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  • Chris Masuda

5 Things your psychiatrist might be thinking of when you discuss adult ADHD

Updated: Feb 14

Attention Deficit Hyperactivity Disorder (ADHD) has become a hot topic on social media lately. There are TikTok and YouTube videos and your best friend talking about how they have it. Your partner and boss and next door neighbor wonder if they have it. Maybe you've noticed how hard it is to concentrate at the last meeting you went to and have started to wonder as well.

As a psychiatrist, I get a lot of referrals from primary care asking me to evaluate potential ADHD. What they usually mean is that someone is struggling with poor concentration and they'd like me to figure out what is causing it. Here are some key points I have floating around in my brain in this situation.

  1. DSM-5 criteria - In psychiatry, we have a ''bible'' of diagnoses that are all collected in this big purple book we have stashed in our offices. This book is called the DSM-5 and is what all the experts have agreed upon for any particular diagnosis. As a patient is telling me their story, I am thinking back to the criteria in the DSM and seeing if it matches the picture the patient is telling me. Symptoms of ADHD fall into two main buckets that include problems with inattention, and problems with hyperactivity or impulsivity. Click here if you'd like to see the actual criteria

  2. Degree of functional impairment - Now the issue with the criteria is that lots of us resonate with many of those symptoms. So does that mean we all have ADHD? Not quite. This is where self diagnosis gets kinda tricky. Results from filling out a self assessment often serve as a good screening tool, but are not diagnostic because of some common pitfalls. One of the things I think about while I'm listening to patients talk about the above symptoms is ''how impairing is it?''. You might resonate with a symptom because you're thinking about how you lost your keys last week, but after talking with your psychiatrist it becomes apparent it only happens once a month and is not a huge deal in your life. On the other hand, you might lose your keys, wallet, and phone every single day and it makes you 10 minutes late to work, causing you to lose several jobs. The degree of functional impairment in these two examples are vastly different.

  3. Timeline - ''Adult ADHD'' is actually not a separate DSM-5 diagnosis. The reason is that all ''adult ADHD'' is simply normal ADHD but diagnosed in adults, despite the disorder having been in their lives the entire time. ADHD is a neurodevelopmental disorder, so it does not just start existing in adulthood. ADHD is sometimes missed in kids for various reasons. Perhaps the kid grew up in decades past, when providers were not diagnosing it as much back then. Perhaps there was lots going on in that family's life. Perhaps the kid was super smart so didn't have to concentrate to excel until they hit college or a highly demanding career. So when I'm listening to a patient's story, I'm asking when the issues started. If they started as an adult, I'm trying to dig deeper and understand if the demands on their concentration changed a lot and could explain it. On the other hand, if someone had a demanding student career or adult career the entire time and concentration only arose as an issue in the middle of it, I'm wondering if there could be another explanation.

  4. Other explanations - As I listen, I wonder about alternate causes of poor concentration. Common culprits include generalized anxiety disorders, depression, hypomania, trauma, or substance issues. I'll go back to losing the keys example. Some people with ADHD might lose their keys a lot due to poor focus in general (thinking of other neutral topics like ''squirrel!!'', but others (like myself) might lose their keys because they're thinking about 10 things they need to do tomorrow and are so worried it makes them not be present and then lose things. In the latter case, it might be more of an anxious process causing issues, but on the surface it sounds almost identical until a professional helps you dig into it more.

  5. Are stimulants even on the table - In an evaluation for concentration issues I am also considering if stimulants like Adderall or Vyvanse or Ritalin are even on the table or not. All medicines have risks and benefits and the stimulants are highly controlled. Risks I'm worried about in adults include stressing out the heart (increasing the rate and force of the heart beats, which can increase blood pressure) and problems with sleep. Many folks also have an irritable crash as the stimulant withdraws. If a person also has a mood disorder I need to screen for bipolar, since stimulants might destabilize mood in that case. If someone struggles with a substance, it makes me more concerned about the risk of addiction or abuse. If someone also has severe anxiety, I consider the stimulant's risk of worsening it.

ADHD can be a very functionally impairing issue that absolutely deserves appropriate treatment. At the same time, I think it is wise to consider the nuances to symptoms and that many other conditions can also cause a similar picture on the surface.

Image by Freepik


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