Quick mandatory reminder 👇

Background

I'll try to keep it short and sweet. My name is Maikel, I'm a 39 years cis gay man from Spain. I've always struggled with sleep and from around 2018 increasingly with having any energy left past noon to continue doing any tasks that require focus. Which is bad because I'm a programmer. I've gone through valerian, melatonin, pills of all sorts and finally doxilamine. Somehow I settled for doxilamine every 3 days to move back my sleeping clock as it tends to shift each day later. Going to the gym first thing in the morning seems to help reach the bed at night tired enough.

I've checked everything possible and more. Count with the fact I'm HIV+ and my CD4 are not at their best count. Let alone I'm on a 4-component medication. On top of that I have another autoimmune called hidradenitis suppurativa (stage 2) that causes major cysts to appear very quicly out of nowhere (can go from nothing to ping-pong ball size within a day) in my armpits and groin area. I have had several surgeries because of this and follow a strict and rigid routine to keep it at bay.

With all this backgorund let's focus on the ADHD or how I reached diagnosis

Non-24 Sleep Disorder

Some definitions

My version (notice the wonderful usage of past tense 😁) shifts usually around 2 hours every day of extra wakefulness, sometimes a lot more. So I use to focus on the time I woke up (which meant some days I slept more, some days less) and if for too many days I slept too litle then take very early one doxilamine pill to sleep more hours and recover.

Of course that wasn't sustainable but nobody did the proper check of why it happened.

The missdiagnosis

For a long time doctors thought I could have hyperthiroidism but every test they did came normal, and multiple doctors made multiple tests both in Spain and the UK, let alone it has now become part of what I get tested every 6 month as part of my regular HIV blood work.

Back in 2018 I finaly managed to quit smoking, it was a long trial and error process until it worked. For a long time after I quit smoking I had anhedonia. In hindsight I think I was using nicotine to treat my ADHD without knowing.

I already had the Non-24h Sleep Disorder, but it got a lot worse. Eventually got so bad for first time ever I spent 3 days unable to sleep and was sent to a psychiatrist. He took notes, asked me about my family mental history, asked about personal experiences I didn't give any importance about (forgetting for 1 full minute about a place that I knew I should know like my hand, Richmond train station, while being there) and eventually reached the conclussion of Panic Disorder. He put me on Sertraline and Prometazine

Did it work? Kind of, I could finally sleep, but I didn't like it at all. It felt like having this artificial euphoria all the time that I couldn't turn off. Then the muscle cramps. And also the imposibility to orgasm. I hated it. After a few months I saw him again and he told me he thinks is more of a dopaminergic sensitivity. Since a panic disorder wouldn't be cured with just meds, if it's purely chemical and therefore problems with my dopamine. He thought I might produce too much of it because of family history. I did tell him his diagnose made no sense since I never feel panic, I just feel "accelerated" sometimes as if someone has pressed the release button of adrenaline out of nowhere. Anyway, I could sleep so I thought case closed. After a while he told me some ways to quit the Sertra and stay on Prometazine so I stayed on that one (much milder) and started my 1 pill every 3 day routine. In Spain there's no prometazine but doxilamine, the effects are the same and both can be bought in the UK and Spain respectively over the counter.

It's shifting again

Back to here ~March my clock started shifting stupidly again. Went again to a psychiatrist (my current one: Ariadna), uploaded her all the docs from my doctor in the UK and we started sertraline again and Zolpidem (more known as Ambien) to bring back to cyrchadiam rythm. It didn't work, it made matters worse. And concentrating now at work became impossible.

The suspicion

I get a message from my brother in law that my niece, who is identical to me, has been diagnosed ADHD. At first it didn't make any sense to me, the one thing where we differ is that she's impulsive, I'm not. But then I discovered there are 3 types of presentation of ADHD. That means the way the symptons can show. And one of them, which I didn't know existed, fits everything including my problems to sleep or concentrate over long periods of time.

I got to a German site that has an english version and start reading, educating myself and finding if there was something I could try before diagnosis to confirm my theory. I read the list of meds on the protocol and figure the easiest one to get was Bupropion. So I got it. Tried 150mg per day of it and from day 1 the changes were magnificent and for the first time ever I went to sleep unaided.

I also discovered that day "putting your mind in blank" is not an idiom, but something neurotypicals can actually do. I literally cried for more than an hour.

Finally the Diagnosis

So I fork 400€ to go to a proper clinic and get assessed by a team of one psychiatrist and one psychologist. Both of them take notes, make me many questions and require my sister to come to be asked as she can tell more objectively than me how I was when I was a kid.

Then I got diagnosed ADHD of inatentive presentation and put on Medikinet 40mg. Initially 20mg to be ramped up to 40 in a week. Doctor knew I got my hands on Bupropion. Told me several ways to quit BP and add methylphenidate instead, I took the drastic one so I could get a clean picture of the effects.

This since ~May 2025 I think. I'm writing this in early September of the same year.

Moving on: Tritation

The good news is that I won't have to explain this background ever again and I have many months to try and test several theories. They said the diagnosis is just the start of the journey and oh boy they're right. There's so much that needs doing even when you have the right meds.

Beginnings with Methylphenidate and unstable results

The 20mg did the job I could finally sit in front of the computer and get work done. But the effect could never be made to last more than 3 hours. This changed when I reached the 40mg dosage. At the beginning I could have them last 4 days, then other days 8 hours or more. I tried to find the logic of it. For which I got my hands on Concerta just to understand the different mechanisms (also the pill bottle is prettier than Medikinet blisters).

I learnt 40mg of Medikinet is equivalent to 72mg of Concerta. But Concerta on any possible gramage, each and every time, altered with my sleep and made me wake up too tired. The effects where stretched so thin it was working while I was sleeping, while during the day I didn't feel the effects strong enough as to reach the same level as medikinet.

So learning about their delivery mechanism I realised to make Medikinet last 8 hours or more I just needed to eat food with it. So I did, one morning gazpacho cup. And, like clockwork, it lasts the 8 hours, sometimes more.

Coffee became something I cannot drink anymore. One mug + MPX = extreme emotional disregulation.

But what is this Elvanse thing? Why is it so pricey? Is it any better?

As some long-gone dead person said ages ago:

the grass is always greener on the other side

So I got my hands on Elvanse 30mg. Those 30 did nothing but 60 did. Each bottle of 30 pills costs 83€ in Spain independently of miligrams per pill so I didn't want to try increasing slower. Eventually tried full term 50mg and found that is the dosage that works best for me. But the effects are very very different than methylphenidate and ultimately decided to go back to Medikinet. Yet the experiment made me uncover another symptom I wasn't aware of.

The 3 main issues ADHD causes me

1. Sleep disorder
2. Executive disfuntion.
3. Emotional disregulation.

With Medikinet I get 1 and 2 sorted, I can work beautifully with zero issues to keep concentrated. With Elvanse what I noticed was entirely different, it fixed number 3. I noticed my irritability going entirely away. That's when I realised the emotional disregulation did affect me too. I was a nicer person to people around me, whereas normally I have to self-censor constantly. It doesn't happen every day nor at the same degree but sometimes it does.

Also my attention was very different on Elvanse, it gives me flexibility but it makes it hard to concentrate on just one thing at once. Task initiation was easy but task maintenance or task lock, hard. While with Medikinet task initiation is harder but task maintenance is easy.

Elvanse also seem to alter my immune system, and with 2 autoimmunes this is no joke. After years without activity I got a few cysts again. Had to go back to clindamicine and ibuprofen to keep them under control and still it became really hard.

Regarding my sleep it made me sleep less but deeper. I needed less hours of sleep to be fully refreshed. But then during the day I felt sleepy several times. So while it worked it wasn't optimal. I don't like napping.

So Medikinet or Elvanse

I'm not entirely 100% about Elvanse though because I've learnt the sun (at least for me) alters both types of pills' effect and the time I did that trial I was in a dark apartment. Today that I took 50mg Elvanse as I was deep cleanign this flat, you can clearly see from this document that I'm having zero issues to concentrate for instance. The problem is the effects were inconsistent. While the one of Medikinet were a lot more consistent.

Elvanse also required me to take one L-tyrosine pill (500mg) each day around noon to keep the effect stable and the crash to a minimum. Also in the mornings despite waking up refreshed I felt anhedonia again. I felt as if someone had deprived me of any dopamine. So I tried with 1 bupropion pill at night (more on this later) and it worked but that's too much complexity. I wanted simplicity. Less is more.

So I went back to Medikinet and kept the Elvanse for days I don't need to work but need to run through several physical tasks (e.g.: deep cleaning of my flat). A one odd Elvanse pill instead of Medikinet for a day doesn't do damage and it helps me get things done that don't require that much focus or concentration but more of a wider attention span like planning or cleaning.

Back to Methylphenidate

I went back to 40mg of Medikinet and tried to figure a way to get the 3 issues sorted with it instead. I never did, instead I managed to bring the 3rd one (emotional disregulation) to some degree of control but not entirely gone. I ultimately figured I couldn't drink any caffeine at all with Medikinet, with Elvanse I made that mistake once and wow, that was a nightmare. By reducing caffeine intake to absolute zero it became "less" of a problem but not entirely gone. I do still get it, just each day a bit less because I'm learning new ways.

So then I settled for Medikinet 40mg as my choice. Tritation's over. Or is it not? We'll see.

Moving on: Self-applied cognitive-behavioral therapy (CBT)

Early on I discovered under the effects of the pills I had to do things differently to the ways I used to. I did try to find a psychologist from my private insurer that could help with this and had 2 sessions with one but they were crap. They didn't focus on the ADHD but on stuff I wasn't interested at all and found no helpful. So I stopped and decided to go my way until I can eventually find one that has decent training to deal with the specifics of ADHD instead. I knew about Cognitive-Behavioral Therapy (CBT) from a very long time ago. When I was a kid I used to read the psychology and psychiatry books of my local library trying to understand my own brain. I'm surprised I didn't figure by then that I had ADHD.

The idea was to find what behaviours, actions and routines I need to change to make an optimal use of the way my brain works under the effects of the meds.

I hate psychiatrists hand you over the pills but they don't give you this information.

How my brain works despite its ADHD

I have a degree in Computing Science and always had the highest marks at first and secondary school without making a concious effort. Since I was a kid I always struggled to concentrate on stuff I didn't find interesting. So I learnt to convince myself of liking stuff. I always thought willpower and focus were hard for everybody, not just me, after all I always had high marks, why would I, as a kid, suspect of anything? I did spend extra time trying to understand how motivation, willpower and focus worked.

So for years I thought there was nothing neurodiverse with my brain, other than the fact I could learnt and process stuff quicker effortlessly. Everybody on my immediate environment including family, teachers and professors knew I have high-cognitive abilities so that never needed testing. That was my normal.

I have clutches, queues and shortcuts, I already told you one but let me enumerate the ones I have found so far:

1. I am a master at convincing myself of finding insteresting, things that I do not.
2. I reduce the friction of those tasks that costs more or add adjacent rewards to make them pleasant. (e.g.: going to the gym = having a very long shower; going to the gym = leaving my mind to wonder for the duration of it; going to the gym = going through my Discovery Weekly spotify playlist). In other words: I wrapped them up with stuff I do enjoy. I call this The Burrito Method ™️
3. I do sometimes overoptimize things just because my inatentiveness makes me see all the angles at once, it is exhausting though. But it's incredibly good for planning or cleaning (beware my cleaning is not your cleaning, more on this later).
4. I use my inatentiveness to plan ahead every decision, even multiple scenarios.
5. I use my inatentiveness combined high my high-cognition (and probably this is where I differ the most with other ADHDers) to picture in my mind some sort of blackboard. I never had to write a TODO list in my entire life to know what I had to do...until the meds.

What Medikinet exactly does to me

Notice the "to me", results may vary. And a quick reminder

The good

1. Completely destroys my inattentiveness. My attention is 100% voluntary.
2. Concentrating and maintaining that concentration on any single task at once is incredibly easy.
3. Makes music sound a lot better.
4. Makes noise bother me a lot less.
5. Allows me to go to sleep at roughly the same time every day.
6. Makes me able to do mental-heavy tasks past noon.
7. Makes learning even easier.
8. Sex is better without the mental noise.

The bad

1. Without the inattentiveness I now need to write TODO lists to know what I'm up to.
2. Without the distractions I can lose track of other tasks that I need to do while the pills are working.
3. Because I'm used to fake interest to trigger concentration, now I overdo it and can lose track of everything else on menial tasks that I found boring.
4. Planning is hard and tasks that require a wider attention span are a lot harder too.
5. Emotional disregulation is better than without meds but it doesn't entirely solve it.

So let's do things differently, right?

We're moving on from brain chemistry but still not leaving it too far behind as reference. What we're doing from now is to find ways to work with or around it. For two goals: one, learn how to use it medicated (so as closed as neurotypical possible) and eventually learn how to never need the meds anymore. The second one is more of a long-term solution that can only be accomplished by truly learning the first one first.

How to plan now?

Medikinet works after for me, ~1 hour after I take the pill. Peaks a lot later but generally I notice a shiver on my scalp during the beginning of its peak. Is almost as if it builds-up, builds-up, builds-up until it goes through a threshold and the shiver always happens. It pretty much feels as if someone was using one of those methalic head massagers on my scalp 👇

Once it works, planning becomes really hard. I am an executioner, I can follow instructions I left behind, but I planning multiple unrelated things becomes hard. So

But sometimes the plans get modified along the way and you need to still remember the other stuff that came along the way and you need to do diffrently, so:

But then where do you check, do you check your phone TODOs? Do you check Obsidian? Do you check ticktick.com? Which one do you check?

Wait, where is my time gone? I didn't plan to spend 3 hours on this. The role of Tonic vs Phasic dopamine

If you're like me and have mastered the art of convincing yourself of finding boring stuff very interesting to somehow trigger your drive. You might now notice one side effect: wasted time on nonsense.

The stuff I previously like now can trigger me in such a way as if they were my life passions. I can completely override anything else I have to do that day and get 100% absorved into them and not realise how my time completely flied.

The problem is not the meds (this is my theory), the problem is 39 years of overcompensation that's why now with normal amounts of dopamine around yet still the same old-behaviours to compensate for lack of it, every like is overpowering. So,

The problem with this one is that it can portray itself as lack of executive function, when in reality is kind of too much of it on the wrong task. Since the switch from Elvanse back to Medikinet I've kept thinking about this because I've realised is not as clear cut as Medikinet solving sleep, exec disfunction and not emotional disregulation whereas Elvanse sleep, emotional disregulation (the most) but not exec disfunction but somewhere in between with the ones they don't solve fully.

Trying to understand why exec disfunction is so hard for me on Elvanse is where I found this issue. With Elvanse I'm motivated on anything that comes to mind so it costs me to stay put on one task (tasks maintenance) but is not the meds, it's me being used to the old-ways as measure. With Medikinet, task maintenance is easy and since motivation is easy to keep I can code for hours and hours. But also, if I rest and do something else for a bit, I might lose 4 hours on that thing without noticing, it's like tunnel vision. So task initiation is what's hard on Medikinet. Because you need ot choose carefully the task you start. As 5 minutes doing something fun, can lead to 5 hours of it before you notice.

So this applies to both and is why I think today Elvanse works, because I'm ensuring I don't try something else and look track of time on it.

Now what's this thing I call tonic vs phasic dopa? First a quick reminder

I tried to understsand the mechanisms of Lisdexamphetamine (Elvanse) vs Methylphenidate (Medikinet/Concerta) and why they worked differently for me. What I found in a nutshell is something along the lines (I'm writing this from memory) that if we imagine our brain as a bucket with some holes like this 👇

Elvanse pretty much, for me, increases the flow of the tap whereas Medikinet patches the holes. Chemically speaking both do both tasks, it just changes the measure in which they do each. Imagine the water is your dopamine. Assume dopamine is that neurotransmitter that you have too little of, in certain key regions of the brain, the ones targetted by MPX or LDX.

Unmedicated up until noon my ADHD issues are not that bad, after 1pm is when they start getting worse. So my theory is that my problems with dopamine are not generation but reuptake. Using the bucket analogy, the holes keep getting bigger after 1pm. This is probably why my ADHD is of inatentive type. More on this shortly.

Dopamine is not as clear cut as it sound either. There are two types of it, one is tonic dopa and the other is phasic dopa and I don't quite understand the mechanisms that convers one into the other. The tonic one is the one we produce steadily around the day while the phasic one is the one we produce when we concentrate on a task. The one you lack the most might define the presentation of ADHD you have and the meds you need (if on the stimulant choice). Now reminder

My theory is Elvanse is brilliant for people with problems of the tonic dopa type (scarcity the whole damn day) while MPX for people with problems of the phasic dopa type (reuptake of this one being too quick or accelerating through the day). Which is why MPX works better for me and my biggest struggle unmedicated is with task maintenance, not task initiation. While medicated becomes task initiation because if I start the wrong task I can get stuck on it and not notice.

The 80mg accident: Tritation 2.0.

I'm moving flats, I'm living in temporary free accomodation, long story. The thing is I made a mistake and believing I didn't have my 40mg pill while I was picking up stuff from one flat, I took the 40mg in the other. That's 80mg of Medikinet. The day was interesting.

To begin with the day was very cloudy, dark and rainy. I went out to fetch something and the shivers on my scalp that mark the beginning of the pills peaking, felt otherwordly. The good benefits of the pills were feeling extra sharp. And the mental silence was for first time in months absolute zero. I immediately realised I took 2 pills.

I did nothing, I just let the day go ahead as planned, worked, got stuff done. Everything fine. Sleeping was a bit harder than usual but not that much because Medikinet has a short life anyway.

But it made me thing, because for first time ever. Medikinet satisfied the 3 issues, a reminder:

For first time ever, Medikinet fixed emotional disregulation, just like Elvanse did. So I wondered: am I taking too little? I talked to my psychiatrist and we're back on tritation. I was on 40mg, she told me to hike the dosage to 50mg for a week and then 60mg for the next and compare the results then talk to her. But then the sun as a factor became obvious.

The strange role of sunlight

This new flat I just moved into when I made the 80mg mistake is a lot sunnier than the one I was before. While I'm working I get as much sunlight as if I were on the street. The windows are big on the office.

The day I took the 80mg it was dark, no sunlight and my ADHD was gone. Whereas now on this new tritation, the days I took 50mg, the results changed drastically depending on weather. Even more so 60mg (I'm there now) which can be overpowering (too much) on sunny days.

I don't seem to find objective information about the role of sunlight on ADHD other than it benefits children, as usual, all ADHD studies are focused on children not adults. All I could find is that the synthesis of vitamin D by the skin somehow triggers also stimulates the synthesis of dopamine. But I haven't found a clear cut explanation of how, why, in what amounts etc yet. It's all taken with a pinch of salt. I need to find more about this, but for now this is what I can do👇

I might go back down to 50mgs though and convince my psychiatrist somehow of allowing me prescription window whereas I keep 50mgs as baseline (40 don't do enough anymore) and can up the dosage to 60 on darker days.

In Coruña this is harder to predict becuase the weather is very unstable, but in Cádiz the weather is more stable and generally sunny. A dark day is rare and we know in advance because the weather prediction is rarely wrong. If I stick in Coruña to 60mg, that is going to be too much in Cádiz.

The theory of the stack

The mind of an ADHDer seems to be a stack. When there's something on the top of the stack it is hard to get to everything else unless you get that one thing out of the way. Methylphenidate makes this a lot easier but still.

My friend Remi is above 50 years old and cannot stop talking, his mouth has a life of its own, he displayed all sort of signs of ADHD and I told him, he starteda asking around to other friends and they all said the same "I thought you knew". I told him it would be worth to get it evaluated as his verborreic mouth fucks his social life heavily and controlling his symptons will make his life a lot simpler. It took a while but he went to my same clinic, and got a diagnosis, in his case the diagnosis report said something along the lines of primarily inatentive with impulse discontrol of speech.

I went with him to the interview where he needed a friend or family to talk about what's weird of him objectively. I was there the whole interview, the parts they ask for me and the parts they ask of him, and discovered his ways to cope. Among them is this stack that I've seen so many ADHDers do.

If a task gains priority, nothing else will get done until that task is moved out of the way. So this ADHDers when they get a new task at work, they just do it immediately, no questions, no priorities, new = done, then next. It requires zero planning, you just do things on a LIFO (last-in, first-out) fashion. Which is not at all my way....until it is.

If something really claims my attention, no amount of pills is going help me. My best choice is to get that done or closed or dealt with ASAP. I've been for a long time trying to answer the question Cádiz or staying in Coruña. I'd rather stay in Coruña but if the housing market doesn't allow me, then there's no point. I hate sharing flats. I'm almost 40, it's fun when you're on your 20s, it isn't when you have patterns, rigid lifestyles, discipline and order on your life to share with a total stranger that will have very different routines and ways to live on their homes. It has taken me a long time on giving up on the idea of living in Coruña. But probably moving to Adrian's flat and discovering the effect of the sun moved the balanced towards Cádiz. Moral of the story, that worry got out of my way, hello productivity again.

The role of coffee

I can't drink coffee. It is that simple. Today I did have a mug of it very early but I haven't had any coffee in more than a week, one mug a week is not enough to do damage. I even had an Elvanse 2 hours after it without any issues.

Coffee in either case MPX or LDX produces the same effect, emotional disregulation taken to the next level. In the case of MPX completely changes the effect of the pills to the worse. In the case of LDX, it pretty much flips them over, if emotional regulation is the thing I get the most from Elvanse, incredible disregulated emotions is what I get if I take a coffee during its effect. It did reach levels of panic attack. I made the mistake once and never did it again.

Today doesn't count, 2 hours after that mug the effects of caffeine were long gone. The only reaosn I took that coffee today was because sun + 60mg of medikinet yesterday were so overpowerin i struggled to sleep so I did take 1 doxilamine, like in the old days. And to cancel out the doxilamine in the morning, nothing works like coffee. Otherwise you feel like an alcohol hangover. It all worked perfectly.

So now I drink decaff. I realised my addiction is more to the routine of preparing it, than to the caffeine itself.

The role of movement

Once thing I get the feeling of is that my brain doesn't work correctly unless my body has been moving for a while (either gym or running). Hence why I think working out first thing is the way to go and something I should never change. Since I'm leaving Coruña I already cancelled the gym. So as soon as I wake up I try to find physical stuff to do. Sometimes is doing some deep cleaning of some part of this house, most times is running 5K.

The role of social media

This goes hand in hand with change number 5. Since you're used to overcompensating to generate drive, this is specifically for social media. If there's a subject you're passionate about you can indeed spend hours on it. So,

Once you're out of working hours, feel free to disable the extension and use your distractin devices a.k.a.: smartphone.

More comming soon

This is all for today, which is not little, the next episode, will include more but won't need the background section. Yay! I'll keep focusing on changes. I have not reviewed the text, not edited it, nor used any LLM to write it, it's all straight from my mind so pardon the typos if you find any. And please do comment.

Where to find me

I'm mostly on Mastodon these days, as a software engineer I cannot tolerate having my random ramblings and thoughts centralised by a commercial entity so you can find me there with the handle @maikel@vmst.io . Mastodon is filled with minorities that are either ignored or silenced in other platforms (LGBTQ+ people, autistic spectrum people, ADHD people, lots of groups). It's really easy to find and compare experiences there with other ADHDers without rudeness, trolls, or bad actors. And there are even group accounts where you can post for everyone subscribed to that account (e.g: @adhd@a.gup.pe) to receive your posts. I highly recommend it. The fediverse is probably the social media of the future, where you are not a product.