HealthyGamerGG - ADHD and Substance Abuse

Episode Date: September 28, 2021

Dr K Talks ADHD, Neuroscience, and Substance Abuse Support this podcast at — https://redcircle.com/healthygamergg/donationsAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy Learn more about your ad choices. Visit megaphone.fm/adchoices

A chill in the air. The howling of the wind. An army of monsters begging for candy at your door. For a perfectly acceptable reasons to stay in this Halloween. That's why there's Drizzly, the go-to app for alcohol delivery. With Drizley, you can compare prices on the biggest selection of beer, wine, and spirits, and choose from a variety of convenient delivery options. It's almost frighteningly easy. So download the Drizzly app or go to Drizley.com. That's D-R-I-Z-L-Y.com. So this paper came out about a month ago. So half of adults with ADHD have had a substance use disorder. Alcohol use disorder is the most common among adults age 20 to 39 with ADHD, followed by cannabis use disorder and other drug disorders.

More than one quarter of those with ADHD had major depression. So what I want to share with you all today is something that I think is really important, which is understanding why people with ADHD are actually prone to, substance use disorders. So in order to kind of explore that with y'all today, here's what we're going to do. We're going to explain, first of all, what ADHD is a disease of. We're going to talk a little bit about, like, you know, what is really wrong in ADHD? What is wrong in substance use disorders? We're going to sort of explore the overlap between those two things and kind of the neuroscientific vulnerabilities of these disorders. And once we understand the neuroscientic vulnerabilities and processes, we'll start

to develop an understanding of like how we can fix it, right? And so this is going to be really tricky because I'm going to try to send you all some pretty complicated neuroscience that, first of all, I don't fully understand because it's so incredibly complicated. But secondly, it's going to be very simplified. And then, you know, really ask you all to sort of apply that understanding to like what you can do if you have ADHD and a substance use disorder. So to begin with. Let's start talking a little bit about, you know, what is ADHD? So if I had to summarize, I'd say that ADHD is first and foremost a disease of executive dysfunction. And so what does executive dysfunction mean? Executive dysfunction is, so our executive function is our brain's

capacity to plan and execute tasks. So, for example, if I want to like study for a test, there are many things that go into studying for a test. And one of the key things that I have to do when studying for a test, first of all, is behavioral inhibition. So I sit down to study for a test. And in order to study for the test, I have to stop myself from doing other things, like, pulling out my phone, you know, logging on to Reddit, like watching Twitch, playing video games, like going to get a snack. So there's a part of my brain that when I focus it in one direction, like prevents me from doing all the other stuff. all those other things. I may have, um, you know, impulses to do those things, but essentially my brain is like, no, we're not going to do that now. Like, we'll check the phone later. So the first thing

that happens in people with ADHD is that they're, they have deficiencies and their behavioral inhibition circuitry. That kind of comes from the frontal lobe. Okay, we'll talk about that in a second. The second thing is that people with ADHD have altered sensitivity to reinforcement. And so what that means is that things that are low-hanging fruit and easily enjoyable are far much more enjoyable to people with ADHD. So if you look at like delayed gratification studies and people with ADHD, where you ask someone with ADHD, hey, I'll give you a dollar now or I'll give you $5 in five minutes. Which one do you want? Literally the brain of someone in ADHD is going to pick the dollar now as opposed to the $5 in five minutes. So,

compared to the neurotypical brain, the sensitivity to reward and reinforcement is altered in ADHD. The third thing that happens in ADHD is a high amount of impulsivity. So people may say, like, is decreased inhibition the same as impulsivity? And it turns out that neuroscientifically, they're actually like discrete mechanisms. So people with ADHD tend to be like a lot more impulsive. So when they have like an impulse, they're much more likely to act on it. That may, correlate with decreased inhibition may also correlate with reward sensitivity, right? So if I have an impulse to like eat chocolate and I enjoy chocolate more than the neurotypical person, it'll be hard for me to diet in a healthy way. Okay? So when we kind of summarize, I kind of think about executive dysfunction in ADHD as having three major components. The first is deficient behavioral inhibition. So it's hard for me to inhibit behaviors. The second is an altered sensitivity to So things that are fun for other people are actually like way more fun for me if I have an ADHD brain.

And we'll get to the neuroscience of this because it involves dopamine reinforcement circuitries and things like that. And the third is a certain amount of inhibit, I mean, impulsivity, which is, and that impulsivity has a lot to do with intolerance to delayed gratification. Okay. So these are the three things that we're going to kind of talk about when it comes to what ADHD is. So the next thing that we're going to kind of touch on is that, so substance use is actually like very, the ADHD brain is very vulnerable to substance use because of these three things. So if we think about like substance use, you know, it involves restraining our ability to like get high, for example. It could be hard enough on its own, right? but when I've got an ADHD brain that has like a deficiency in behavioral inhibition

has an altered sensation of reward and has like more impulsive kind of behaviors, it makes it really easy for me to use substances. So I think if we kind of look at what gets people to use substances and what protects people from using substances, the way that our brains protect us from using substances are kind of handicapped in the ADHD brain. So it makes us much more prone to using substances. So this is where if we kind of look at the mechanisms of ADHD and if we look at kind of the mechanisms of ADHD, what we'll kind of see is we'll map these mechanisms onto a few different parts of our brain. Okay. So what we're going to now do is take a quick look at

the brain. And so let's take, let's understand the neuroscience of this, okay? So we have a couple of different parts of our brain. So the first is going to be the prefrontal cortex. So the prefrontal cortex is responsible for inhibition. So there's also another part of our brain called the anterior cingulate cortex, which is kind of back here. And the anterior cingulate cortex results in poor selective attention and poor inhibitory control.

So the frontal lobes are responsible for inhibition, but the interior singular cortexes as well. And what we know in people with ADHD is that they've got basically like a reduced activity in the interior

singular cortex, okay? And the third thing that we're going to kind of talk about and this is important for drug use is impaired dopamine activity across the brain. So this may sound

kind of weird but you guys know that like with ADHD ADHD we actually give people stimulant medication, right? So this is going to sound kind of weird. But if you look at the

brain, of someone with ADHD, what essentially happens is that, like, they're getting too many thoughts too fast. And if you look at that, what that really is, it's not that their brain is actually moving too quickly. It's that their brain is not able to turn down the volume of some thoughts. So when you give someone with ADHD stimulant medication, what you're actually stimulating is the PFC. So stimulant medication increases the activity of stimulant. of the PFC and allows you to actually focus on one thing. So it doesn't actually speed up the brain.

It actually boosts your PFC function, which in turn will allow you to negatively inhibit like other thoughts and impulses. Does that make sense? Okay. So the next thing to understand is that people with ADHD have impaired dopamine activity. And so part of the problem is that we know that in the PFC in the anterior cingulate cortex and we'll get to the striatum in a second. We know that we have low dopamine

or some kind of dopamine dysfunction in the brain of ADHD. And so if you kind of look at it, like what drug use will actually do is increase your dopamine levels. So one of the reasons that people with ADHD will use substances is to almost self-medicate. So they have a baseline low dopamine activity

which results in ADHD symptoms. And when I add drugs, I'm going to boost add rugs. When I add drugs, it's actually going to increase my dopamine activity, which will result in almost like some amount of self-medication. The problem is that this effect is temporary. So over time, when I use drugs, at the very beginning,

it'll stimulate parts like the PFC. It'll also kind of have some effects on kind of the amygdala over here in the hippocampus. you'll get stimulation here by drugs. Okay? But the problem is that over time, is you use drugs, they stop increasing dopamine over here.

And let me know if this is too much, okay? And what actually happens is they start to like affect this part of our brain called the striatum. So drug use, when I use drugs temporarily, it sort of has effects, let's say, over here and over here. But over time, it'll start to activate. a different part of my brain called the striatum. And then what happens, once it starts acting in the striatum, what it actually does is decrease dopamine.

So then when I increase my drug use, it actually has a paradoxical effect to decrease dopamine and then makes the ADHD worse. So this has to do with the way that our brain actually like acclimatizes to drug use. So just to kind of recap, and apologies if I'm saying this over and over again. So in the beginning, we have dopamine. deficiency here and not a good amount of activity in our PFC. If I use certain drugs, I can actually boost the dopamine over here and it creates a self-medicating effect. This will sort of

explain to you why people with ADHD may be vulnerable to substance use because it's almost self-medicating in some way. Then what happens through chronic drug use is that the parts of my brain that get affected change. And once we get to the striatum, what we actually see is a decrease in dopamine activity and then ADHD worsens. And there's some interesting evidence for this. So if you look at the D2 receptor, so I don't know if you guys kind of know this, but you know, like, so if I have a molecule of dopamine, the number of receptors I have will kind of increase the signal. So if I have like three receptors in one molecule of dopamine and this molecule of dopamine is kind of floating around, it has a very high chance of like increasing the dopamine

signal. I can also increase the dopamine signal by increasing the molecules of dopamine, right? Because then I can go over here. I can go over here. I can go over here. So what we actually see in people who are abstinent, I know this is going to sound kind of weird, but what we see in people who are abstinent is a lower number of dopamine receptors. And so if you have a lower number of dopamine receptors, shouldn't that mean that you will get less dopaminergic activity? And the answer paradoxically is no, because the reason you have a lower number of receptors is because you're not bombarding yourself with dopamine. So over time, what happens, I know this sounds kind of weird, but over time, what happens is we develop tolerance. And so as we develop tolerance, it can kind of make some weird

changes to our dopamine receptor circuitry and actually alter our sensitivity to dopamine. So when people actually become abstinent, the reason that their dopamine receptors kind of go down, it actually results in them not being bombard. Sorry, I just got confused there. But as you sort of decrease the number of dopamine receptors in abstinence, it sort of signals a resetting of your dopamine system. The other thing that we sort of seem to understand is that dopamine blockade in this part of your brain, if you blow, lock dopamine, it reduces ADHD symptoms, and reduces substance use symptoms. So this is what's kind of interesting here is that once we move from this part of our brain to this

part of our brain, we start to like alter our dopamine metabolism in some way that's honestly like pretty complicated and it's hard to follow. But the end result is that once we're acting from the striatum, we see increased impacts of dopamine and ADHD symptoms worsen. Okay, that's kind of the key takeaway. And I apologize if I confused you all there for a few seconds. The key takeaway here, though, is that if we look at the different regions of our brain, what we can sort of start to see is, first of all, why dopamine increase originally helps people with ADHD. And as our brain adapts and we start to see dopaminergic changes over here, we'll see a decreased dopamine response and ADHD actually worsening over time.

And then what happens with this person once we have like striatal activity of substance use in substance use or prolonged substance use is that not only they're kind of addicted to the substance, but the ADHD actually gets worse. Okay. So next thing, med school PTSD. So next thing to kind of explore is like let's talk a little bit about the mechanisms of ADHD, okay? And let's talk about some of the mechanisms of ADHD and understand why people with ADHD are prone to substance use. So we reviewed a little bit of the neuroscience,

but the first reason that people do it is to self-medicate, right? And this is essentially what I was explaining earlier, which is that people are dopamine deficient in ADHD. This may be part of the reason why they're sensitive to rewards. And so as we increase dopamine through substances, for some amount of time, it may actually improve the ADHD. And this is also why we'll use stimulants, which can be substances of abuse, to treat ADHD. So it kind of makes sense. Okay? So the first reason is self-medication. The second reason is a little bit psychological. Okay. So this isn't something that we really understand the neuroscience very well, but this is something I've observed as a clinician. And we'll talk about this maybe in a future lecture. So ADHD is associated with a lot of shame. Okay. So this is what happens in people with ADHD. Like you're smart, you know you're smart. You look around and there are other people that are able to do normal things. People that are stupider than you are that are able to do normal things. And you can't do those things. Despite your IQ, you can't do those things.

Despite all of your potential, you can't do those things. Despite being in gifted and talented classes when you were in the third grade, you can't seem to focus your mind and pass a single exam in high school. So what happens in ADHD is people don't understand that they've got ADHD. So what happens is that they just feel like they're busted in some way. And they feel like they suck at life. They don't really understand because the other problem that we see in ADHD is oftentimes people have high IQs. and they develop compensatory mechanisms.

So what that means is that despite your ADHD, you basically use like some kind of weird IQ compensation to make it so that you can function semi-normally. But this IQ compensation, it's sort of like, I have a flat tire, but I'm so strong that I can just push the car, which like allows you to go 15 miles an hour when everyone else is going like super slow. So you're like doing, exerting a ton of effort to ultimately get something that's kind of normal despite a very heavy handicap.

And over time, these compensatory mechanisms no longer work. And so you used to be able to do what other people could do. And despite your high IQ, now you suddenly suck at life, which deals, which results in a bunch of shame. And the more shame you have, the more you need coping mechanisms. And then generally speaking, because your brain is remember, sensitive to reward, because you've got an ADHD brain, the kinds of coping mechanisms you end up with are maladaptive ones. So it's hard for you to sit there and meditate if you've got ADHD.

So instead, what you're going to turn to is drugs and video games and social media. Right? Because you're so ashamed of yourself. So this is kind of the second place where drug use comes in, where generally speaking, what drugs do, I kind of think about them like clinically as an escape. And so ADHD gives people's minds things to escape from, right? Because in my mind, like, I'm an idiot. Like I should be able to do it, but I can't do it. So I need to run away from that.

So I get prone to drugs. And so the third thing, which I'm sort of separating out, even though it's kind of, you know, maybe under self-medication, is that I do think that there's a neurovulnerability here, which is important. So like I've kind of outlined, there are a lot of things about the brains of people with ADHD that are a little bit different. Their sensitivity to reward. Their inability to inhibit impulses. And so what this kind of results in is, you know, like a vulnerability to substance use. So a vulnerability to substance use disorders. So if we kind of look at like, you know, why these things correlate, there's definitely like this self-medication kind of hypothesis. There's a society.

psychological component and basically like your brain has substance use. If we kind of think about it in video game terms, you know, like you've got fire resist and ice resist and lightning resist. And like substance use disorder or addiction resist for ADHD people is like minus 50%. So you're kind of born with this inherent trait of like having minus 50% addiction resist. And so this is why people with substance use disorders and 80 or people with ADHD while like half of them have substance use disorders. So then the natural question is, okay, okay, Dr. Kay, what do we do about it? Okay? So now I think I can just kind of say this to you all. So this is going to be tricky. So this is going to be one of the parts of when we talk on stream where I'm going to say particular things and they're going to be hard to implement, but I'm still going to go ahead and do this. Okay. So a lot of times here on stream, what we try to do is give you guys easily accessible solutions that like you can do it in five minutes or ten minutes.

This is one of the cases where actually what I really want to do is not give you all an easily accessible solution, but a plan of attack that unfortunately is quite difficult. The first thing that you've got to do is stop separating out substance use from ADHD. And this is really important. So a lot of people that I work with who have ADHD will say, oh, Dr. Kay, I have, you know, like I have trouble with motivation, right? Like, I'm so ADHD. like I have trouble in school. I have trouble in motivation with motivation. How do I get motivated?

How do I find out what I want to do in my life? And they mentally separate out the fact that they smoke pot every day from like these problems. They're like, oh no, I'm lazy. It's not like the pot. Like I'm lazy. It's not the alcohol. It's not the video games. They're not a causative factor.

They aren't the reason I'm lazy. They are the result of my laziness. Right. So it's kind of interesting, but if you have a motivational problem, if you have ADHD and you use any kind of substance, okay, marijuana, alcohol, stimulants, even video games, you have to understand that as long as you're using that substance, all of this cycle is going to be going on in your brain and you're really not helping your brain to achieve motivation. So anytime you have a comorbid disorder, so this gets into the idea of dual diagnosis. So when you've got depression and alcohol addiction, you can't deal with either of them on their own. Because if you've got depression and you're depressed,

it's going to make it far easier for you to reach for like booze. And if you drink all the time, your brain is going to be more prone to depression. So like you can't separate out these problems anymore. So like this is, it's kind of harsh, but like I've heard so many people who will say, oh, my problem is motivation, laziness, or ADHD, or it's this. but it's certainly not the pot.

Like, that's fine. Like, haven't you read all the research? Like, pot doesn't make you stupid or pot doesn't cause this. That's fine. Like, it's being legalized. It's like safe. Like, I like it.

I enjoy it. It's good. And I hate to break it to you, but if you're using any kind of substance and you have problems with ADHD, those two things are going to be, the substance is going to be contributing to the problem. Like, 100%.

So the first thing you've got to do is stop separating out the substance use from all of your other problems. Your problems are not going to get fixed as long as you're using substances. Okay? Maybe a little bit of a hyperbole there. But honestly, it's been my experience as a clinician that, like, you've got to take the substance use seriously. So what that practically means is you've got to get sober. So if you really want to fix this, you have to start by getting sober. And I know that that's not easy

and has its own, you know, challenges. But the simple truth is that if you're using substances and you've got ADHD and you think the problem is ADHD, you got to get sober. The second thing is that you have to deal with the shame of ADHD, right? So this is a psychological thing. Getting sober is more about neuroscience, right? So it's about resetting your dopamine and stuff like that. But you've got to deal with the shame of ADHD. So this is where getting in the therapy is a very good idea. So oftentimes when I stream, I will talk about how coaching is fantastic and you should sign up for coaching for reasons, A, B, and C. This is one of the cases where I'm seriously going to say, if you have a substance use of disorder and you have ADHD, don't sign up to see a

healthy gamer coach. Go see an actual dual diagnosis clinician. Go to someone who can help you with ADHD and substance use. Because you've got to like do the therapy, right? You've got to deal with that shame which causes you to reach for the substance of abuse. The third thing that you've got to do is do a dopamine detox. So this is going to be very hard for someone with ADHD because remember that your propensity for boredom is going to be like your tolerance of boredom is going to be like your tolerance of boredom is to be super low. But the unfortunate thing is that you're kind of handicapped, you're stuck. Because if you're using the substance and you have the paradoxical effect of dopamine in the striatum, which is that over time you're decreasing your dopamine usage. And remember that low levels of dopamine

are correlated with ADHD, which means that your substance use is literally making your ADHD worse. So you've got to not only get sober, but do a dopamine detox. And give yourself a chance to reset, whatever that dopamine circuitry is, so that you can start to, like, respond in kind of healthier ways, okay? And then the fourth thing that you've got to do is meditate. So I know we talk a lot about meditation on stream. We say it's, like, really good for all kinds of stuff.

The reason I include it here is because everything that we're, all of the solutions to this are basically removing bad things, right? It's like getting sober, going to therapy, doing a dopamine, detox. It's all removal of stuff. It's all restriction of stuff. So the one thing that you can really do to like add, it's something that you can actively do, it's not getting rid of something, is meditate. And there's good evidence, overwhelming evidence, I would say, that meditation strengthens your frontal lobes, right? So that's where we go back to the idea of the prefrontal cortex. It strengthens things like your ability to control impulsivity. It strengthens your capacity to inhibit things, like inhibit or, like inhibit or. impulses. And then the fifth thing to do is to recognize that your environment, that you are prone to particular weaknesses based on your environment. So you must very carefully control your environment. So let's remember what are the three vulnerabilities for people with ADHD and substance use? So you're more impulsive, right? And you can't

control, it's difficult to inhibit behaviors. So if you are in a situation where there are going to be notifications and things pulling at your attention, your attention is going to use any excuse it can to not study. So if you give it any kind of excuse to not study, it will get distracted as easily as possible. So what I say very practically for people is think for a second about all of the things that could distract you from studying. So notifications on your phone, access to Reddit, you know, being able to alt tab, using a laptop even, right? So using a computer or using your phone for schoolwork because all of those things are going to make it easy for you to get distracted. So if you want to be effective, what you really have to do is control your

environment because remember that you have like a high level of distractibility, right? So you have like your impulsivity resistance is also minus 50%. So if you are in an environment where you're being exposed to impulsive distractions, you're much more likely to get distracted. The other thing to remember is that your reward sensitivity is also kind of messed up. So if you look at Twitter, if you, not only are you more prone to open up Twitter, but you are, once you open up Twitter compared to the neurotypical brain, you are much more likely to enjoy Twitter than another person, which means that for a normal person who gets distracted, they may spend 15 minutes on Twitter and their mind will once again restrain itself and go back to the studying. But for someone with ADHD, that 15 minutes is going to be

two hours. Because the dopaminergic response that you get, the sensitivity to reward that you have, you're actually far more sensitive to reward. So all of these things like social media and Twitter and video games are actually going to pull your brain in even more than the neurotypical person. So it's really hard. Like I'm not saying that any of this stuff is easy, but you must control your environment. And as like, as strongly as you can, as rigidly as you can, as you strict as strictly as you can, think about all of the impulsive sources of distraction you may have and recognize that if any one of those things happens, there's a decent chance you're screwed. Because if you get distracted and you do something that's dopaminergic and rewarding, your brain is literally going to love

that reward so much. Even if you don't personally like enjoy it or you think it's fun, the ability for your brain to engage in that behavior for two hours is actually way higher. So you've got to be like far, far more careful. It's like you're walking a tightrope with your attention. and any kind of gust of wind can blow you off course. Okay? So, just to kind of summarize, it is unfortunate that people with ADHD are very prone to substance use disorders. I'm not surprised at all that half of people with ADHD end up having a substance use disorder.

As it turns out, if we look at what ADHD is, it sort of is composed of three things as it relates to substance use disorders. It's more than that, for example. So we talked about emotional dysregulation and things like that. But there are three kind of major mechanisms that we're thinking about. One is increased sensitivity to reward. So the brains of people with ADHD are more likely to enjoy enjoyable things. Okay.

So that's what makes it easy to love drugs, right? Because someone else can get just a regular amount of high or a regular amount of drunk. But boy, is it super awesome when you get high and when you get drunk. The second thing is that people with ADHD are more impulsive. So if we look at drug use, like impulsivity correlates with an increased. amount of drug use. There was even one study that I looked at that like people with ADHD are more likely to engage with in harmful, high risk drug associated behaviors. Like people with ADHD are more likely to drive while intoxicated than people without ADHD. The third thing that ADHD does

is prevents you from inhibiting your, prevents inhibition. So in our brains, like, I may want to do something but then like I feel like doing something else and then my frontal lobes will inhibit that part of my brain. Or it will inhibit that impulse so that I can stay focused on task. So the combination of being able to, of dysregulated inhibition of impulsivity and sensitivity to reward really make it easy to fall into drugs. A quick summary of the neuroscience,

and this is kind of a couple of key takeaways here. So the first is that people with ADHD have some kind of problem with their dopamine circuitry. And that low levels of dopamine. of dopamine are correlated with high ADHD symptoms. What that means is that when you use drugs, originally, it'll actually increase your dopamine. And I suspect that a lot of the people, a lot of the reasons that people with ADHD use drugs is because it actually offers some element of self-medication. The problem is that if we look at chronic drug use,

originally drugs activate dopamine levels in the prefrontal cortex and other parts like our mesolimbic system and via the nucleus accumbens. This is a lot of called the mesolimbic pathway. I didn't really get into it. But over time, when we use substances, our brain adapts and it affects the levels of dopamine and other parts of our brain. So we start to see a shift from those circuits to the striatum. And once you're into the striatum, we actually see a drop in dopamine with drug use. And with that drop of dopamine with drug use, we see worsening of ADHD symptoms. So people get into it originally out of self-medication, but then it ends up self-sabotaging. The second thing, the second reason that people with ADHD reach for drugs in

my clinical experience is because of the high amount of shame and like, I suck at life because I have ADHD. Very common and unfortunate experience. And then there's another set of, you know, neurovoluntabilities that we've kind of talked about that sort of make you prone to substance use. So the end result of this is that like you, you end up getting like 50% vulnerability to substance use if you have ADHD. So then the question becomes, what do we do about it? And unfortunately, this is where there are a lot of important things to do, and none of them are easy and none of them are simple.

At the top of the list is get sober. I'm sorry, but you can't convince yourself anymore that drugs are like an acceptable thing to do if you've got ADHD. If you have ADHD that is not well controlled and it's negatively impacting your life, honestly, the first thing to do is to get sober. Second thing to do is ideally work with a dual diagnosis clinician who can do therapy to help you work through shame as well as do CBT around ADHD and stuff like that and can help you like get into the process of recovery.

Third thing that you can do is a dopamine detox. So this is going to be really tough for people with ADHD because dopamine detox, the primary problem is essentially boredom. We have a video about dopamine detox that y'all can check out. But dopamine detoxes are going to help you reset your dopamine levels. adjust that that D2 receptor level in the striatum. And once that reset happens, hopefully the ADHD will get better as well. And like that sensitivity to reward stuff will sort of get normalized some. And then the last thing, the four, that was third thing, right? So fourth thing to do

is to meditate. So meditation has been shown to strengthen the frontal lobes, improve things like impulsivity, improve things like your ability to inhibit distractions and focus your attention. And then The fifth thing to do is control your environment. So this is crucial because you do have impulsivity vulnerabilities. You do have distraction vulnerabilities. So if your environment is like a normal environment, other people may be able to not get that distracted. Or if they do get distracted, they'll spend 15 minutes on Reddit before they go back to studying. Whereas your sensitivity to reward is so like out of whack that if you start on Twitter, your brain is going to love it so much that you'll lose two hours before you realize it.

So you must, must, must be very, very strict about your environment if you were trying to do work. So I hope that's been helpful for y'all. I think unfortunately ADHD and substance use are two of the most challenging conditions to try to build a healthy life with. It's so hard because so much of our society is like, how can I say this? So much of our society preys on the vulnerabilities that the ADHD brain has. And as technology is getting more robust, as, you know, these mega companies and video game developers are like paying people millions and billions of dollars to figure out how to engage your attention and increase user engagement, it's just preying on the ADHD brain even more and more and more. So it's really unfortunate that it's honestly like quite an uphill battle. But I don't know how to simplify it. I mean, I think our goal here at Healthy Gamer is to help you all with this stuff. And helping y'all with this stuff starts with like an honest assessment of like where we are, right?

If you want to overcome cancer, sticking your head in the sand is not how you do it. It involves surveillance. It involves diagnosis. It involves prognostication. It involves understanding what's the hill that we have to climb. And even if it's a super high hill, we have to really acknowledge that and understand like what we're getting ourselves into because that's going to be ultimately how we come up with the best sort of plan.