“There You Are”: ADHD Medication, Day One
Spoiler: it feels less like being medicated and more like meeting yourself.
It was just past seven in the morning. I was on my way to my golf club, where a tee time was waiting for me at eight o'clock sharp. I had left home later than usual, but I wasn't anxious, stressed, or unsettled as I normally am. Ordinarily, I leave with a much wider margin, and as I'm barely out the door to catch my bus, nervous droplets of sweat bead at my temples and the small of my back, while my mind is already wriggling everywhere around me. Not this time. I walked towards my bus stop with a calm mind and a purposeful stride. There was a short wait. It didn't trouble me — "wow, that's new", I thought.
I think it was only once I was seated on the bus that I truly felt the medication begin to take hold. An unfamiliar state settled over me, new, solid, stable. The constant inner gesticulation, the cognitive and nervous hum, seemed quietened, as though a volume knob had been turned down. It was the absence of that inner noise that made me realise how thoroughly I had been invaded, overwhelmed, without pause, all day long, by those internal fidgets and flickers of the mind that so often spilled beyond my skin and expressed themselves outwardly: a restless body, a jiggling foot, a tapping hand, fingers winding around each other, the repeated touching of an earlobe, the hem of a sleeve, rubbing the rough patches on my phone case, and even tics like washing my hands 38 times a day (I counted).
Strange as it was, this deep calm was not unfamiliar. So, I leaned further into the moment to investigate what was truly happening. What followed was a surprising, almost solemn moment: as if I were meeting myself, finally. "There you are," I thought. "Yes. Here I am," I replied, as though we recognised each other through veils of movement.
Good shots, bad shots
On the first tee. No playing partner today. Just me, my clubs, and the course. What followed was a round of golf unlike anything I had known before. Ordinarily, a good shot triggers a surge of over-enthusiasm that floods me and overwhelms me, and a missed shot triggers a wave of bursting anger I can barely contain. Moving through those high emotional peaks and deep valleys of despair dozens of times within 3 hours is exhausting, far more so than walking eighteen holes in mischievous Scottish weather.
Today, none of that. Good shots produced not an enthusiasm that swept me away, but a replenishing satisfaction. Poor shots produced not a fit of anger, but a generative perplexity. No outbursts, no flooding. Peaceful rest. Undisturbed quiet. It felt as if some doors had finally unlocked, letting a newfound serenity in.
I also noticed a presence of far greater quality than before. That internal voice commanding me to reset my shoulder, watch the angle of my arm, check my foot placement — it was still there, but somehow more respectful of the moment. Less agitated. Less all over me.
On the bus home, I grasped the full measure of the contrast. And with it, the staggering quantities of energy wasted over decades in the effort to hold together a dispersed bodymind. For the first time, I truly registered the full weight of the ravaging chaos that had been coursing through every corner of my fabric. Sitting there, I savoured the calm that had settled inside me. It had a new texture. Thick, soft, fluid, still. My eyes filled with tears at the contact with this new way of being present in the world: all those years of crossing days that were more exhausting than the last.
To understand what happened that morning, it helps to know a little about what ADHD actually does to the brain and what methylphenidate, the active ingredient in Concerta (the medication I am now on), does in response.
What ADHD does to the brain
The ADHD brain is not a broken or a sick brain. It is a brain that struggles to regulate dopamine and norepinephrine, two neurotransmitters that govern attention, emotional regulation, and the capacity to filter what matters from what doesn't (Faraone et al. 2015; Purper-Ouakil et al. 2011).
When these systems are under-regulated, the result is not simply difficulty concentrating. It is a constant internal noise and physical agitation: a restless nervous system that cannot easily settle, that reacts to everything with roughly equal intensity, that generates what many people with ADHD describe as an incessant internal hum.
Neurotransmitters are like messengers. Neurons use small capsules of neurotransmitters to send messages to other nearby neurons. When a capsule reaches the recipient neuron, the latter is activated to continue transmitting the message along the neuronal chain to which it belongs. Once the recipient neuron is activated, the neurotransmitter capsule is returned to the emitter neuron for recycling for a subsequent message. This process is called reuptake and is carried out by transporters, which are proteins responsible for clearing the space between the two neurons by “sucking up” neurotransmitters back into the emitter neuron (for recycling and reuse). The transporters’ role is also to maintain the correct dose of neurotransmitters between neurons.
In an ADHD brain, this neuronal ballet is cut short by several mechanisms. First, transporters are hyperactive, meaning they “clean” the area too quickly, before the message is transmitted. Second, the recipient neuron has receptors that are less sensitive and require a greater quantity of neurotransmitter to be activated. Lastly, the emitter neuron might send too small a quantity at the start. In other words, the hyperactivity, inattention, emotional dysregulation, and impulsivity characterising ADHD stem, in part, from this communication deficit between neurons: the levels of dopamine and norepinephrine travelling from the emitting neuron to the recipient neuron are insufficient, or the emission is too weak or brief to effectively activate the recipient neuron.
Methylphenidate is a stimulant medication primarily used to treat ADHD. It works by slowing the reabsorption (reuptake) of dopamine and noradrenaline in the prefrontal cortex, the region of the brain responsible for executive function, impulse regulation, and sustained attention (Engert and Pruessner 2008). By slowing reuptake, methylphenidate increases dopamine and noradrenaline levels in the space between neurons (the synaptic cleft). The result is increased activity at the receptors of the recipient neurons — the message has been heard! That is why increased levels of those two neurotransmitters lead to therapeutic effects in ADHD: attention is better regulated, as are emotions and the capacity to organise and prioritise tasks.
Another often overlooked aspect of an ADHD brain is the overactivation of the Default Mode Network (DMN). The DMN is active when you’re daydreaming or not focused on a specific task, when your mind wanders freely. When you start engaging in a task and focus on it, the DMN deactivates until the next mind-wandering session. In ADHD, the DMN is often more active and fails to deactivate when engaging in a task. This is the underlying mechanism behind the tendency to be pulled away from the task at hand towards unrelated thoughts (Rubia 2018).
Methylphenidate does not produce more energy. It reduces the cost of functioning. The brain no longer needs to work as hard simply to stay functional. The noise quiets. What remains is not artificial calm, but something closer to a normal baseline — a baseline many people with ADHD have never had consistent access to before.
This is why the effect, when it works, can feel less like being medicated and more like meeting yourself.
Back together
One word to describe how I felt today: gathered. As if reassembled into a state of being in this world I never knew was possible. But I also feel worn and bruised. I have been a pinball on steroids all my life, and today I am a marathon runner, finally crossing a finish line I wasn't sure I would ever reach, falling into the arms of another self who had been waiting there, ready to hold me, to take care of us at last. At that moment, I catch a glimpse of what some people mean when they say that life is worth living.
From my seat on the bus, I watch life moving around me; people, cars, birds, clouds, traffic turning green. Everything seems covered by a new shade. The feeling of having arrived somewhere, for a new beginning.
References
Engert, Veronika, and Jens C. Pruessner. 2008. ‘Dopaminergic and Noradrenergic Contributions to Functionality in ADHD: The Role of Methylphenidate’. Current Neuropharmacology 6 (4): 322–28. https://doi.org/10.2174/157015908787386069.
Faraone, Stephen V., Philip Asherson, Tobias Banaschewski, et al. 2015. ‘Attention-Deficit/Hyperactivity Disorder’. Nature Reviews Disease Primers 1 (1): 15020. https://doi.org/10.1038/nrdp.2015.20.
Rubia, Katya. 2018. ‘Cognitive Neuroscience of Attention Deficit Hyperactivity Disorder (ADHD) and Its Clinical Translation’. Frontiers in Human Neuroscience 12 (March): 100. https://doi.org/10.3389/fnhum.2018.00100.