Notes from a withdrawal episode (part 0)

I was starkly aware of how my last post, Notes from a withdrawal episode, felt somewhat incomplete but couldn’t really figure out what it was that was “missing” from it. Someone on twitter had asked whether being on the medication was of any help and I responded to this saying it was too large a topic to cover in tweets and that it wasn’t something I could address on twitter — it would involve really gathering my thoughts and writing a thread there while doing so perhaps felt daunting at that point. It still took me a while to figure out what was missing from my last post was something of a description of what being on Methylphenidate was like and so I decided to write this post about it as something of a prequel to my last post. Like I’d mentioned to the person that had asked that it wasn’t as straightforward an answer as good or bad.

My psychiatrist had initially started me off on a course of Atomoxetine when I got the diagnosis and it felt like it helped initially, because of the novelty of it, I imagine. Regardless, it took me a while to understand that it wasn’t working for me, perhaps owing to the other drug I was on — Sertraline, a powerful SSRI commonly known by its generic name Zoloft — which often left me feeling groggy and exhausted all the time. It was when my doctor started me off on Methylphenidate that I started seeing consistent changes.

Now this is a powerful stimulant and tricky to procure considering it is an amphetamine. The relationship between ADHD and powerful stimulants is interesting. People with ADHD typically have lower levels of dopamine and vastly limited means to access it.¹ Dopamine is the “reward” hormone and is automatically released by the brain when one does activities they enjoy but this release pathway isn’t as reliable or functional for someone with ADHD.² In order to artificially regulate dopamine levels, stimulants such as amphetamines are used to hack the automatic dopamine-high the drug provides as remedy for dysfunctional dopamine signalling. My doctor got me started on Methylphenidate roughly 8 months back. Lower doses at first, slowly leading up to a steady 40 mg (50 mg more recently).

Initially, it felt a little exhilarating — possibly owing to the novelty — but I was fairly certain of a difference in how motivated I felt. Creative bursts, or hyperfocus sessions for that matter, were more frequent when I’m unmedicated (and not in withdrawal) but they’re also notoriously unreliable. They’re too random and unpredictable in all senses of the word and any attempts at doing things consistency ultimately fail because the kind of motivation is ultimately moody and manic. Sometimes, a kind of restlessness overpowers my ability to do anything meaningful and I’m left annoyed and irritable with my brain on overdrive. The medication, in a sense, helps gather these unmanageable peaks and troughs and even them out into a more steady sort of motivation. Oddly enough, I still find that I’m more involved and capable of things that need more creative solutions in some of my unmedicated hyperfocus sessions.

I’m typically well aware of what tasks I’m yet to complete and despite that I’m almost never able to get myself to do those things unmedicated. I can maybe get one, relatively simple task done in the same short-lived bursts of clarity described earlier but the moment I’m done with it, an irritability and often a kind of anxiety sets in, possibly stemming from fatigue. For perhaps the first 2-3 months on the medication, I was able to do some of the larger tasks with ease although I still needed breaks.

I could also notice, over the course of the entire period of time I was on the medication, how I was significantly less preoccupied with lowered self-esteem and getting carried away into dramatic depressive states triggered by criticism or rejection (rejection sensitive dysphoria)³ — I even found that I was more straightforward with dealing with conversations of the sort that bothered me, especially those involving having my experiences invalidated.

I need to be constantly stimulated externally — a good coffee in the morning that gets me going and more importantly keeps me alert. I’m more dependent on this while I’m off the medication. Thinking back on it, a large part of what I look for here is some degree of comfort — as little sources of annoyance and a relatively peaceful space to do things — to be able to work with any amount of consistency. While on medication, these stop being needs.

The medication, however, has a few side effects that I’ve observed — there are a lot more that one should look out for, some of these often quite serious too.⁴ The most prominent of these was insomnia. I’ve had issues with sleep all along but this worsened for the initial few months on the medication. The only solution that showed promise in dealing with this was to plan and keep to a regular routine. Melatonin could potentially help fall asleep but it made me nauseous on the next day for several hours after waking. This, coupled with intense withdrawal symptoms are perhaps the biggest issues I faced.

This doesn’t cover everything, nor was it intended to. There are a few things I have consciously omitted for the sake of my own sanity. Regardless, I hope to make this and the other post into a series I keep adding to periodically.