8 Years of ADHD Treatment Advice in 20 Minutes (From a PMHNP Who's Seen It All)

Cedric: You are listening to the
Compass Point Institute Podcast.

Today Jon Murphy Psychiatric Nurse
Practitioner shares his clinical insights

about optimal treatment and diagnosis
of ADHD from a clinician's perspective.

Jon Murphy, PMHNP: This is about ADHD.

We're gonna talk diagnosis, we're
gonna talk treatment and ADHD as

an idea and a diagnosis in general.

It's not just attention issues.

We can think of it as involving dopamine.

So just, let's just put that out there.

We got two brain chemicals or
two, two full person chemicals.

Let's say like we have two
chemicals in the human body that

right now that we want think of.

There's a, there's really a zillion, but
we just want to think about two right now.

Serotonin and dopamine.

Dopamine we hear a lot about these days.

It's basically the pleasure chemical.

When you click on your iPhone
and your mind goes, Ooh, I just

saw something good on TikTok.

That is dopamine.

And ADHD is a neurodevelopmental disorder,
meaning We're identifying individuals

whose neurodevelopment is Not firing and
wiring in a way that we would expect.

So we want to see the pattern.

We wanna spot Mostly because it's a very
good indicator that this individual, by

applying pharmacotherapy, identifying
those that meet criteria also indicates.

A very high likelihood that dopaminergic,
pharmacotherapy or stimulant medication

applied will be therapeutic, meaning

life is safer, better,
healthier with medications.

So does a therapy for these patients.

Not for patients with depression
or anxiety or other things, but

for looking at executive function
and ADHD and neurodevelopment in

this way, we're considering that,
but not everyone wants medication.

So identifying this diagnosis is
necessary for a variety of other

reasons, because if it's not treated,
we want to consider that too.

We want to consider ADHD conceptually
first, understanding how.

Holistically that affects the
presentation of the psychiatric

patient, and I am talking about adults
and the sort of outpatient one-on-one

telepsychiatry a relationship.

So we're looking for
something that's chronic.

It's not acute.

How do we spot it?

So the DSM five criteria, I love
'cause it's a really strong basis for

the identification of people that.

Not only will benefit from a very
particular category of psycho

pharmaceutical, but to understand and
delineate where other issues end and

where, executive function issues begin.

ADHD is an issue of the mind.

So when we think about the mind,
the brain, the squishy thing, we

wanna think about the frontal lobe.

That's that prefrontal cortex in the
front, otherwise known as I am me and me

as I, the adult brain, the me, the you,
the part of ourselves that talks and

has a narrative, but there's also other
parts of our brain that are of the mind.

We have our motor cortex,
we have our memories a sense

of balance, proprioception.

When you get a little bit down the
line, you got your limbic system.

Your limbic system is like in the middle
of your brain, and it connects to the

beginning of your spinal cord, which
is your peripheral nervous system.

All the electrical signals and cables
and wires that go all over your

body, make your heart beat, make your
lungs breathe, make all the things

happen on a biological level down to.

The single cell ' cause we are cellular
organisms and the limbic system

contains a few things that we want to
think about, but it's in the middle.

We think about the brain the sort
of prefrontal cortex as the top.

We think about the peripheral
nervous system as the middle.

And we think about the body as the bottom.

So let's dive into the middle.

'cause this is the bridge
between the mind and the body.

It is the hippocampus, which is a
part of the brain that basically

we think of it as emotional memory.

I remember remembering this in
school 'cause it's like a, all

right the hippo maybe, let's say
the hippo is a really good memory.

So the hippo went to the campus to learn.

He is like really smart.

So that hippo has a, one of
those graduation caps on.

So anytime you know the way trauma
works or the way survival works,

automatic responses, survival responses,
there's a hippo at an academic

campus, and he's taken out that file.

The hippocampus is that part of the brain
and it's right next to the amygdala.

The amygdala is the part of the
brain that's reacts rapidly,

and it secretes the cortisol and
it's basically the fear center.

So if that hippo goes to his
university campus and he pulls out

a file and it's not a very good one,
it's actually red with Xs on it.

Ah, it's scary.

He runs over to the amygdala.

And the amygdala secretes cortisol
reacts very strongly, and that is

the, you think about the amygdalas
generating the worst panic attacks the

largest indicator of acute distress.

And then we have sort of a fight or
flight mechanism, and this is the seesaw.

In the brainstem here, lizard brain.

We're going lizard brain.

And when we're in the lizard
brain, we got fight and flight.

Ah, but it's not quite that simple,
but we can keep it there for now.

Fight and flight.

Ah, rest and digest.

Relax and, ah, so it's on one
side, it's the activation, and

on the other side it's the rest.

On the one side it's stress and
hypervigilance self-protection.

On the other side, it's, I'm good.

We're surviving and thriving.

'cause we need to grow and we
need to rest to grow and to

truly thrive, we need to relax.

And that's the whole person view.

So ADHD exists at the top in
our mind, the prefrontal cortex.

we're not.

Utilizing medication to do
anything directly that is gonna

affect nervous system regulation.

So the limbic system also is
the sort of emotional center.

There's other parts of just the
sort of way we process and emotions.

These parts of the brain
are highly reactive.

Cedric: During emotional responses
and that's basically input.

It is input from our sensory experience
of the world, what we see, what we

feel, what we touch, what we go through.

That input goes in and that part of the
brain our nervous system, the limbic

system, that old Hippo campus puts it
all together really quick and spits

it out and boom and then much later,
or if at all, our prefrontal cortex

up there catches up, it's whoa, huh,
look a butterfly, or What's happening?

So that's slower.

And when we're using that part of our
brain let me use my reasoning system.

Let me think about it.

Is it the right time to do it?

So people with ADHD, we can say
they're prefrontal cortex and they're

like, oh, let's think about it.

Jon Murphy, PMHNP: I'm thinking about it.

It's not reliably there.

Sometimes it isn't, sometimes it isn't.

And we can also look at that
as a sort of deficit or.

Issue, let's say, is an imbalance you
could say of dopaminergic response.

So the dopamine pathways, which
activate a prefrontal cortex.

So we can think of this
phenomenon as another seesaw.

On one side, you have hyperfocus.

On the other side, you have in attention.

and on hyperfocused side, you have
stimulation, excitement, novelty

activation, and on the other side you
have inattention, difficulty sustaining

attention, following through with tasks,
forgetfulness, distractibility, so on.

So you have your inattentive
symptoms and you have your

hyperactive impulsive symptoms.

And then you're looking at them
now, what, where are they now?

Can't focus.

Okay.

When at work, outside of work with
friends, with family, doing this, doing or

that, like what's going on in your life?

Is it when you sit down at your desk,
where are you when you're doing it?

what environment are you in?

What domain of life, what role are you in?

Externally, what's going on internally?

We just covered all that internal stuff.

What's going on externally?

Oh, I really need to do this,
that, and the other thing.

I need to focus in on the job.

So yeah, our job could be not a good fit.

We could be in a toxic workplace.

So we don't look in one
domain, we look in two.

So yes, he could be in a toxic workplace.

However, we're gonna see the deficit as
manifest in other areas, forgetfulness

in attention, distractibility.

Difficulty sustaining attention,
difficulty with prioritization,

seeing big picture, following through
with, bigger tasks, breaking them

down, knowing where to get in and
follow through with it until the end.

And you'll see a sort of swing on the
other side of, novelty, getting really

excited, trouble sticking with things,
or perhaps compensatory mechanisms.

Maybe there are some
things that were learned.

Scaffolding, behavioral scaffolding,
so the wheels can come off.

What happened in life recently?

Is there a new job that you had?

Yeah, going back to
school, that's a big one.

We also have historical,
what have you been through?

So what were you born as?

What have you been?

What have you been through and
what are you going through?

Those are the things, 'cause we
react and respond to those things.

So what goes on internally without
consideration for those facts.

It's just silly, isn't it?

So we gotta look at the full picture.

ADHD has complex presentations.

You have difficulty with sustaining
attention and a sort of deficit

as it relates to frontal lobe
functioning, dopaminergic signaling,

logical, linear or adult brain.

The grownup me, the grownup
in there is not there.

As often, but whether or not
that's gonna be the case or that

criteria fits, is hard to ascertain.

So if someone comes into your office, no
matter who you are, and they say to you,

I think I have ADHD or I saw on TikTok, or
whatever it is, we just want to go, okay.

There's nothing wrong with that.

So if you have, if that
makes you go what the heck?

That's you.

So explore every time a new
piece of information as a

clinician enters your head.

If you feel it, like, when I
started, it was a punch in the gut.

if we're gonna be in the business
of helping other people, we

need to do one of two things, we
need to apply it to ourselves.

Or if that's too difficult, we need
to say in our heads, do as I say,

not as I do, whatever gets us to
that place where we're present.

Because it's all about the
art and science of caring.

So it's really cool.

It's like we're not
law enforcement people.

We're not lawyers.

We're not the sort of checks and balances
of society where people that care and

we, but all, we have a DEA license.

So I think that can feel scary but
we've been licensed and vetted by the

system for a reason, if you're engaging
a patient in ADHD treatment, I think

there's that sort of thing we have to do
right at the door is understand we are

the gatekeepers and that's a good thing.

We should feel good about it and we should
know the difference between us and others.

So for us to apply medication and
us to apply these clinical skills

and develop these clinical skills,

if we're gonna do this, we have
to also understand the world

in which we actually live in.

So I think it's about what is the
medication doing, and then what are

the systems that we're navigating?

So the DEA and the Controlled
Substance Act and all this and that,

it's like at the end of the day we're
applying a therapy for a medication.

And once they're vetted.

Then we've identified that's a, that's
the treatment that is applied that

we have to reassess that treatment.

Just like any, so I just think the,
once we get into the legal issue,

there's a deeper philosophical
conversation there with the scheduling

of drugs, schedule two stimulants
and Schedule four benzodiazepines.

I'm very careful with those medicines
and I've had more issues myself.

at the end of the day.

We don't need to think too much about
the things that are just requirements.

We have this whole list of ethical
guidelines nursing practice act,

each individual state compliance.

There's all these things.

So if we're in compliance with all
these things, then we go, okay, good.

we're doing our best.

And that's, I think we gotta be able
to leave the rest at the door so we

can have as much energy to focus on the
task at hand, which is helping people.

So the nervous system, it's the
involuntary automatic responses.

Contrary to popular belief, all
emotional reactions are normal.

So when it comes to the patient dialogue,
setting the frame, or setting the goals,

and we're trying to allow for autonomy.

So I'm thinking about
the big picture here.

When we're going back to diagnosis
of ADHD, I never say no outright.

I would have to have a clear clinical
presentation in my head that explains ADHD

rather than mask it.

So if someone comes in,
they're like, I have a problem.

we have to drill down the symptoms.

Okay, you're inattentive,
you have difficulty starting

tasks, you're forgetful.

But then we get into it there.

So we're symptom focused.

These are the problems ' cause they
have problems and we're supposed to have

solutions or at least be able to guide
people or reorient them to the solution.

So it's like expectations in reality.

That's all we're doing.

We're setting expectations.

We're taking expectations in reality
and lining them up for people and

along the way, helping them do that.

Trying to sort out the individual
differences that have sort of the

ways in which we can pattern, I've
seen so many patterns over the years.

So that's why I wanna get
into this ADHD framework.

'cause ADHD is best housed
in the holistic whole person.

So it's cognitive, it's frontal
lobe, it's impulse control.

It's executive function, but it
is not what we've been through.

It's not our reactions to things.

It's not, our mood, which
is the electrical signaling.

So we have the chemical.

Serotonin.

That's the nervous system level.

Think dopamine, that's the frontal lobe.

And then we got electrical,
which is the wiring of our being.

Our brain fires off it emits a sort
of frequency that we can read through

an EEG Get the read, the brainwave.

Speaking of brainwaves,
there's state of mind.

When we're awake, we oscillate
between two states of mind,

beta state and Alpha State.

Alpha State is more think
about the alpha in the jungle.

It's just on autopilot,
doing his alpha thing.

So we're gonna be in Alpha State,
reflective, Daydreamy, but we're

also gonna be in a beta state.

We're actively planning, there's
gonna be less beta wave activity

in someone with ADHD on a whole.

These sort of mind states just
in a, this binary is something to

consider among the other binaries.

So we have the brain, we got this
brain wave sort of oscillation.

We have dopamine firing in
signaling the pleasure chemical.

So this sort of phenomenon where
we're like seeking stimulation.

So therapeutically, if we're
thinking about the fact that

these individuals have a deficit
inconsistent dopamine regulation,

the stimulation seeking will this,
there's a pattern, there's a, there's

some, this is what we're looking for.

This is the big picture.

Okay?

There's not enough stimulation.

So where are you getting, and
this is where adaptation occurs.

So we're crafting a sort of
narrative, okay, you have untreated

ADHD, or maybe you did have ADHD.

How did it go?

So along the way, we're just
putting this all together.

When it fits.

If it walks like a duck,
it walks like a duck.

When it doesn't fit.

Oh, hey, I can't focus.

Alright.

Where?

Oh, work.

Everything's tough.

It's alright, let's talk about school.

Alright.

I was great in school.

All right, hold on.

A lot of people with ADHD did great in
school, so we have to think about that.

But there's learning.

This is why I like to isolate
education to a question.

It's, Hey, tell me about when you first
went to school, learning how to read,

learning how to write, how did that go?

Because that will tell us early sort
of childhood developmental, educational

stages where learning and absorbing
information, the brains turning online.

Many people with ADHD during that
time are very natural learners.

Learning how to read, learning
how to write can be, it's

really one way or the other.

You have, this.

Skyrocketing intellect or you
have a learning disability or

sort of, maybe teachers concerned
from a young age or something.

So we also have the family
history, which is huge.

So if you hear a flag for
that, someone has ADHD in the

family, that's very likely.

But again, with other people in ADHD, this
set of skills that we're developing is

not the set of skills that people have.

People with ADHD go and learn the skills
and feel understood and have a community.

But the way ADHD is expressed
functionally is very individualized

because the components to.

Symptom control and behavioral
modification as well as the

path toward improvement.

What areas need to be improved?

The perception of the person
that's fairly individualized.

It's actually very individualized.

We all have our own sort
of creature comforts.

This is like one of the cool things about
ADHD is there's like a lot of sameness.

People with ADHD are never gonna be.

All the time doing the same thing.

But it's about balance.

It's about coming back to a balance.

So we're still gonna
fall into inattention.

We're still gonna have those hyperfocus,
but we wanna allow medication as

well as these skills to bring in a
consistency that is an all or nothing.

So we're moving past the immediate
moment and having sense for

a more consistent and stable.

Passing of time.

That's very grounding when it
comes to the chaos that many

people face prior to diagnosis.

And I've seen patients that
have started ADHD treatment.

You get of course the people that started
when they were a kid and they're just

continuing treatment all the way to like
people in their sixties And I think that.

I would've when I first started,
that would've made me nervous and I

think the more you work with these
medications, when these patients

develop a system for yourself and apply
this philosophy and this approach,

things start to feel a lot better.

'cause it's very consistent.

It's people are not as
complicated as I once thought.

So medication is the second CEU.

We will get into that in a minute.

I just wanted to end this demo with
the idea of those checklists of the

tova whatever tool that you have
that's gonna help you feel good.

I think we need to read our own

resistance or if we're feeling
anxious, if we're feeling nervous,

that can tell us, maybe we're not sure.

It's always okay to wait to say, maybe
to say, I have to think about it.

Because you're gonna see
depressive symptoms, you're gonna

see anxiety symptoms, you're
gonna see mood irregularity.

So before we get into medications,
the next time I hit record, I'm

gonna go into sort of a deeper
dive of all these comorbidities.

Cedric: If you are interested
in becoming a patient of Jon's

visit www.myfocuspath.com

- now proudly serving the Pacific Northwest.

and stay tuned to the Compass
Point Institute Podcast because

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