booze and if you drink all the time your brain is going to be more prone to depression so like you can't separate out these problems anymore so like this is it's kind of harsh but like i i've heard so many people who will say oh my problem is motivation laziness or adhd or it's this but it's certainly not the pot like that's fine like haven't you read all the research like pot doesn't make you stupid or pot doesn't cause this it's fine like it's being legalized it's like safe like i like it i enjoy it it's good and i hate to break it to you but if you're using any kind of substance and you have problems with adhd those two things are going to be the substance is going to be contributing to the problem like 100 so first thing you've got to do is stop separating out the substance use from all of your other problems your problems are not going to get fixed as long as you're using substances okay maybe a little bit of a hyperbole there like but honestly it's been my experience as a clinician that like you've got to take the substance you seriously so what that practically means is you got to get sober so if you really want to fix this you have to start by getting sober and i know that that's not easy and has its own own you know challenges but the simple truth is that if you're using substances and you've got adhd and you think the problem is adhd you got to get sober the second thing is that you have to deal with the shame of adhd right so this is a psychological thing getting sober is more about neuroscience right so it's about resetting your dopamine and stuff like that but you got to deal with the shame of adhd so this is where getting into therapy is a very good idea so oftentimes when i stream i will talk about how coaching is fantastic and you should sign up for coaching for reasons a b and c this is one of the cases where i'm seriously going to say if you have a substance use disorder and you have adhd don't sign up to see a healthy gamer coach go see an actual dual diagnosis clinician go to someone who can help you with adhd and substance use because you've got to like do the therapy right you've got to deal with that shame which causes you to reach for the substance of abuse the third thing that you've got to do is do a dopamine detox so this is going to be very hard for someone with adhd because remember that your propensity for boredom is going to be like your tolerance of boredom is going to be super low um but the unfortunate thing is that you're kind of handicapped you're stuck because if you're using the substance and you have the paradoxical effect of dopamine in the striatum which is that over time you're decreasing your dopamine usage and remember that low levels of dopamine are correlated with adhd which means that your substance use is literally making your adhd worse so you've gotta not only get sober but do a dopamine detox and give your chance and give yourself a chance to reset whatever that dopamine circuitry is uh so that you can start to like respond in kind of healthier ways okay and then the fourth thing that you've got to do is meditate so i know we talk a lot about meditation on stream we say it's like really good for all kinds of stuff the the reason i include it here is because everything that we're all of the solutions to this are basically removing bad things right it's like getting sober going to therapy doing a dopamine detox it's all removal of stuff it's all restriction of stuff so the one thing that you can really do to like add it's something that you can actively do it's not getting rid of something is meditate and there's oh good evidence overwhelming evidence i would say that meditation strengthens your frontal lobes right so that's where we go back to the idea of the prefrontal cortex um it strengthens things like your ability to control impulsivity it strengthens your capacity to inhibit things uh like inhibit impulses and then the fifth thing to do is to recognize that your environment that you are prone to particular weaknesses based on your environment so you must very carefully control your environment so let's remember what are the three vulnerabilities for people with adhd and substance use um decrease so you're more impulsive right and you can't control your it's difficult to inhibit behaviors so if you are in a situation where there are going to be notifications and things pulling at your attention your attention is going to use any excuse it can to not study so if you give it any kind of excuse to not study it will get distracted as easily as possible so what i say very practically for people is think for a second about all of the things that could distract you from studying so notifications on your phone access to reddit you know being able to alt tab using a laptop even right so using a computer or using your phone for school work because all of those things are going to make it easy for you to get distracted so if you want to be effective what you really have to do is control your environment because remember that you have like a high level of distractibility right so you have like your impulsivity resistance is also minus 50 so if you are in an environment where you're being exposed to impulsive distractions you're much more likely to get distracted the other thing to remember is that your your reward sensitivity is also kind of messed up so if you look at twitter if you not only are you more prone to open up twitter but you are once you open up twitter compared to the neurotypical brain you are much more likely to enjoy twitter than another person which means that for a normal person who gets distracted they may spend 15 minutes on twitter and their mind will once again restrain itself and go back to the studying but for someone with adhd that 15 minutes is gonna be two hours because the dopaminergic response that you get the the sensitivity to reward that you have you're actually far more sensitive to reward so all of these things like social media and twitter and video games are actually going to pull your brain in even more than the neurotypical person so it's really hard like i'm not saying that any of this stuff is easy but you must control your environment and as as like as like strongly as you can as rigidly as you can as you strict as strictly as you can think about all of the impulsive sources of distraction you may have and recognize that if any one of those things happens there's a decent chance you're screwed because if you get distracted and you do something that's dopaminergic and rewarding your brain is literally going to love that reward so much even if you don't personally like enjoy it or you think it's fun the ability for your brain to engage in that behavior for two hours is actually way higher so you've got to be like far far more careful it's like you're walking a tightrope with your attention and any kind of gusts of wind can blow you off course okay so just to kind of summarize it is unfortunate that people with adhd are very prone to substance use disorders i'm not surprised at all that half of people with adhd end up having a substance use disorder as it turns out if we look at what adhd is it sort of is composed of three things as it relates to substance use disorders it's more than that for example so we talked about emotional dysregulation and things like that but there are three kind of major mechanisms that we're thinking about one is increased sensitivity reward so the brains of people with adhd are more likely to enjoy enjoyable things okay so that's what makes it easy to love drugs right because someone else can get just a regular amount of high or a regular amount of drunk but boy is it super awesome when you get high and when you get drunk the second thing is that people with adhd are more impulsive so if we look at drug use like impulsivity correlates with an increased amount of drug use there was even one study that i looked at that like people with adhd are more likely to engage with in harmful high-risk drug-associated behaviors like people with adhd are more likely to drive while intoxicated than people without adhd the third thing with that adhd does is prevents you from inhibiting your im prevents inhibition so in our brains like i may want to do something but then like i feel like doing something else and then my frontal lobes will inhibit that part of my brain that will inhibit that impulse so that i can stay focused on task so the combination of being able to of dysregulated inhibition of impulsivity and sensitivity to reward really make it easy to fall into drugs a quick summary of the neuroscience and this is there's this kind of a couple of key takeaways here so the first is that people with adhd have some kind of problem with their dopamine circuitry and that low levels of dopamine are correlated with high adhd symptoms what that means is that when you use drugs originally it'll actually increase your dopamine and i suspect that a lot of the people a lot of the reasons that people with adhd use drugs is because it actually offers some element of self-medication the problem is that if we look at chronic drug use originally drugs activate dopamine levels in the prefrontal cortex and other parts like our mesolimbic system and via the nucleus accumbens this is called the mesolimbic pathway i didn't really get into it but over time when we use substances our brain adapts and it affects the levels of dopamine in other parts of our brain so we start to see a shift from those circuits to the striatum and once you're into the striatum we actually see a drop in dopamine with drug use and with that drop of dopamine with drug use we see worsening of adhd symptoms so people get into it originally out of self-medication but then it ends up self-sabotaging the second thing the second reason that people with adhd reach for drugs in my clinical experience is because of the high amount of shame and like i suck at life because i have adhd very common and unfortunate experience and then there's another set of you know neuro vulnerabilities that we've kind of talked about that sort of make you prone to substance use so the end result of this is that like you you end up getting like 50 vulnerability to substance use if you have adhd so the question becomes what do we do about it and unfortunately this is where there are a lot of important things to do and none of them are easy and none of them are simple at the top of the list is get sober i'm sorry but you can't convince yourself anymore that drugs are like an acceptable thing to do if you've got adhd if you have adhd that is not well controlled and it's negatively impacting your life honestly the first thing to do is to get sober second thing to do is ideally work with a dual diagnosis clinician who can do therapy to help you work through shame as well as like do cbt around adhd and stuff like that and can help you like get into the process of recovery third thing that you can do is a dopamine detox so this is going to be really tough for people with adhd because dopamine detox the primary problem is essentially boredom we have a video about dopamine detox that you all can check out um but dopamine detoxes are going to help you reset your dopamine levels hopefully adjust that that d2 receptor level in the striatum and once that reset happens hopefully the adhd will get better as well and like that sensitivity to reward stuff will sort of get normalized some and then the last thing uh the uh that was third thing right so fourth thing to do is to meditate so meditation has been shown to strengthen the frontal lobes improve things like impulsivity improve things like your ability to inhibit info inhibit distractions and focus your attention and then the fifth thing to do is control your environment so this is crucial because you do have impulsivity vulnerabilities you do have distraction vulnerabilities so if your environment is like a normal environment other people may be able to not get that distracted or if they do get distracted they'll spend 15 minutes on reddit before they go back to studying whereas your sensitivity to reward is so like out of whack that if you start on twitter your brain is gonna love it so much that you'll lose two hours before you realize it so you must must must be very very strict about your environment if you were trying to do work so i hope that's been helpful for y'all i think unfortunately adhd and substance use are two of the most challenging conditions to try to build a healthy life with it's so hard because so much of our society is like how can i say this so much of our society preys on the vulnerabilities that the adhd brain has and as technology is getting more robust as you know these mega companies and video game developers are like paying people millions and billions of dollars to figure out how to engage your attention and increase user engagement it's just preying on the adhd brain even more and more and more so it's really unfortunate that it's honestly like quite an uphill battle but i don't know how to simplify it i mean i think our goal here at healthy gamer is to help y'all with this stuff and helping you all with this stuff starts with like an honest assessment of like where we are right if you want to overcome cancer sticking your head in the sand is not how you do it it involves surveillance it involves diagnosis it involves prognostication it involves understanding what's the hill that we have to climb and even if it's a super high hill we have to really acknowledge that and understand like what we're getting ourselves into because that's going to be ultimately how we come up with the best sort of plan you

Channel: HealthyGamerGG

Views: 892,770

Keywords: adhd, adhd addiction, adhd and addiction, adhd and substance abuse, adhd dr k, adhd substance abuse, dr k adhd, dr kanojia, drk, healthy gamer gg, healthygamergg, mental health, psychiatrist, twitch, why adhd is linked with addiction

Id: HNje-HuIYdI

Length: 35min 33sec (2133 seconds)

Published: Tue Sep 28 2021