Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse

1. 0:00 – 2:11

   Dr. John Kruse

   1. AHAndrew Huberman0:00

      Welcome to the Huberman Lab podcast, where we discuss science and science-based tools for everyday life. I'm Andrew Huberman, and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. My guest today is Dr. John Kruse. Dr. John Kruse is an MD-PhD and practicing psychiatrist who specializes in the treatment of ADHD in both kids and in adults. As you'll see during today's episode, Dr. Kruse is among the world's top experts in understanding the various treatments for ADHD and tools for helping to overcome non-clinical issues with focus and attention. We, of course, discuss the drug treatments for ADHD, so those include Adderall, Ritalin, Vyvanse, Modafinil, Wellbutrin, basically all the drugs that are used to treat ADHD, and we cover their relative advantages and disadvantages. We also talk about the use of caffeine for focus and how caffeine can interact with those various drugs. Dr. Kruse also educates us on how specific behaviors, like our sleep timing, so not just the amount of sleep we get, but when we sleep, as well as our meals, our exercise, how all that can shape our levels of attention and focus. And that, of course, is relevant not just to people struggling with attention and focus or who have ADHD, but to everybody. Dr. Kruse isn't just a psychiatrist. He also has a background in circadian biology research, and he offers the intriguing idea that ADHD and other deficits in focus may, in many cases, be the consequence of a misregulated circadian rhythm. He tells us how to test that idea and potentially how to fix it. By the end of today's episode, you'll understand what stimulants do, the possible origins of ADHD in both kids and adults, and both the behavioral and drug treatments and non-prescription approaches to overcoming brain fog and focus challenges. So by the end of today's episode, you'll be armed with a ton of new knowledge and you'll have a lot of practical tools you can apply. Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is, however, part of my desire and effort to bring zero-cost-to-consumer information about science and science-related tools to the general public. In keeping with that theme, this episode does include sponsors. And now for my discussion with Dr. John Kruse.

2. 2:11 – 5:37

   Attention-Deficit/Hyperactivity Disorder (ADHD)

   1. AHAndrew Huberman2:11

      Dr. John Kruse, welcome.

   2. JKDr. John Kruse2:13

      I'm glad to be here today.

   3. AHAndrew Huberman2:15

      Let's talk about ADHD, and probably best if we start off by just kind of laying out what it is. Is the H, is the hyperactivity component always in there? Uh, childhood ADHD, adult ADHD, maybe, if you would, just give us the- the top contour of this and then we can get into ways to combat ADHD depending on different circumstances, different needs, this sort of thing.

   4. JKDr. John Kruse2:41

      I'll just start out by saying that like most things in neuroscience and psychiatry, we- we have some definitions and we have lots of different thoughts and frameworks to approach things, so I'll start with our diagnostic category or how we- how we diagnose ADHD, and that is there are 18 different symptoms, nine of them are hyperactive-impulsive, nine of them are inattentive. So the inattentive ones are things like forgetting to follow through on things, losing items, um, being easily distracted. The impulsive and hyperactive ones are cutting people off in conversations, blurting things out, running around, um, fidgeting. But the definitions themselves were designed with a child population in mind because until roughly the mid-'90s, it was dogma that this was a disease, neurodevelopmental disease of childhood and that every child who had it outgrew it. That is dramatically wrong. Um, some kids do, most kids don't. The latest work suggests that most adults fluctuate in time with the severity of their ADHD symptoms. So jumping back to the definition, so we have these 18 different symptoms. As an adult, you need to have at least five of them, and when we say have them, all of these are things that normal people can display at any time. So any of us might interrupt someone, might have trouble sitting, might have trouble attending to a task, but to meet the criteria, these have to be displayed an excessive amount of time and an- or to an excessive degree to the extent that they're causing some dysfunction or distress and that they have to be displayed in multiple realms of life. So if it's only at work that you have trouble completing your task, you know, that might have something to do with your boss or an uncomfortable chair or something. So these have to be, um, traits that are displayed in multiple realms of life. Um, they have to cause, again, distress or dysfunction, they have to be to an extent that's beyond what a normal person does, and what's strange is often ADHD has a stigma it's not a real diagnosis partly because there isn't some, a fancy word is pathognomonic, you know, some classic symptom that's characteristic exactly of that. So with schizophrenia, we have hallucinations. Most people aren't having hallucinations. If you have those, you know, you might have schizophrenia or a drug effect, but- but that's unusual. Again, with ADHD, they're all usual behaviors, it's just to an unusual extent. So the diagnosis comes under s- uh, a lot of signum- stigma and questioning, you know, isn't this just normal behavior carried to an- a ridiculous extent?

3. 5:37 – 11:43

   Genetics & Environment; COVID Pandemic & ADHD Diagnoses

   1. JKDr. John Kruse5:37

   2. AHAndrew Huberman5:37

      So you mentioned that there can be a lot of environmental dependence. One thing that I, and I know a lot of people wonder about, is with the advent of more people working at home, uh, and certainly during lockdowns kids were at home for school as well, but is it the case that when somebody with ADHD is in their home environment where they're-... typically, you know, more options of things to do, that the symptoms get worse. As opposed to when they go to, say, a restaurant or to school or to, uh, play a sport or to work where, sure, there are multiple things you can do in those environments, but they're more constrained in terms of the-

   3. JKDr. John Kruse6:22

      Mm-hmm.

   4. AHAndrew Huberman6:22

      ... the, the different sides of one self, the different activities that one tends to, um, engage in. Is that, is that common?

   5. JKDr. John Kruse6:30

      Yeah, so I'll back up a little bit. The, like all of our other mental health or psychiatric conditions, there's clearly both a biological component to ADHD and clearly a social environment or ... The, the nature and nurture question isn't which is it-

   6. AHAndrew Huberman6:43

      Mm-hmm.

   7. JKDr. John Kruse6:43

      ... it's always both. So with ADHD, we know there's a very strong genetic component. The heritability factor is around .8, which is about as strong as the heritability factor for height or for schizophrenia.

   8. AHAndrew Huberman6:55

      So does that mean that if you're an identical twin and your twin has ADHD, that there's a sort of a, essentially a .8 probability that you'll have it as well? Or is this through the-

   9. JKDr. John Kruse7:06

      Yeah, I mean, heritability is a little more technically-

   10. AHAndrew Huberman7:10

       Sure.

   11. JKDr. John Kruse7:10

       ... sophisticated and it's about the variants due to gen- um-

   12. AHAndrew Huberman7:13

       Sure.

   13. JKDr. John Kruse7:14

       But it's high likelihood.

   14. AHAndrew Huberman7:16

       Mm-hmm.

   15. JKDr. John Kruse7:16

       Yeah. So this tends to run in families. But, but again, it has a social ... It, it's ... You're not just a brain in the world, you're a brain interacting with the world. And with ADHD, we like to frame it as both structure is important and demands are important. So one of the aspects of ADHD, separate from the d- official how we characterize it in term- or diagnose it in terms of symptoms, we most often are understanding it this day and age as a problem with executive functions of the brain. How the brain's working memory works, how selective attention works or doesn't work. How emotional regulation is working or not. How impulse control is working. And essentially, the ADHD brain is less able to provide the structure it needs, so it's more reliant on an optimal structure in the outside world. So getting the home versus, um, working in a w- office environment. Part of the problem is if you're in a, a traditional office environment, you know, you're starting a specific time. Everyone else is doing their work at a certain time. You know, when you go to lunch is clear. You may have people checking in or seeing you in the hallway. You know, "Larry, is your ... How far along are you on this coding project? Are you gonna be ready for it on time?" When you're home, you don't get any of that reinforcement. You don't have any of that structure. So I mean, structure is a Goldilocks issue. It's not just more structure is always good, 'cause if you put or impose too much structure on someone, so most people with ADHD are really lousy assembly line workers. They don't want to be just st- picking up one bolt, screwing it on the side of a Lexus or whatever and watching the car move down the line. That's too stultifying, too limiting, too structured. So you need the optimal amount of structure and with COVID and working from home and kids being at the home, so one thing it created is less structure for the day, but it also increased the demand s- side of the equation. So the cognitive demand, not only did you have to manage your own time and schedule now, in addition to doing your work you had to schedule, but you might've had screaming kids in the other room or you might've had your partner who wants to use that room for, you know, their quiet meetings some of the time when you're trying to do it-

   16. AHAndrew Huberman9:38

       Yeah.

   17. JKDr. John Kruse9:38

       ... so the demands increased for many people and the structure decreased and that was sort of a, um ... It's a p- perfect storm for creating more ADHD. And what's really interesting from a mental health perspective, at the very start of the COVID epidemic, public mental health figures said, you know, "We know if this is a massive epidemic and we're gonna have to do quarantine, peop- We know depression's gonna go up. We know anxiety's gonna go up. We know alcohol and substance abuse is gonna go up. We know PTSD and domestic violence is gonna go up." They claimed suicide would go up. That was incorrect and I, we can get into that, but I think there's an ADHD reason why it didn't go up. Nobody that I heard was mentioning that ADHD would go up. And part of it is because partly to hold onto its legitimacy as a real psychiatric diagnosis, both many patients and many researchers in the field hold so strongly to, "This is a biological condition. Why would it change?" You know? I mean, we can understand why PTSD, more people are being traumatized. Uncle Joe just died from coughing his lungs out from COVID. You know, PTSD, it's easy to see. Or depression. You've just lost your job and your whole industry, you know, if you're a restaurant worker, that's not coming back. So we could easily relate stories as to why these other conditions were gonna go up, but there was no prediction again mostly because I think the, the defensiveness of the ADHD community and not wanting to acknowledge as much that there's a real nurture component and not just a nature component. And yet, what we've seen just looking at prescriptions and, and, you know, this ... The media's jumped all over this. Not only have ADHD diagnoses gone up considerably but also, um, prescription stimulants have shot up dramatically in the last few years.

4. 11:43 – 14:26

   Sponsors: Eight Sleep & Joovv

   1. JKDr. John Kruse11:43

   2. AHAndrew Huberman11:43

      I'd like to take a quick break and thank our sponsor, Eight Sleep. Eight Sleep makes smart mattress covers with cooling, heating, and sleep tracking capacity. Now, I've spoken before on this podcast about the critical need for us to get adequate amounts of quality sleep each night. Now, one of the best ways to ensure a great night sleep is to ensure that the temperature of your sleeping environment is correct.And that's because in order to fall and stay deeply asleep, your body temperature actually has to drop by about one to three degrees. And in order to wake up feeling refreshed and energized, your body temperature actually has to increase about one to three degrees. Eight Sleep makes it very easy to control the temperature of your sleeping environment by allowing you to program the temperature of your mattress cover at the beginning, middle, and end of the night. I've been sleeping on an Eight Sleep mattress cover for nearly four years now, and it has completely transformed and improved the quality of my sleep. Eight Sleep recently launched their newest generation of the Pod cover, called the Pod 4 Ultra. The Pod 4 Ultra has improved cooling and heating capacity. I find that very useful because I like to make the bed really cool at the beginning of the night, even colder in the middle of the night, and warm as I wake up. That's what gives me the most slow wave sleep and rapid eye movement sleep. It also has snoring detection that will automatically lift your head a few degrees to improve your airflow and stop your snoring. If you'd like to try an Eight Sleep mattress cover, go to eightsleep.com/huberman to save up to $350 off their Pod 4 Ultra. Eight Sleep currently ships in the USA, Canada, UK, select countries in the EU, and Australia. Again, that's eightsleep.com/huberman. Today's episode is also brought to us by Joovv. Joovv makes medical grade red light therapy devices. Now, if there's one thing that I have consistently emphasized on this podcast, it is the incredible impact that light can have on our biology. Now, in addition to sunlight, red light and near infrared light sources have been shown to have positive effects on improving numerous aspects of cellular and organ health, including faster muscle recovery, improved skin health and wound healing, improvements in acne, reduced pain and inflammation, even mitochondrial function, and improving vision itself. What sets Joovv lights apart and why they're my preferred red light therapy device is that they use clinically proven wavelengths, meaning specific wavelengths of red light and near infrared light in combination to trigger the optimal cellular adaptations. Personally, I use the Joovv whole body panel about three to four times a week, and I use the Joovv handheld light both at home and when I travel. If you'd like to try Joovv, you can go to Joovv, spelled J-O-O-V-V, .com/huberman. Joovv is offering an exclusive discount to all Huberman Lab listeners with up to $400 off Joovv products. Again, that's Joovv, spelled J-O-O-V-V, .com/huberman to get up to $400 off.

5. 14:26 – 20:40

   ADHD, Interest & Careers

   1. AHAndrew Huberman14:26

      I'm fascinated by this relationship between kind of optimal structure and difficulty, or at least optimal structure versus having some, um, margins for exploration at one's job. I- I realize it's very difficult to throw out, uh, kind of pan statements about what sorts of work and professions are going to be best for people with ADHD, but, um, in your clinical observation, can you perhaps point us to kind of clusters of professions where people with ADHD tend to gravitate toward because they- they have s- sufficient or even hyper, uh, proficiency there? Like, would we say, like, the creative arts, where, you know, as long as they can get themself to- to, uh- uh, to the theater, um, they tend to do well when... I- improv, I'm- I'm using extreme, kind of almost silly examples, but those are professions, indeed. Versus, um, a job where people have, quote-unquote, "banker's hours," where it's, you know, 9:00 to 5:00. I could see that being an advantage, also being very difficult-

   2. JKDr. John Kruse15:28

      Mm-hmm.

   3. AHAndrew Huberman15:28

      ... then, of course. Or accounting, where, you know, literally-

   4. JKDr. John Kruse15:31

      Mm-hmm.

   5. AHAndrew Huberman15:31

      ... decimal points matter and- and every- every digit counts. So are there sort of clusters?

   6. JKDr. John Kruse15:37

      I'm gonna step back and answer... I'll get to your answer, but I'm gonna a- to frame it two different ways first. One is, and I didn't come up with this, but I think it's one of the most insightful quips about ADHD, is that non-ADHD brains are importance-driven. You know, if you know you have to move your car 'cause you'll get a parking ticket, you go out and move it. If you know taxes need to be paid in April, you know, it's a boring, thankless job, nobody en- well, maybe a few people enjoy it, but most of us aren't CPAs at heart, you take care of it. The ADHD brain, in contrast, is an interest-driven brain. So they know, "Yeah, yeah, yeah, I should be doing my taxes, but hey, look at how the Warriors are doing in their basketball playoff game. Look at this cool cat video. Oh, I'd rather do something else." So regarding career or work, I think the most important thing is that it's interesting to you. So I- we can talk about realms of work or certain, um, career paths, but if it's not compelling to you, if it's not interesting to you, if, it's- it's gonna be hard to work at it, even if it structurally may be a better support for you.

   7. AHAndrew Huberman16:49

      Does that carry over to other domains of life? Do you see, for instance, that people with ADHD are, um, have a harder time with parenting? Um, not that, um, kids aren't super interesting, but, you know, some of their activities might be less interesting to parents than others versus people who are just, um... I think of this word importance-driven as just kind of, like, really dutiful. Like, it's- it's- it- you do it because you're supposed to do it.

   8. JKDr. John Kruse17:15

      Part of how the field ac- actually in the '90s started becoming aware that adults could have ADHD is that all these clinicians who were having ADHD clinics for kids were starting to notice, "Wait a minute. This parent is showing up 20 minutes late to pick up his kid. Wait a minute. The parent didn't fill f- the prescription, so the kid went for two weeks without the medication." They started becoming more aware of adult... ADHD in adults by seeing that the adults who were parents to these kids, and again, there's a strong genetic connection, had ADHD. So there are certainly wonderful, loving, supportive, nurturing parents with ADHD, but studies that have looked at, you know, trying to find some objective measures are-... things more likely to be forgotten, misplaced, mislaid, go off track with an ADHD family? Absolutely. And one of the more powerful sets of interventions for kids with ADHD, separate from medications, is family-based training that helps get the whole family, one, to understand how the kid's brain is working differently, but actually it might not be that different. It might be exactly how dad or mom's brain is working. But to help them function as more consistent parents. So the other bias I'd say again before specif- identifying specific careers is that as a society, we've long cherished or valued lo- you know, the- the guy who worked 50 years for Eastman Kodak Company and got the gold watch at the end was sort of the epitome of what you should strive for in a career. But if you're interest-driven and your interests change... So for many people with ADHD, the best career is actually not one 50-year career, it's 10 five-year careers-

   9. AHAndrew Huberman19:10

      Mm-hmm.

   10. JKDr. John Kruse19:10

       ... or five 10-year careers. And part of it is, is the whole work world has become more fragmented and, you know, upheaval is the name of the game and break things quickly is the motto of Silicon Valley. Not, I didn't phrase that quite right, but, uh, the message I think is still there. We're accepting more that many career trajectories are gonna look not like just one beautiful arc, but I think there's a sort of a normocentric bias to that is what you should strive for. And if you are changing careers, you... That's a bad thing. And yet, lots of people who do worthwhile things in life and often because of their more varied experience, they're bringing more to their, what they're doing. So I think we need to value that and embrace that as an option and accept that maybe for some people, that is an optimal career path.

   11. AHAndrew Huberman20:07

       I can relate. I mean, I spent 20-plus years training to become a bench scientist and run a lab, and then now I still teach and hold my appointment. Still involved in a bit of research, but I'm in a second career now, ish.

   12. JKDr. John Kruse20:21

       Mm-hmm.

   13. AHAndrew Huberman20:21

       Um, and I imagine there'll be a third, um... We can talk later if you think I have ADHD or not. Um, I certainly consume a lot of caffeine, and we'll come back to the idea, the relationship between, um, uh, levels of caffeine consumption and, uh, possi- possible ADHD. We'll see, we're seeding the discussion for later on that.

6. 20:40 – 27:39

   Social Media & Distractibility; ADHD & Lifespan Effect

   1. AHAndrew Huberman20:40

      We hear pretty often that social media and scrolling, um, X or scrolling Instagram or TikTok is quote unquote "giving people ADHD." Um, are there any data either clinical or otherwise that suggests that the mere practice of looking at, you know, 10,000 different contexts or even, you know, you know, 15 videos in, for a minute while standing at the bus stop is somehow creating, um, more distractibility in other domains of life?

   2. JKDr. John Kruse21:15

      Yeah, so I'd say there's a lot of good neuroscience research, neuro-psychological data that the more time you spend immersed in social media and it's the constant int- It's the barrage of information and, and not just the volume of information, but that you are constantly being interrupted and that most of these interruptions are intentionally designed to attract your attention and that the more people practice thinking that way or being in the world that way, yes, it's harder to sustain attention for long periods of time, that you are... Y- you train yourself to overreact to any new distractions, so... So the core elements of some of the executive functions that are impaired in ADHD, we are all becoming more ADHD-like. So that, that's the thesis of the book that I've been working on that's still several months from going anywhere, but it, I, I call it Attention Deficit World. And one of the things that's been frustrating is that there's been this huge disconnect. There have been people writing about, you know, the question you're asking, that the neuroscience, our brains getting more distracted, are, are we becoming... You know, it's not just distracted. You know, immersion in this media world or social media, cell phone, however you want to break it down, it's not all bad. It's not just that concentration is worse. So you know, detecting visual items in the environment, being a- there's some things that people become more adept at, whether that's actually a good thing to be more adept at. Um, people who do, um, multitask more quickly or switch in and out of it, they're still not doing as well on that task if they had no distractions and just focused solely, but they're multitasking better than people who don't immerse themselves a lot in the internet. So there's a whole literature and popular books in attention. We know everyone's getting a little more distracted and... But all the books that talk about that say, "Well, this is just sort of everyday stuff. This has nothing to do with ADHD." And there's lots of wonderful ADHD books out there and they say ADHD is this discrete condition, even if they acknowledge it's on a spectrum of severity, but that it's really serious stuff and we don't... You know, just 'cause you forgot your homework or you left your car keys or you can't remember where you parked your car, everyone does that, and we wanna make sure that you respect that ADHD is a serious and potentially disruptive condition. And, and when I say serious, and I'm gonna go on this tangent for a little bit, the caricatures of ADHD is, you know, "Oh, there's the squirrel." You know, it's silly, its people are distracted, ditzy, late, doing things that we make fun of in society.... and we ignore the... Many of these things can have a more serious repercussions inside to it. So, a kid who has ADHD, their life expectancy is about 10 years shorter than their non-ADHD peers. That is the same extent of cutting off life as having diabetes or having major depression.

   3. AHAndrew Huberman24:33

      Is that because of, um, accidents-

   4. JKDr. John Kruse24:36

      Um-

   5. AHAndrew Huberman24:36

      ... addiction, injury?

   6. JKDr. John Kruse24:37

      It's... Almost all of it is two factors, and they're almost equally. One is accidents, so motor vehicle accidents. You know, if you're driving distracted, you're more likely to be involved in accidents. But it's also, you know, the, the kid who's probably being more daring with the tractor on the farm, or dairying the bull, or... I mean, all sorts of accidents, not just motor vehicle accidents. And the other is suicide. And some of the suicide is 'cause there is an overlap with depression and anxiety and other factors, but I'm convinced... And not many people are looking at this angle. Some are. With suicide, we focus so much on the despair, the misery, that someone hates their life. I mean, but there's lots and lots of depressed people who don't kill themselves. The other really important element to suicide is impulsivity, is lots of people feel really bad, but we know having guns in households increases the rate of likelihood someone's gonna shoot them. Accessibility to tools that you can quickly use to kill yourself, which shows if you slow down the thinking process, if you give people more time, if they are less impulsive, they are less likely to kill themselves. They still might be miserable. Um, and that's, m- that's my explanation for why even though during COVID lockdowns, um, we did see increases in depression, we did see increases of PTSD, we did see increases in domestic abuse and battering, and we saw actually a decrease in suicide during that time.

   7. AHAndrew Huberman26:17

      Hmm.

   8. JKDr. John Kruse26:17

      How does that make any sense? And it wasn't huge, but since suicide's been going up every year prior to that, it's pretty clear and blatant in the data and remarkable. And my claim is so many more people were at home, you know, your kid's not around to play with the gun or find the gun or, you know, you know what's going on, or poison, or hanging themselves from the door, or whatever else they might do.

   9. AHAndrew Huberman26:42

      Very interesting. I, I didn't realize that ADHD carried this, um, lifespan liability. Um, and 10 years is certainly significant.

   10. JKDr. John Kruse26:52

       There's also the middle ground. So I, I sort of mentioned the, the caricature is sort of the silliness and the trivial of being late for your friends at the restaurant or forgetting your car keys, and the extreme is death. But in between, we know ADHD measurably derails education, disrupts social relationships, impacts your likelihood of your earning potential. I mean, ADHD isn't just an academic cognitive problem. It isn't just who's gonna jump through the hoops and get through school. It isn't just who's turning in their reports or, um, doing their work on time in the workplace. It's also having social implications. And in all of those areas, it's having measurable, detrimental, significant impacts on people's lives.

7. 27:39 – 33:45

   Hyperfocus, Flow States

   1. JKDr. John Kruse27:39

   2. AHAndrew Huberman27:39

      My understanding, and, and you'll see how this weaves into the previous, uh, question in a moment. My understanding is that people with ADHD have the ability to focus quite intensely on things that really capture their interest. Um, I, I don't know if I have ADHD or not. I, I suspect if I do, it's rather mild or I just feel lucky that I, uh, went through the educational system at a time when there were no smartphones.

   3. JKDr. John Kruse28:06

      Mm-hmm.

   4. AHAndrew Huberman28:07

      I'm really grateful for that. I actually used to unplug the phone in the laboratory where I was a PhD student so that I could just do experiments from 5:00 PM on-

   5. JKDr. John Kruse28:14

      Mm-hmm.

   6. AHAndrew Huberman28:14

      ... 'cause that was the only way people could reach me. And I certainly am familiar with the... It's, it's almost a drug-like effect of dropping into an activity. Sometimes people call it-

   7. JKDr. John Kruse28:26

      Mm-hmm.

   8. AHAndrew Huberman28:26

      ... flow, but for me, it just is dropping into an activity. Did some early morning writing this morning, and gosh, the, the feeling of pleasure just everywhere from head to toe after doing 20 minutes of focused work-

   9. JKDr. John Kruse28:38

      Mm-hmm.

   10. AHAndrew Huberman28:38

       ... or 30 minutes of focused work is, is so striking to me. And yet I, like, I think most people, find it difficult sometimes to just get rid of all the distractions unless there's a deadline-

   11. JKDr. John Kruse28:49

       Mm-hmm.

   12. AHAndrew Huberman28:49

       ... which is one of the reasons I love deadlines. So the question is this. Is it true that people with ADHD can in fact focus, but that somehow whatever, uh, neural or neurochemical thresholds are there to allow them to drop into focus, um, they're just much higher thresholds? It just takes more fear of a deadline, or fear of a consequence, or excitement about the activity. Uh, is, is that true?

   13. JKDr. John Kruse29:14

       Yeah, so I'll back up a little bit, and I maybe should have said this when we were talking about diagnosis and what is ADHD. And many people think it's a horrible title because it focuses on attention deficit hyperactivity disorder, and it's very clear as you're enumerating here, it's not a deficit of attention. If it's a deficit at all, it's a deficit of control over attention. And with attention, there's at least three different realms where we're controlling it. I mean, one is we direct attention. So if something's important going on over there or there, so we have to be able to shift it. Two, you have to be able to sustain it, so if, if it's a situation that's appropriate to be sustaining it. And three is you need to shift out of it if it's inappropriate to stay in it. And in all three of those realms, people with ADHD have less volitional control over their attention. So many people in the ADHD f- who experience it describe hyper-focus as one of their superpowers, and that is where they're getting so absorbed in their work that they are...... you know, so busy coding that actually everyone else in the office has left and it's only when the janitor is coming and emptying the garbage cans at 11:00 PM that they say, "Oh my God, um, where is everyone? I'm still here." 'Cause I was so intently working on the project. Some people strongly resist the idea that flow, and I'm gonna butcher the Csik, Csik-

   14. AHAndrew Huberman30:41

       Uh, Csikszentmihalyi.

   15. JKDr. John Kruse30:43

       ... Csik.

   16. AHAndrew Huberman30:43

       Yeah. No one can pronounce his name.

   17. JKDr. John Kruse30:44

       Yeah, it's his name.

   18. AHAndrew Huberman30:45

       Uh, even fewer can spell it.

   19. JKDr. John Kruse30:46

       Yeah.

   20. AHAndrew Huberman30:46

       So we're okay, yeah.

   21. JKDr. John Kruse30:47

       My reading of wha- when I sort of delved into this, I think hyperfocus is exactly a flow state 'cause people are describing the same lack of awareness of time, lack of... And it's always, I mean, it's a task that's somewhat challenging and engaging and interesting. It's not just that, you know, if it were just about enjoyment or bliss, you could hyperfocus looking at a s- a beautiful flower. People don't describe that.

   22. AHAndrew Huberman31:16

       Mm-hmm.

   23. JKDr. John Kruse31:16

       So it, it needs the right amount of challenge. It can't be too easy. It can't be too hard. It has to be something important and interesting to you. Um, it involves, you know, oblivion not just to time, but also to lots of space going around you. Um, so I think they are pretty close, if not the same, phenomena, flow and hyperfocus. And some people with ADHD, and I think some who are ones who learn what situational factors or what internal factors can help get them into that state, but, but many of them still struggle at, at showing up when they don't want to be hyperfocused on something or, or have trouble engaging it when it would be useful to.

   24. AHAndrew Huberman32:03

       I sometimes use the absent-minded professor excuse, um, but only, uh, half-jokingly. There, there's a photograph that I love of the great Oliver Sacks, the neurologist turned writer, man who mistook his wife for his hat, Awakenings and so forth.

   25. JKDr. John Kruse32:18

       Mm-hmm.

   26. AHAndrew Huberman32:18

       Um, people may be familiar with Oliver's work. And, and it's a photograph of Oliver at a train station, lots of bodies moving around, um, him, some blurry, so there's motion there. And he's standing there with, um, I think he's got his pipe in his mouth, um, and he's writing outside the train station. His bag has fallen to the floor. Some items are coming out.

   27. JKDr. John Kruse32:42

       Mm-hmm.

   28. AHAndrew Huberman32:42

       And he's a, he was a known and self-professed, um, meth- methamphetamine addict for a great portion of his, uh, medical and, um, writing career. Um, and, you know, sort of alluded to the idea that he had these tendencies. And I, I raise this as an example because I see that photo and I see somebody who's in hyperfocus in a very just, um, busy environment.

   29. JKDr. John Kruse33:05

       Mm-hmm.

   30. AHAndrew Huberman33:05

       But he wrote, I've spent a lot of time with his work and his autobiography, et cetera, and talked to people who knew him, and it seemed that he was constantly seeking novel environments where there was a lot of stimulation and somehow that allowed him to drop into these tunnels of focus. Whereas when he spent a lot of time alone, there were bouts of focus, but the quiet actually became a distraction. It was as if somebody in here were speculating, um, uh, about diagnoses, but that there's something about external anchors and internal anchors and that l- you know, finding that sweet spot is really about knowing ourselves and where we work best at particular times.

8. 33:45 – 41:06

   Tools: 4 Essential Behaviors for ADHD; Regular Meal Schedule

   1. AHAndrew Huberman33:45

      And this is something I'd like to transition into here is talking about the fact that there isn't just one environment that works for somebody. It seems like it's often the case that it's certain environments for morning, certain environments for afternoon, certain environments having returned from vacation. It, you can probably see where I'm going with this. What are your thoughts on people trying to, with ADHD or not, trying to, um, identify sort of best conditions for them and how important is circadian, uh, time here? I know you have... And of course I mentioned in the introduction that you have a lot of background in, in circadian biology, which I think brings in a, a really additional and unique dynamic to, to your understanding of ADHD.

   2. JKDr. John Kruse34:28

      So many people come to me as a psychiatrist for ADHD are f- primarily focused on medications. And we still know that the stimulants are the single most powerful, I mean, in terms of extent of symptom reduction overall and in terms of the percentage of people they help, they're our most potent tool. I mean, the medicine's not gonna change everything and you need to be focusing on your life as well. And I always start with scheduling. And many people with ADHD find scheduling anathema, that that's, you know, like the slaves on the galley ship being told you have to row stroke, stroke, stroke. And what I tell them is that the part of you that's gonna help make the schedule that works for you isn't some evil task master trying to make you do what you don't wanna do. It's actually the wisest, smartest, nicest, kindest part of you that's identified what are your lifetime, what are your bigger goals? How are we gonna match what you're doing in the minute to line up with those bigger goals? So, and this analogy isn't perfect, but the best one I've come up with, so rather than the guy in the Viking ship, the person, you, the part of you that's making your schedule is a mother hen who's sort of counting all the chicks and making things aligned into sh- nestling down and hunkering around you and taking care of you and nurturing you. And with scheduling, what I tell people is before you slot in your work or your homework or your school or, or externally derived tasks, I, I tell people, "You need to have the four basics." And sleep is far and away the biggest basic, particularly for AD- it's, it's essential for all of us, but it's particularly critical for ADHD. And there's particular reasons why it's a particular challenge for people with ADHD. But I'm trying to think if I can imagine a counter-example. I would say-All the successful people I know with ADHD have found some way to try to regularize their sleep compared to what it would be if, if they were just... So the four essentials I say are sleep, eating, exercise or some amount of movement. 'Cause again, with the hyperactivity, there's, there's people who can sit at a desk for 12 hours not even getting up to, for a bathroom break or to eat or anything. That's not just bad f- I mean, that's bad for your brain, bad for your body. And then the fourth thing I put in is a miscellaneous category of me time, relaxation, meditation. I, I put all those in the same slot. Maybe they shouldn't. And all those need to be in place. Um, we can talk more about sleep but I'll just say a little bit more about the eating component. One of my... So we have our diagnostic criteria for ADHD, but I had, over the years, two different real-life tests. Um, the office I had was in a old Victorian home, so it was a home office. The office itself was at the, entrance was at the end of a short but very steep driveway, so it was a separate door. And I would always explain to every new patient the exact same thing. You know, "There's a house at 45 Hartford. The office is at 45A. The entrance is at the end of the driveway." And I actually did the data on it. Um, the only people who ever showed up at the front door, the home door, were the people with ADHD. Now everyone with... It wasn't, um, it was specific for ADHD. It wasn't completely sensitive, so some of the ADHD people got it right. But never did anyone who was coming in for OCD or depression or PTSD show up at the front door. And I gave the instructions the same time, and sometimes I didn't know beforehand that the person was coming in for ADHD 'cause they didn't know. But if they showed up at the front door, that always made me, uh, you know, "Uh-oh. I better make sure I ask specific detailed questions about the ADHD possible component." So the other m- sort of real-life diagnostic test I had, if someone during the evaluation would say something like, or in a subsequent session, "Oh, it was four o'clock yesterday and I just realized I hadn't eaten all day," ding, ding, ding, ding, ding. That's, I mean, I have people who diet. I have people who have, you know, fasting regimens or others. But they're not forgetting to eat.

   3. AHAndrew Huberman38:56

      Hmm.

   4. JKDr. John Kruse38:57

      And it's not that everyone with ADHD does that. But either, either not getting the right intero- receptive cues from your body or not paying attention to them is something that's been a, you know, measurable in people with ADHD. So-

   5. AHAndrew Huberman39:11

      So having a regular meal schedule.

   6. JKDr. John Kruse39:13

      So having a regular meal schedule and again, getting back to the COVID and workplace. If you're, you know, I had lots of people in tech who really lamented, "Now I have to work for home. They were giving me lunch, a healthy nice lunch each day at work." They're scrambling to, to even use the home, you know, meal delivery systems 'cause getting that organized and set up is just too overwhelming for them. And again, these are bright people who are succeeding in most parts of their life.

   7. AHAndrew Huberman39:42

      Are these people with ADHD sometimes also starting a meal, taking a few bites, and then going back to work and then, like the meal never really, um, never really ends? It just sort of, uh, sort of fragments into the rest of the day?

   8. JKDr. John Kruse39:55

      Yeah, I mean that can be one variation.

   9. AHAndrew Huberman39:57

      Mm-hmm. Mm-hmm.

   10. JKDr. John Kruse39:57

       But it's, it's often just completely forgetting or being oblivious to it. Or I mean, the other ways ADHD is c- can play a role is, "I was meaning to have breakfast before I left the house," but always when it's time to leave the house you forget that you hadn't done this and the kids' shoes need to be tied and, "Oh, do I need a new toothbrush? I better go check upstairs before I go out 'cause I'm going to the CVS store." I mean, time management is a problem with ADHD, you know, an executive function problem. Interestingly, it's not one of the 18 symptoms in our official checklist. So our official checklist is sort of a crude clinical attempt to map out a lot of the aspects of ADHD, but it misses a lot. So there's emotional regulation problems. We know something like 60% of people with ADHD acknowledge having, th- that emotions explode or come up bigger or stronger and are harder to regulate. And that's nowhere acknowledged in our official diagnostic symptomatology.

9. 41:06 – 42:21

   Sponsor: AG1

   1. JKDr. John Kruse41:06

   2. AHAndrew Huberman41:06

      I'd like to take a quick break and thank our sponsor, AG1. AG1 is an all-in-one vitamin mineral probiotic drink with adaptogens. I've been taking AG1 daily since 2012, so I'm delighted that they're sponsoring this podcast. The reason I started taking AG1 and the reason I still take AG1 is because it is the highest quality and most complete foundational nutritional supplement. What that means is that AG1 ensures that you're getting all the necessary vitamins, minerals, and other micronutrients to form a strong foundation for your daily health. AG1 also has probiotics and prebiotics that support a healthy gut microbiome. Your gut microbiome consists of trillions of microorganisms that line your digestive tract and impact things such as your immune system status, your metabolic health, your hormone health, and much more. So I've consistently found that when I take AG1 daily, my digestion is improved, my immune system is more robust, and my mood and mental focus are at their best. In fact, if I could take just one supplement, that supplement would be AG1. If you'd like to try AG1, you can go to drinkag1.com/huberman to claim a special offer. They'll give you five free travel packs plus a year's supply of vitamin D3K2 with your order of AG1. Again, go to drinkag1.com/huberman to claim this special offer.

10. 42:21 – 48:06

    Tool: Regular Sleep Timing; Stimulants & Sleep

    1. AHAndrew Huberman42:21

       So we've got sleep, eating, exercise or movement, and relaxation. Maybe-Um, before we start talking about some medications and some other factors that modulate ADHD, if we could maybe step through each of those, and, um, you could share with us some of your favorite tools that you, um, give your patients, um, and that you teach online. Um, realizing of course that each one of those is a vast topic that could, we could do entire... we have done entire podcasts on. But, um, I'm curious about your, um, favorite go-to tools. We were talking about a few of these before we started. So sleep, um, regular to bed and wake-up times?

    2. JKDr. John Kruse43:01

       Matthew Walker and his great book on sleep, one of my favorite things about it is he really emphasizes this point, that quality sleep isn't just about eight hours. It isn't just duration. It's getting quality sleep, and the timing of your sleep is every bit as important as the duration. So if you're used to sleeping midnight to 8:00 AM and you're staying up dancing or partying until 4:00 AM and you say, "Oh, it's the weekend, I can sleep in 'til noon," you may still get those eight hours, but they're not restorative to the same extent as if you had slept at your regular time. And it's... I mean, my, my PhD research was on circadian rhythms. We had realms of data back then, so this is 40, um, 30-plus years ago. We had every bit as much data then that, that the timing of sleep was as important as the duration, and yet every public service announcement just says, "Get your eight hours of sleep." You know, why are we leaving out this other piece? We've known for decades that people with ADHD have a strong propensity to being night owls, to have a different cro- chronotype where they're maybe more effective or functional later in the day, a tendency to stay up. Um, for many years now, we've actually known that there's a s- this is strongly genetically controlled, so we do have, you know... There are genetic markers affecting sleep timing that are over-represented strongly in the ADHD community. So some of it is you are pushed that way, but some of it is the nature of ADHD that if you... You know, procrastinating's part of ADHD. If you procrastinate, you're gonna push things off 'til the end of the day. Um, some people, the end of the day is a n- better time to work 'cause there's fewer distractions. You know, if everyone else is asleep finally, no one's gonna come in and interrupt your work or ask what your thoughts on this project are. But again, getting regular sleep, and regular and sufficient doesn't mean it has to be what I'd say normal. You know, if it works for you, if you can build your career and your social life around sleeping from 2:00 AM 'til 10:00 AM every day, I'd say go for it if you can be consistent with it. Um, so what are the things that help with getting regular sleep? One thing paradoxically for many people is actually being on stimulant medications.

    3. AHAndrew Huberman45:22

       Mm-hmm.

    4. JKDr. John Kruse45:23

       So stimulants do have a, as a side effect, some people have insomnia, some people stay up later, but more people with ADHD tend to, either because it's, the drug is wearing off at the end of the day and there's some crash in alertness or energy, or because they're, uh, being more productively ener- expending energy and are more tired at the end of the day, or it's just helping synchronize circadian clocks by getting a consistent start earlier in the day. We don't know the mechanism by which it works. There's, there's lots of plausible and overlapping ones, but again, daytime alertness medications can help.

    5. AHAndrew Huberman46:00

       Can I run something by you in that context?

    6. JKDr. John Kruse46:02

       Sure.

    7. AHAndrew Huberman46:02

       Before we jump back. Um, I don't consistently take stimulants except caffeine, and I limit my caffeine intake to prior to 2:00 PM, and I stack it pretty heavy in the early part of the day. But on occasion, I'll take 25 to 50 milligrams of Wellbutrin, which, uh, as you know better than I, is, um, slightly dopaminergic but certainly triggers, uh, noradrenergic release, so, um, epinephrine, norepinephrine stimu- it's a stimulant. On the days when I take that, which again is very rare, and I track my sleep every night, I notice a significant improvement in my sleep and significant increase in my rapid eye movement sleep. It's extremely consistent. So from that, I, um, sort of, uh, reverse engineered the major effect being norepinephrine. Epinephrine I decided, well, I would do something else that I know raises epinephrine, which is I'll do a cold plunge first thing in the morning of one to three minutes long. And the effect isn't quite as strong, but on those same days when I do that clearly adrenaline-raising activity, I also see a, uh, for me, a significant increase in my rapid eye movement sleep and the quality of sleep later that night. So I think there s- really is something to this epinephrine, obviously, uh, b- going, you know, hand-in-hand with stimulants. Um, epinephrine spike early and throughout the day, um, with better rapid eye movement sleep at night. Does that logically hold for you? It's just a story-

    8. JKDr. John Kruse47:37

       Yeah, yeah.

    9. AHAndrew Huberman47:37

       ... but, you know.

    10. JKDr. John Kruse47:38

        I, I was gonna say, there's, both those have some science background, so I'd say I'm glad it works, and what's hard to sorting out is why it's working is one is, you know, potential placebo effect. You're doing it because you're thinking or hoping it works, good. And two, I'd say maybe even more importantly than the placebo effect is the days that you're deciding to do this, there's something different about those days to begin with 'cause you're not doing it every day. So

11. 48:06 – 52:30

    Insomnia; Tools: Bedtime Structure, Exercise, Phones, Breathing

    1. JKDr. John Kruse48:07

       those potential issues aside, I'll, I'll jump into insomnia, and Matthew Walker talks about some of this. To me, maybe the biggest finding in insomnia sleep medicine in the last 20 years is that almost everyone who has a problem with insomnia doesn't have a problem with sleep. Huh, what, that sound like I'm contradicting myself? What I mean is-... the sleep system's intact. It's there, it's waiting to arrive and put you to sleep each night. What the problem, and th- this is from the sleep researchers, with at least 90% of, probably more, of people who have insomnia problems is the failure of the daytime arousal system to shut off properly. So normally, we have these two mutually inhibitory systems. A wakefulness arousal system and a sleep sedation system. And usually when one turns on, the other turns off. And with most people's problem with insomnia, it isn't that sleep is weak or insufficient or not there. It's sitting, it's waiting there, it just can't land on the landing pad because you're too aroused or too awake. I mean, maybe that helps the arousal system to turn off better at the end of the day if it's gotten more fully engaged during the day, I don't know. But it, it feeds back more into some of the non-medication approaches to helping with sleep, and that is doing everything you can. Again, not just to force sleep or push it, 'cause that doesn't work very well. It's getting rid of arousal, it's dampening arousal. So for people with ADHD, one is, you know, deciding on what's a reasonable bedtime. You know, having a, thinking about this ahead of time. And two, eliminating any stimulation or... I mean, so exercise, I'm a big fan of. I'm a marathon runner, I know you're heavily into exercise as well. Um, exercising too late in the evening can elevate body temperature, disrupt falling asleep. So physical arousal, we don't want to be doing a lot of late in the day, and emotional, intellectually, cognitive arousal too. So the biggest single tool in modern life is do not have your phone in your bedroom. And that's hard for lots of people to do, but if it's there, you're gonna be checking it. I mean, studies have even shown even if you're not checking it, if it's there, you're thinking about it or looking at it. Just having it away, out of sight, is better than having it visible and turned off. Two is using, if you have someone you're sharing a bed with or family members, using them to help reinforce. Yes, it... And it's really helpful to talk about this ahead of time, because the exact same words can either be sounding like a nag or someone trying to exert their power over you, rather than... But people with ADHD, we know, need reminders. They know they need some of that external structure, and if you are on the same page and can have a partner or kid or someone else present, "Hey, Dad, shouldn't you be turning off the computer and heading to bed right now?" That can be helpful. Again, it can be destructive if it's not done in a framework where both people are onboard, and it's not fair to make the other person responsible for your own behavior. But lots of people are usually happy to help the person with ADHD be more organized in their life. So we were also talking a little bit before, one of my favorite tools for falling asleep is actually cyclic sighing. I mean, there are other, box breathing and other techniques that help someone relax. So we know cyclic sighing engages the parasympathetic nervous system, our rest and digest system. I mean, one of the things that happens normally in the transition every night when you fall asleep is you're going from primarily sympathetic tone to primarily parasympathetic tone. So anything that is strengthening or putting you there already makes it easier. Um, I know you have videos about cyclic sighing, and I do too.

    2. AHAndrew Huberman52:18

       Mm-hmm.

    3. JKDr. John Kruse52:19

       I mean, my own experience, which I was sharing with you before we started talking, was not only does cyclic sighing help me fall asleep better, it actually helped me stay asleep throughout the night better.

12. 52:30 – 56:35

    Nighttime Waking Up; Cyclic Sighing

    1. JKDr. John Kruse52:30

    2. AHAndrew Huberman52:30

       That's a remarkable thing, because many people, including myself, have very little trouble falling asleep, especially given how I stack caffeine in the early part of the day and then stop in the afternoon. It allows me to fall asleep within seconds, um, somewhere, for me, typically around 10:00 PM. Somewhere between 10:00 and 11:00 PM is my typical bedtime, but then I consistently wake up, uh, at, uh, you know, 3:00 in the morning. Usually get up, use the restroom, and then go back to sleep, most of the time without too much trouble, provided there isn't a lot of stress in my external life and provided the phone is not in, in the bedroom. Um, but as we were also talking about before we, uh, turned on the microphones, um, this idea that our bladders get smaller as we age is, is complete nonsense, right? So that can't be the explanation why people wake up, uh, more in the middle of the night as, as they get older.

    3. JKDr. John Kruse53:22

       Yeah, I mean, some might. I mean, some, it may be a prostate issue. You know, clearly that isn't accounting for half the population, but I think it's much more the neurologic innervation of our bladder. You know, all our nerves start functioning not quite as well, and they're just getting the signal that I really need to urinate right now when pretty clearly most of those people don't. They could wait, but the signal is arriving that says you have to, and it's believable and you don't want to deal with it if it's... You know, you don't want to not listen to it if it is right, so.

    4. AHAndrew Huberman53:57

       How much cyclic sighing are you doing before sleep, and how long before sleep is the cyclic sighing done?

    5. JKDr. John Kruse54:02

       So when I read your paper with Spiegel and others, January... For years, I've said I don't have a meditation practice. Most people think I'm sort of so chill or relaxed that I do. I-

    6. AHAndrew Huberman54:13

       You seem like a pretty mellow dude. (laughs)

    7. JKDr. John Kruse54:16

       I, I haven't ever taken the time to do it, which I'm embarrassed by, so I said, read the paper, "I can do five minutes a day of cyclic sighing." And I tried, and it was... Some days I was getting it in and many days I wasn't getting it in till bedtime, which is the... Then I slept really well till I was around 40 and not so well the next 20 years. Both the-... mostly with the trouble falling asleep, even though I knew relaxation techniques and others. So I wound up just consistently doing it to do it more for the general health, and I do have slightly elevated blood pressure, and relaxation and to see what effect it would have, and it was clear. So I do about five minutes and much more than five minutes, I tell people, and I might be doing it a little slower than most, count out about 20 or 25 reps of it and if you lose track, doesn't matter. Just go back to the lowest number 'cause, again, everything we're trying to do is decrease arousal. If you have a timer on it and you do it for five minutes and then you're woken up, you're reversing or mitigating some of the benefit of doing it. So, I, my recommendation is to do it for five minutes, about, but do it by counting reps, and don't focus or, you know, if it's six minutes, if it's four. I mean, there's so many aspects of this, and we know the exhalation has to be longer. I was trying to find, 'cause, you know, does anyone systematically... You know, is a four-second exhalation better than 10 versus 6? And those studies would be so simplistic and easy to do, but, you know, there's lots of variables that we can play with to see what's optimal. I don't think we know at all what's optimal, but we know what's good enough to work.

    8. AHAndrew Huberman56:04

       I'm delighted to hear that it's worked so well for you. I, um, as people know, I'm a huge fan of The Physiological Sigh.

    9. JKDr. John Kruse56:09

       Yes.

    10. AHAndrew Huberman56:09

        And I take no credit for having discovered it. It was discovered by physiologists in the 1930s, right.

    11. JKDr. John Kruse56:13

        Yes. Also, also throughout the data point that I, I shared with you is that prior to trying cyclic sigh- sighing at nighttime, I was waking up virtually every single night, once a night, to urinate, and in the 18 months, 20 months since I've been doing it, I think it's been a total of four times that I've woken up during the night to urinate.

    12. AHAndrew Huberman56:34

        Fantastic.

13. 56:35 – 1:04:32

    Exercise; Addiction, Risk, Kids & Stimulants; Catecholamines & Focus

    1. AHAndrew Huberman56:36

       So we were talking about sleep. You mentioned earlier, um, encouraging people with ADHD or who think they might have ADHD to keep a somewhat regular eating schedule, or at least to make sure that they're eating. (laughs)

    2. JKDr. John Kruse56:48

       Yeah.

    3. AHAndrew Huberman56:49

       Um, and to not let their meals get fragmented into starting a meal then finishing it later. Like, have, for some people it's breakfast, lunch, and dinner. For some people, like myself, it's lunch, snack, dinner. Whatever it is, keeping a regular schedule. Um, exercise. Uh, aside from encouraging people to not exercise too late in the day, um, certainly not, um, caffeine and exercise late in the day, are there any data about specific types of exercise being better for, um, ADHD independent of effects on sleep? I realize they're hard to tease apart.

    4. JKDr. John Kruse57:24

       Yeah, there's a few studies looking at acute aerobic exercise. Part of it is that it's hard to study people when they're exercising during many exerci- yeah, I mean, you're not gonna wire someone up when they're swimming, for example.

    5. AHAndrew Huberman57:39

       Right.

    6. JKDr. John Kruse57:39

       So there's not a lot of studies in any one approach and there's so much diversity that often it just gets lumped together. So there do seem to be some acute effects of measurably improving some of the executive functions associated with better attention from acute exercise, and there seem to be some more general or longer-term benefits from people who are consistently actively exercising, having, you know, being able to concentrate longer, being able to sh- switch att- attention more appropriately or effectively. And there's a huge body of sort of clinical la- literature of patients reporting, you know, "I know I feel much more alert the day I get my workout in the gym in," or, "I feel better," or that, you know, "The week I took off from that was a big mistake." But I would say identifying yet what's the most valuable or what's the best duration, I ran through the data about a year or two ago and it's, I could say that we can't make any conclusions, and I would say at some level, try it and see what works for you, and that's what's important. It isn't what works for everyone.

    7. AHAndrew Huberman58:48

       Is there a relationship between ADHD and addiction because of the impulsivity component?

    8. JKDr. John Kruse58:55

       Yes and, uh, and. So the answer is, and these are really rough statistics. I actually, one of my pet peeves is people who quote, "Oh, the rate of this is 27.43%." Well, it might've been in that study, but that's looking at one population, at one set of... So I use ballpark figures. The ballpark figure is Americans in the last 20 years, more than that, about 20% of Americans run into some addiction, substance addiction problem, you know, either alcohol or drugs. People with ADHD have a rate that's almost double that, and it's higher in men than in women.

    9. AHAndrew Huberman59:33

       Double?

    10. JKDr. John Kruse59:33

        Uh, almost double. Almost 40% risk.

    11. AHAndrew Huberman59:36

        And that's for substance abuse and not, um-

    12. JKDr. John Kruse59:38

        That's substance-

    13. AHAndrew Huberman59:38

        ... behavioral addictions?

    14. JKDr. John Kruse59:40

        Yeah. That's substance abuse, and that's looking at abuse, and we can get into the related topic of what's misuse and versus abuse, and I have pet peeves there. However, kids who are put on stimulant medications when they're young, and, and I should say that stimulants themselves do have a small potential for addiction, but putting kids on stimulants pretty much normalizes the rate of addiction problems, so-

    15. AHAndrew Huberman1:00:07

        So it protects them.

    16. JKDr. John Kruse1:00:07

        ... cuts it in half. It protects them.

    17. AHAndrew Huberman1:00:09

        This is a really important point that I think maybe we just hover on for a second, um, because I think many people, including myself, assume that, well, if you were, you know, putting these kids on amphetamines of which, you know, many of the medications for ADHD are, th- that we're creating kids that are addicted-

    18. JKDr. John Kruse1:00:28

        Addicted.

    19. AHAndrew Huberman1:00:28

        ... to amphetamines-

    20. JKDr. John Kruse1:00:29

        Yeah.

    21. AHAndrew Huberman1:00:29

        ... or to a hyperstimulation, period. But you're telling me it's actually protective to put kids with real-

    22. JKDr. John Kruse1:00:37

        Yeah.

    23. AHAndrew Huberman1:00:37

        ... ADHD on medication for ADHD?

    24. JKDr. John Kruse1:00:39

        Yeah. I can say not absolutely every study has found this, but several large meta-analyses have gone back and most of them have found this fairly dramatic...... benefit to being on stimulants as a kid, in terms of specifically reducing substance abuse risk. And some of them that have looked at this when I said it was a "Yes, and," um, it seems to be that it's not just the impulsivity traits, but some of the inattentive ones too. You know, if your teacher's lecturing about the risks of alcohol or this and this, and you're zoning out the window and looking at the plane flying by, you have less pertinent information on the topics. You may be less attentive to the negative effects that other kids are seeing among their classmates who are stoners at this age, or X, Y, or Z. So it seems that both inattentive sets of ADHD symptoms and the impulsive, you know, thrill-seeking, not weighing the consequences heavily, are all contributing to this heightened risk.

    25. AHAndrew Huberman1:01:42

        I have this model in my head that is, um, perhaps completely wrong, maybe partially wrong, um, and it, it goes something like this: that we know that the neural circuits involved in executive control and directing attention and maintaining attention and avoiding distraction, this kind of thing, um, use dopamine and epinephrine and norepinephrine, um, at least to some extent. And we know that people with ADHD are capable of focus. As you said, it's a, it's a failure to direct that focus, maintain it, et cetera. So I've heard from you before this discussion that, you know, people that, you know, tend to drink lots and lots of caffeine or who can drop into an activity, but have a lot of distractibility, that, you know, they might have ADHD. So what I'm imagining here is that the threshold to get dopamine, epinephrine, and norepinephrine released is either much higher or more complicated, um, for people with ADHD. And so what they're seeking is these catecholamines, these three chemicals, dopamine, epinephrine, norepinephrine, and that if they're given a, a medication that puts them in that range where they're getting it, then they're good. They can stop seeking it, so to speak. Um, and I'm raising this now because we're talking about addiction. Addiction is a, you know, pursuit of things, essentially. And I, I guess what I'm saying is i- i- it seems to me that the model of ADHD that we hear about is that, you know, people can't focus, um, you know, their dopamine circuits are all out of whack, and then you put them on this dopaminergic drug and, you know, basically you get them addicted to that tunnel vision or something. But I, I have this model in mind now that what we are all seeking is to have portions of our day where we are directing our focus towards meaningful bill, things that are, you know, generative in our life, work, school, relationships, et cetera. And that whether or not it's pharmacology or exercise or, or what have you, that it's, it's just about getting into this plane of, of consciousness. And I say that in no woo or abstract terms. Is, is that right? I mean, are we, are we really talking about here is a failure to access enough of these neuromodulators and, and these medications, which we're about to talk about, are really about putting us in the realm where those neuromodulators are just more accessible?

    26. JKDr. John Kruse1:04:04

        I'll just say, I can go with that. (laughs)

    27. AHAndrew Huberman1:04:07

        Okay. Well, you're the expert. I mean, I mean, I'm, I'm putting this together based on kind of what we were talking about, like getting enough sleep, to me, is a way of being able to have enough arousal during the day. Um, you know, exercise or these medications, just different ways of being able to access arousal. Like, if you don't sleep, you can't access arousal during the day. So okay, with that, I'm gonna hold that model in mind, and I'm gonna keep testing it to try and, uh, destroy it as we go forward. Um,

14. 1:04:32 – 1:16:46

    Ritalin, Stimulants, Amphetamines; Amphetamine-Induced Psychosis & Risks

    1. AHAndrew Huberman1:04:32

       let's talk about the medications, since, uh, you raised those. Um, and, you know, the first one I ever heard about was Ritalin.

    2. JKDr. John Kruse1:04:41

       Mm-hmm.

    3. AHAndrew Huberman1:04:42

       Um, let's start with Ritalin. Um, how often is Ritalin used nowadays, and what is Ritalin doing, uh, neurochemically, and what are your thoughts on Ri- Ritalin as a, a useful drug for childhood and adult ADHD? And I'm happy to repeat those questions.

    4. JKDr. John Kruse1:04:58

       Let's see. So, so Ritalin is, or generic methylphenidate, and there's dozens now of slow-release versions, and there's even a patch, a skin patch instead of an oral version. Our definition of what a stimulant is, is really squishy and vague. In its broadest sense, it's any drug that has an effect in the body like the sympathetic nervous system, which is a norepinephrine-driven fight or flight arousal system. So by the loosest criteria, caffeine's a stimulant, um, Wellbutrin's a stimulant, even though we classify it as an antidepressant. Um, some of the decongestants are stimulants. But more often when we're talking ADHD medicines, we're using stimulant more specifically for amphetamine-based products like Adderall and Vyvanse, and again, there's a host now of newer branded extended-release forms, and methylphenidate, and we lump the two together. Probably most ADHD experts agree with, and this is where I'm gonna be disagreeing with most of them, I don't consider Ritalin a full stimulant. So the neuropharmacologists differ a little bit, but amphetamine is a strong dopamine and norepinephrine re-uptake blocker, so it prevents what's already been released from being taken back up, so more is available longer. But in addition to that, amphetamine is a pretty potent, let's just say, vesicle manipulator, so it's actually forcing a bigger release from the vesicles when they're synaptically released. So it's not just that the signal lasts longer and is stronger because of that. It's a bigger signal. Depending on what study you look at, most of the studies suggest that methylphenidate is actually a pretty weak vesicular manipulator, and some studies don't find any impact there at all.... which means if methylphenidate is basically a norepinephrine and dopamine re-uptake inhibitor, that's what Wellbutrin is, that's one of the com- you know, it's... And so, so why I would further say, if you look at the efficacy data, how well do these work in resolving ADHD symptoms? All the meta-analyses lump Adderall products, amphetamine, and methylphenidate products here, and say, you know, they're here 'cause they work better. This is, you know, success in reducing ADHD symptoms. And all of our Strattera, At- uh, Atomoxetine, Wellbutrin, I use Cymbalta a lot, Modafinil, Guanfacine, all these other things are down here as less effective. But if you actually look at any of the plots that I've looked at and separate out, methylphenidate is actually closer to the pack below. It's the amphetamine products are head and shoulders above everything else. Methylphenidate's usually at the top of the rest of the crowd. But if you're just looking at the, the data objectively, there's a clear decision point. So in terms of efficacy, amphetamine products are stronger. Um, but in terms of some of the side, the, you know, the, uh, side effect that I worry most about, it's not at all common, but it's one of the horrible ones, is amphetamine-induced psychosis. Now that we're finally looking at that a little more closely, 'cause for years the ADHD experts have said, "Yeah, it's really rare. Let's not look at it at all. Let's not pay attention, move along." You know, don't look. Um, with amphetamine, Adderall products, and that's probably dose dependent, but it's close to one out of 500 people. And what's, I'm going off on a tangent here, but I'll keep following it 'cause it's an important tangent. It's only one out of 500 people. That's uncommon, but this is a really bad condition 'cause, so amphetamine-induced psychosis is a schizophrenic-like picture. Usually someone is really paranoid, really worried that their friends are manipulating them or the police are spying on them. I mean, if you drink too much alcohol, you can be batshit crazy as, that's a highly technical term there. I mean, you can be out of touch with reality. You can be hallucinating. You can be saying all sorts of nasty things. But if it's alcohol-induced, you fall asleep at the end of that night, you wake up the next morning, you may feel horrible with a hangover. You're not hallucinating. You're not psychotic anymore. Hopefully you're regretting what you did. Probably not remembering much of what you did.

    5. AHAndrew Huberman1:09:30

       People will let you know. (laughs)

    6. JKDr. John Kruse1:09:32

       With amphetamine-induced psychosis, on the other hand, classically and characteristically in what I've seen clinically, it continues for days, weeks, or months after stopping the medication. Which means we are sh- we've, we've changed someone's brain and we don't have lots and lots of data and it's actually only come to us because people are concerned about marijuana causing a similar picture. So now we're studying this a little more. But with amphetamine-induced psychosis, about tw- and these are again rounding from different studies, about 20%, if you look 20 years out, about 20% of those people are in a permanent psychotic state still. So again, it's uncommon, but it's such a bad outcome that we really should be alerting people to it. And I've been asto- I, I saw much higher risk of this for, I can get into it if we need a reasons, in my population in, in San Francisco. But I've had people coming from all the most prominent ADHD clinics over the years or just moved to the area, and when I'd say this, give this as my introduction to, you know, "I'm happy to continue on this, but are you aware?" To a person they said, "No one ever told me that." Now maybe they have ADHD and weren't listening, but it's so uniformly consistent that they didn't hear or know that that was a side effect.

    7. AHAndrew Huberman1:10:55

       And one in 500 isn't a trivially small number.

    8. JKDr. John Kruse1:10:58

       No, it's not trivial.

    9. AHAndrew Huberman1:10:59

       Mm-hmm.

    10. JKDr. John Kruse1:10:59

        And, I mean, why I got alerted to it is my rate in San Francisco is actually higher than one out of 100. Um, and so I'll go into, I think, a couple different reasons. One is I worked with a lot of HIV positive men, and we know HIV, particularly in the days before we had effective antivirals, is a virus that goes to the brain and affect, you know, there's a HIV-induced dementia. So probably some of these people had brains that were compromised because of that and more vulnerable. Two, a high incidence of methamphetamine. So methamphetamine street speed is a chemically different molecule than amphetamine, has an extra methyl group, and an extra methyl group can mean a lot. Um, so it's a cousin, but methamphetamine we know has higher rates of psychosis, higher rates of addiction. Um, is- tends to be more rewarding. But again, in that population, and many of them would hide that history from me, but I think that... The very first person I had with methamphetamine-induced psychosis, a guy in his 40s, HIV positive for years, this was back in early mid-90s, was able to finish school in his mid-40s, get a good paying job in two years on stimulants, and then had a full-blown psychotic episode where he, his dad had died of a heart attack 10 years earlier. He was threatening his mom 'cause he believed his mom had poisoned her. He flew over to Rhode Island where she was living. He was making threats from a payphone. And because Rhode Island's so small, he was actually calling from out of state, so it was a federal crime. He got thrown in federal prison for this. And, and he stayed psychotic for months after he wasn't using any... But it later turned out he had had a psychotic episode 10 years earlier on street meth, which he...... lied about when I did the evaluation. So the other high-risk group I had was I was known in San Francisco as someone who worked with adults with ADHD at the early stages of recognizing ADHD, so ... And I was comfortable with the broader range of stimulant dosages, and many providers are. So I had people who had ... And they were all young, white males, straight males, who had histor- ... And I don't know how many, how many of those demographics are relevant, but who had histories of taking stimulants, having a psychotic episode, again, being really paranoid, all ... I- and again, the numbers aren't huge, but at least five people with this general profile. But even though they were paranoid, even though they were severely impaired enough that each of them wound up in a psychiatric in-patient hospital, which is pretty hard to get into in this day and age, or even 20 years ago, they all liked something about the experience enough that they all wanted to get back on ... And, and all of them knew enough to lie about this past. So they didn't tell me about, you know, they didn't ... They presented ... All of them also had ADHD. You know, they presented with ADHD. They'd say, "I've been on stimulants before," and, you know, "I'm not working with that doctor 'cause my insurance changed," or they had moved to the area. So they, they gave plausible histories and most of those, within a month or two of restarting it, wound up back in the psychiatric hospital. I had one guy, bright computer programmer, late 20s, calling me from inside the psychiatric hospital to try to get me to prescribe more Adderall to him. And not only that, he had convinced-

    11. AHAndrew Huberman1:14:44

        Mm-hmm.

    12. JKDr. John Kruse1:14:44

        ... his in-patient psychiatrist that this was a good idea, that this was important to treating his ADHD and helping him retain his job.

    13. AHAndrew Huberman1:14:52

        Wow. So these are, as you said, um, straight, white males who have psychotic episodes on their ADHD meds. And s- continue to seek those meds because they, quote-unquote, "like" the experience. It, it feels like a manic high, the dopaminer- the high dopaminergic state.

    14. JKDr. John Kruse1:15:14

        Yeah. And, and I n- and j- it, there's ... You put the word mania in there, manic, and lots of people define this as amphetamine-induced mania rather than psychosis. I don't, because one is uniformly, and maybe other people are seeing more, that these people were paranoid, they were worried, they were anxious, they were delusional, but they weren't overtly enjoying it. They weren't having a great time. They weren't saying, "I'm gonna party with all you friends and I'm only worried about the people there." And, yes, they were talking more loudly, they were sleeping less, which is, could be characteristic of mania, but there was no positive affect that I, or police reports, or often families give you extensive history of everything that was going on, that there was nothing euphoric they were describing about it. I mean, I think th- the second piece is how much of they ... It's unclear how much they actually remember or recall, or ... Either through, you know, psychological suppression of it or physiologic, they're in a different enough state it didn't register properly. It's not clear. But they tend not to r- recall the paranoi- and, and by paranoia, it's persecutory delusions. You know, I have people who assaulted family members thinking that they were being spied on, manipulated, when they just were the parents trying to take care of their kids.

15. 1:16:46 – 1:18:03

    Sponsor: LMNT

    1. AHAndrew Huberman1:16:46

       I'd like to take a quick break and thank one of our sponsors, LMNT. LMNT is an electrolyte drink that has everything you need and nothing you don't. That means the electrolytes, sodium, magnesium, and potassium in the correct ratios, but no sugar. We should all know that proper hydration is critical for optimal brain and body function. In fact, even a slight degree of dehydration can diminish your cognitive and physical performance to a considerable degree. It's also important that you're not just hydrated, but that you get adequate amounts of electrolytes in the right ratios. Drinking a packet of LMNT dissolved in water makes it very easy to ensure that you're getting adequate amounts of hydration and electrolytes. To make sure that I'm getting proper amounts of both, I dissolve one packet of LMNT in about 16 to 32 ounces of water when I wake up in the morning, and I drink that basically first thing in the morning. I'll also drink a packet of LMNT dissolved in water during any kind of physical exercise that I'm doing, especially on hot days when I'm sweating a lot and losing water and electrolytes. There are a bunch of different great-tasting flavors of LMNT. I like the watermelon, I like the raspberry, I like the citrus. Basically, I like all of them. If you'd like to try LMNT, you can go to drinklmnt.com/huberman to claim an LMNT sample pack with the purchase of any LMNT drink mix. Again, that's Drink LMNT, spelled L-M-N-T, so it's drinklmnt.com/huberman to claim a free sample pack.

16. 1:18:03 – 1:26:06

    Adult ADHD & Medications; Stimulants & Cardiovascular Risk?

    1. AHAndrew Huberman1:18:03

       What are the options for people that think that they may have ADHD? Uh, let, let me phrase it differently. Someone comes in and you ... They have, you know ... Let's say an adult. They have five of the 18, um, w- uh, criteria. Um, they, they meet the criteria for ADHD. Do you tend to ... Uh, well, after telling them about sleep, food, exercise, and relaxation, after that's squared away, if the decision is to medicate, do you dec- and assuming they're not on any other medications, which cluster in this, um, two sets of clusters that you described before, the amphetamine type, the Adderall, Vyvanse, um, et cetera, versus the ... I realize you put Ritalin at the top of the bottom cloud.

    2. JKDr. John Kruse1:18:53

       Mm-hmm.

    3. AHAndrew Huberman1:18:53

       Um, Wellbutrin, Ritalin, um, Modafinil, uh, you mentioned Cymbalta. Uh, wh- which cluster do you go to first?

    4. JKDr. John Kruse1:19:04

       I mean, some of this is just individual style rather than intellectually thinking one is better than that. And my style is usually to listen as closely as I can to what the patient wants. That doesn't mean agree with them, but to, to explain in as much detail as I can what I perceive the risks and the likelihood of those are, and what I perceive the benefits to be. Um, for years, just statistically, I had many more people who are on non-stimulants than stimulants compared to the general ADHD population. And that's even accounting for, by many variables I'd had, I- I've always worked with a lot of people who are on disability from Medicare. I also work with people who are on Medicaid in the city's insurance before Obamacare happened. So I've worked with, not entirely, but a skewed, more dysfunctional, more severely afflicted population, which again you would think would be a better match for the more powerful drugs. Um, I would, I'll, I'll jump back, but this actually is a situation where we have more powerful drugs. So often when I treat people with depression, they'll try one or two or three antidepressants and say, "Well give me something that's more powerful." And with depression, maybe we can put ketamine out of the picture, and I know this is a side issue, but all of our antidepressants seem to work equally well. We don't have potent antidepressants and non-pot- uh, that got FDA approved, it works in a certain range of likelihood. But with the stimulants, amphetamine-based products really are more powerful, and more so than with depression or many of our other conditions where it's more a categorical, this will help or not as long as you're above a threshold, there's a more linear relationship. If you, if a little bit of Wellbutrin helps, a l- a lot, it's likely to help more. I mean, you might start getting more side effect issues and there may be good reasons to not keep going up, um, but there's a more linear dosage results relationship.

    5. AHAndrew Huberman1:21:09

       Do you worry about, um, strain on, uh, the heart with amphetamine products? Um, just even if it's relatively low dose over time, just, you know, the, just the strain on the calcium channels and on the, on, on the heart, uh, you know, is it true that, um, that stimulant-based medications for ADHD can, quote-unquote, "weaken the heart?"

    6. JKDr. John Kruse1:21:32

       Uh, when you use that term, I was, I was talking with Rob beforehand about running marathons. And when I ran the 100th anniversary of the Boston Marathon, they had some of the medical literature from the previous decades. And one of the medical warnings was, you know, maybe you could do one or two marathons in your life, but don't do more than that because your heart will wear out.

    7. AHAndrew Huberman1:21:53

       (laughs)

    8. JKDr. John Kruse1:21:54

       And, you know, I've run 100 and my heart, I think, is still beating. So we know things we thought we knew at one point.

    9. AHAndrew Huberman1:22:01

       Mm-hmm.

    10. JKDr. John Kruse1:22:02

        Common cardiovascular effects of not just the stimulants, but the non-stimulants that are affecting norepinephrine, so Wellbutrin, Cymbalta, um, Modafinil it's less clear and we can get into that when we talk about Modafinil, but clearly methylphenidate, amphetamine, on average increase, at therapeutic doses, increase heart rate a few points, increase blood pressure a few points. But part of that obscures that probably 80% of people don't have any change and maybe 20% have a, maybe a more slightly significant change. So we know that there's some impact there. We know there's some people with extremely rare genetic underlying conditions, um, usually related to the neurologic wiring of the heart who are particularly vulnerable to dropping dead from a stimulant. And almost every year, there's, you know, a well-trained athlete, either a professional player, or more often a high school or college player, college, you know, who will take cocaine, take Ritalin, take prescription stimulant, and drop dead of a heart attack. Um, the risk of that's so uncommon, this is 15 years ago when Adderall XR came out, the Canadian government was worried enough about this risk that they banned Adderall XR for almost a year. And because they have a comprehensive medical system, they could look more extensively at the numbers, and this is looking at kids. The percentage of kids who dropped dead with Adderall was tiny, and not just tiny, it was lower than the kids who aren't on Adderall who dropped dead of a heart attack. So part of it is, if you're in this rare genetic condition, almost always there's family members or you've had some other near death or syncopal episode where you passed out. So history taking of the individual and family history, and if you're at all worried or concerned, you can do EKGs, which should detect most of those electrical abnormalities. But the cardiology and lots of my colleagues practice maybe a more conservative cover your ass medicine approach where everyone has to have an EKG before they're on a stimulant. Uh, even the cardiology associations have said that seems to be a waste of resources. Absolutely do a thorough history, absolutely do a thorough family history. If there's anything of concern or if the patient's anxious about it, get an EKG. But other than that, these should be generally safe for most people's hearts. So there was a meta-analysis that came out earlier this year on... So most of the studies looking at more serious other than just mild hypertension or mild elevation of heart rate, um, haven't found much, but most of them only look, you know, a year out or a year of treatment, do we see rates of heart attacks? Do we see rates of strokes? Do we see rates of a- dangerous arrhythmias?... and in general, they're looking at a young population, where these events are really uncommon anyway, and most of them didn't find any evidence of problems in a year or two out. A more recent study looked as long as 14 years out, and there they found measurable, statistically significant increase in risk that increased during the first three years of being on a stimulant and... increased at a much lower rate for the next 10 years, sort of plateaued out, but still measurably higher than people with ADHD who weren't on a stimulant. But the absolute rate is still really, really low. So for most people, it's not a risk. I mean, on the other hand, if you start these medicines when you're 10 or 20 and may be on them for 60 years, we don't have, or we, we don't know whether potentially more people are getting into more trouble.

17. 1:26:06 – 1:33:49

    Adult ADHD Medication Choices, Psychosis, Cannabis

    1. AHAndrew Huberman1:26:06

       So if somebody presents as, um, having ADHD as an adult and they've never touched stimulants, and they're, uh... would you start them on Ritalin, Wellbutrin, or Adderall, or something in the Adderall, Vyvanse class?

    2. JKDr. John Kruse1:26:19

       So, so thanks for bringing-

    3. AHAndrew Huberman1:26:21

       Yeah.

    4. JKDr. John Kruse1:26:21

       ... me back to your question.

    5. AHAndrew Huberman1:26:22

       Sure.

    6. JKDr. John Kruse1:26:23

       Um, and I'm, and I'm going to jump at, you threw in a sort of qualifying phrase, never been on any stimulant in their life or tried it or something. Or, and what I would say-

    7. AHAndrew Huberman1:26:31

       At least not consistently. Yeah.

    8. JKDr. John Kruse1:26:32

       Wha- what I would say is lots... these drugs are fairly common in our society, both illicitly and licitly. I mean, we know lots of kids, lots of adults with ADHD share their medication. Lots of people have tried these things, even if it's just once or twice. And that itself is valuable clinical data, you know, if they felt too revved up from it, you know. So if they have, I try to find out what dose was it, what did it do for you? What good things did it do for you? What bad things did it do for you? So my presentation is, is usually, you know, Adderall is likely to be the most strongly effective, or I more often are using Vyvanse. These are the other options, but Adderall also has, again, greater r- rare but risk for these bad problems. What... you know, does that scare you? Some people are petrified, they're not going to go anywhere near that. Some people say, "Yeah, I'm not that concerned about it." And most people do come in with some friends at work, family members, X, Y, or Z, you know, they think they know what the drug is likely to have as an effect on them, and I tend to, at least as a starting point, listen to that, and... Now, I mean, there are cert- m- reasons I absolutely would not. I mean, my worry, again, I, I saw more of it than I think most people in a higher rate with amphetamine-induced psychosis. But a friend from college was just trying to refer a friend's son, who's 27 and had a psychotic episode on ma- on marijuana, and does have ADHD, and is in bed depressed and not going to work, and is being evaluated by two Nor- New York City doctors, but the psychiatrist kept him on Adderall. I absolutely... Again, the, the, the likelihood of recurrence seems so high that if you have a family history of schizophrenia or psychosis, or you've had any experience of it, I would not prescribe a stimulant, a- an amphetamine-based stimulant.

    9. AHAndrew Huberman1:28:44

       Could we go so far as to say, and I suspect the answer is no, but because nowadays we're hearing more about the possibility, I want to highlight possibility, of high THC cannabis causing psychotic episodes, this is something I've stressed on this podcast, on social media. I took a lot of heat for this, um, from the traditional press, um, and then ironically they're now putting out information that es- uh, essentially speaks to the same.

Episode duration: 2:38:05