It is common for me to diagnose ADHD in an adult client within the initial visit – to the dismay, consternation and disapproval of many of those adults!
You’d think that folks who’ve been suffering internally for years, because they are disappointed and distressed about their own daily functioning, would be relieved to have the (or an) answer to their “Why?” questions. But, over the 20 years that I’ve diagnosed hundreds of adults with ADHD, only one was actually delighted to finally understand why she experienced life as she did!
I want so much for clients to understand and take charge of their often frustrating and disappointing ADHD behaviors, as soon as possible. It’s a shame that so many have all kinds of inaccurate notions about Adult ADHD, leading some to actually reject the diagnosis completely and choose not to return to learn more and/or for treatment. Some clients even criticize me for making a quick diagnosis, suggesting that I don’t have enough information to make a diagnosis so quickly.
Then, I wonder: Why does someone think that, just because they don’t know the source of many of their problems, an experienced psychologist like me wouldn’t? My responsibility as a psychologist is to make a diagnosis and work with them to create a treatment plan to address the problems they present. That’s the same responsibility as a physician, who sees patients. Who wants to go to a physician who takes weeks to diagnose pain, when one visit could be enough? What leads some clients to believe that their problems are so complex (and unique) that they couldn’t be identified and labeled expeditiously by an experienced expert?
Anyhow, if you’re curious about what actually makes ADHD in adults relatively easy to diagnose, here’s what you need to know. Adult ADHD has its own distinguishing features, which differentiate it from mental health conditions with overlapping characteristics such as anxiety, depression, bipolar disorder and narcissistic personality disorder.
Of the conditions that demonstrate overlapping observable behaviors, bipolar disorder is the most important to differentiate from ADHD. That’s because the kind of medication that usually has a positive effect on ADHD - by reducing troublesome ADHD behaviors through an increase in brain dopamine and norepinephrine - can, conversely, have a negative affect in those with bipolar disorder, by stimulating an unhealthy manic response.
Here are behaviors and features that usually distinguish ADHD from other conditions:
- Diagnosable in early childhood
- Part of daily living throughout life
- A chronically “busy” brain
- Worry about one’s own performance rather than external events
- Relatively weak impulse control, often including addictive behaviors that increase dopamine bursts such as sexual addiction/online pornography and addictive eating
- A chronic feeling of dissatisfaction (“not having enough; something is missing”)
- Depending on interest for intrinsic motivation and negative consequences for extrinsic motivation
- Feeling like an imposter
- Less awareness of their interpersonal and behavioral problems than someone very familiar with them
A slightly complicating factor, however, is that adult ADHD doesn’t manifest itself in exactly the same way in everyone with ADHD. Brain differences and one’s inborn personality can have an effect on how ADHD feels and looks. For instance, people with ADHD whose personality tends toward conscientiousness and “rule-following” will spend more time organizing and making lists so they don’t leave “loose ends.” They are fixers and finishers by nature. Moreover, they will be less likely to acknowledge or even be aware of performance problems from ADHD, because they’ve learned to compensate - to the best of their ability - for difficulty with the following (executive functioning) challenges typical of ADHD:
- Self-awareness.
- Inhibition/self-restraint.
- Non-Verbal Working Memory: The ability to hold things in mind.
- Verbal Working Memory: Self-speech, or internal speech.
- Emotional Self-Regulation.
- Self-motivation.
- Planning and Problem Solving.
Nevertheless, unless the demands of home and work life hit a level beyond their capacity to compensate, these people will just work harder and longer. They’re also most likely to describe their “busy brain,” (a distinctive feature of ADHD) as natural, normal, and expected, because they have so much to do. The impatience, irritability and short temper at the end of the day will also be understood as justifiable, because they “have so much on their plate”. But, the fact is, they’ve exhausted their executive functioning capacity at work, and there’s nothing left for emotion self-regulation later in the day and evening.
But, I must admit, that although I’ve said I’m disappointed that so many adults fight the diagnosis of ADHD instead of quickly moving to effective treatment, it’s easy to understand why adults might deny and refuse to accept the diagnosis:
- Fear of being stigmatized by the diagnosis or being “exposed” at work
- Media reports leading to the mistaken belief that ADHD is over-diagnosed
- Mistaken belief that ADHD is a problem of little boys
- Belief that people with high academic achievement couldn’t have ADHD
- Belief that ADHD is only about focus and being able to pay attention
- Having been to psychotherapy before, & never having been told that ADHD was a factor
- Even their psychiatrists may not know much about ADHD in adults
Here’s a passage from ADDitude’s ADHD Medical Review Panel, Updated on July 16, 2019
“Surveys tell us that most general physicians, even most psychiatrists, undergo no training on ADHD. “Ninety-three percent of adult psychiatrists, when asked, report that they’ve never had any ADHD training, either in their residency or in their continuing medical education, whether in children, adolescents, or adults,” says Dr. William Dodson, a board-certified adult psychiatrist who has specialized in adults with ADHD for the last 23 years, and adds that the average age of diagnosis in his practice is 39. It’s no wonder so many struggle to get an accurate ADHD diagnosis in adulthood.”
- Preference for a diagnosis or condition that isn’t genetic in origin
- Unwilling to consider a diagnosis that means their ADHD brain is different than a neuro-typical brain
- Preferring to blame their problems on some sort of trauma or other people, and
- Less than sharp self-awareness (one of the features of executive function), and
- Feeling criticized and offended by the diagnosis, because they experience, what some practitioners in the field call “rejection sensitivity.”
And, one more thing. Let’s go back to the first point I made about making a diagnosis - the need to differentiate ADHD from mental health conditions that have overlapping features. Adult ADHD is often accompanied by some level of anxiety and/or depression. That makes complete sense to me. Why wouldn’t adults with untreated ADHD be anxious and/or depressed? Especially if they’re conscientious, they’re likely to be disappointed in themselves, because they don’t function the way they think they should, in view of their intelligence. They’re constantly worrying that they might “f--- up” because of concentration or memory or motivation problems. That would be anxiety provoking and depressing to anyone who is serious about taking responsibility for his or her behavior.
Nevertheless, I’ve found that, when mild or moderate depression and/or anxiety exist alongside Adult ADHD, there’s a good chance that either or both of them are secondary to ADHD! In my experience, when ADHD is treated, mild to moderate anxiety and depression usually melt away. If not, there’s treatment for what remains.
So, that’s my response to those who are unwilling to consider Adult ADHD as the source of their problems. But, in the end, I have to remind myself that, just like the woman on the new HBO program, Diagnosis, some people just won’t accept facts they don’t like.
For more information, please contact me by calling (240) 277-4427.