ADHD Personality

[thoffen]

Those who clicked on this thread are probably not going to get a discussion on what they expected coming in. There are abundant threads about adult ADHD and concerns of people seeking ADHD treatment to avoid feeling responsible for their shortcomings. While I believe that some of those people have ADHD, my experience, particularly with intelligent people from generally stable homes with more inattentive symptoms and impairment in executive function than hyperactivity/impulsivity, is decidedly opposite of this model. I have had several patients who are quite resistant to the diagnosis and treatment and quite adept at hiding the existence and severity of their symptoms from providers. I believe that hiding to be an unconscious defensive operation. I'll share some experiences how many people with ADHD develop a personality central to it, and I have intentionally left the word "disorder" out of it. I will disclaim that this affinity and understanding is largely driven by my own personal experience, and my sharing here has many aims, but among them is challenging myself to understand better where I am biased.

Firstly, the people I am talking about are not lacking in desire to take personal responsibility. They are lacking in capacity. In part, a greater pressure to take personal responsibility for things is enacted, and this can certainly be helpful in overcoming barriers at times. It can also be pathologic. When a person in this state experiences failure to execute a desire (as is normal for all but central for ADHD sufferers), the guilt over this failure is irrationally intense. It presents as a barrier to overcoming awareness of their challenges and confronting minor discrepancies in expected functioning. People with ADHD tend to be quite skilled at denial and may actually be lauded for their creative efforts to solve every other problem in the world except the one assigned to them. Much of the motivation to solve those other problems comes from defenses enacted to avoid confronting the guilt over failing to do the thing they believe they are supposed to be doing. People with ADHD have an intuitive awareness of misattributions of bad intent. This is because their failures have always been taught to them as their fault, and most spend a lot of time trying to understand their own intentions. They usually fail in that regard, but it does help them at least develop intuition into how others are motivated. Sometimes recognizing that misattribution is inappropriately recognized as projection, etc., but really it is hard to put this awareness to effect when no one teaches you what it represents and how it might be used. People with ADHD are often very sensitive to criticism. They are wanting desperately to know what motivates them, so any feedback they receive is taken personally. It is not a failure of desire for constructive criticism or capacity to adapt to feedback; there is an anticipation that they will be given absolute confirmation of the fear their life is built around: that the suffering they have experienced on behalf of their failures is their fault because they are not good enough. Of course, that confirmation never really comes because it never really was true, but we cannot expect that knowledge to be worth much just as we cannot expect PTSD patients to abandon their hypervigilance merely because they rationally learn that the threat is not real.

Hypervigilance is a good word to describe ADHD. It's just not something very often clinically observable. A person with significant attentional difficulties is always scanning their environment and making note of all the distractions that exist and actively attempting to manage them. They inherently feel powerless to remove the distractions, so much active cognitive effort is used to contain them. This pressure certainly does not help to focus on the task at hand, and even the slightest aggression toward someone's lack of attention drastically amplifies the pressure. That aggression is misguided, of course, but it is such an ingrained response in so many of us when we feel disrespected that it is difficult to contain even when we fully appreciate the need to. Scanning for that aggression (a pause in speech, a raised voice, an increase in eye contact, a tap of the foot, a minute difference in affect) becomes an art form because detecting the aggression not only signals threat of impending danger, it provides information that the person with ADHD otherwise lacks. They often do not know what is expected of them despite a strong desire to meet those expectations, and the best way to find out is often by utilizing that vigilance. Of course, as a younger child, people have not learned self-control. Children with ADHD display a lot of emotion and automatic defiance. It is communication; they are needing something from the environment that they cannot provide for themselves. Unfortunately, that communication is rarely understood for the purity of its intent. It is instead interpreted as defiance, hostility, lack of desire for the good behavior, what have you. Really, people with ADHD often have intense desire for the good behavior, but they need you to help them manage their competing desires in order to perform the good behavior, and they cannot manage those competing desires because their capacity to remove attention to these competing desires is impaired. In this way, ADHD can be thought of also as Inattention-deficit disorder. The result of that is these communications of intensity of affect, distress, and difficulty contending with competing desire is met with punishment and information that this behavior is willful. It is not, but a child does not know their own motivations. They must be taught them. So a child learns to believe that these deficits are a product of their own choice. If they ever think otherwise and choose to display them in anticipation of help, they are met with punishment and further accusations. This is why the hypervigilance becomes hidden. There is nothing to be gained in its display, and doing so puts someone at risk of further exposure of their own inadequacy and perceived responsibility for that inadequacy. People with ADHD often don't recognize their hypervigilance, in part because no one could properly name it, and in part because they are unable to appreciate the ways in which their own internal experience does not match that of others. If you ask them about it, they might even report that they do not possess enough vigilance. That is because the world has taught them that their lack of execution is a result of their lack of desire and subsequent choices. They are acutely aware of their failures to execute, so this is how they explain it to themselves. It produces a wellspring of internal distress. Resistance to diagnosis and treatment may represent that same fear. If medicine confers these abilities, then it is not they who possess them, and they really don't want it bad enough. This thinking is flawed, but it must be explored and honored to have success.

Of course, some degree of these failures and these experiences and ideas are part of all of our experiences. Normal includes attentional difficulties and misattributions of intent and malice and development of some degree of vigilance for the needs and aggressions of others. This is why I did not title my post ADHD Experience. What needs to be recognized is how early and central these challenges are to an ADHD sufferer and how it has molded their personality.

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[wolfvgang22]

 

[Shikima]

What about the late teens/early 20s who never needed to study in high school, graduated with a very good GPA but now is not getting the same grades while attending University asking for Adderall because they cannot focus/concentrate?

 

[randomdoc1]

What about the late teens/early 20s who never needed to study in high school, graduated with a very good GPA but now is not getting the same grades while attending University asking for Adderall because they cannot focus/concentrate?

How dare you question their ADHD?! They swear they have all sx in the DSM, even more confirmatory if they are reciting the DSM IV criteria. Besides, the Adderall helped so much! And shame on you for even considering their daily THC, etoh, possible depression, anxiety, the 20 credits they're taking...

 

[Shikima]

How dare you question their ADHD?! They swear they have all sx in the DSM, even more confirmatory if they are reciting the DSM IV criteria. Besides, the Adderall helped so much! And shame on you for even considering their daily THC, etoh, possible depression, anxiety, the 20 credits they're taking...

Oh yeah, I forgot to mention the drug use occasionally and showing up late for appointments.

 

[Fan_of_Meehl]

Thank God for applied behavior analysis.

 

[thoffen]

🙂 I'm thankful for confused or questioning responses alike. The experience I am talking about is not the same as all the other threads about stimulants. We all get plenty of that and are right to have aggression toward it and question its validity. The experience I'm talking about is one you probably won't have much of if you don't screen for and have a high index of suspicion for ADHD. Some were diagnosed as a child and will provide that history, and you might ask them about it, but they probably won't give you much convincing evidence of ongoing dysfunction. That's because they have learned that they are responsible for their shortcomings, so they won't think that it is an ongoing problem, and adults have found ways to compensate for, hide, or restructure their lives so that the DSM symptoms might not even really be present so much in their direct form. I suppose you might encounter them coming to you for ADHD treatment if they were diagnosed as a child and want to continue treatment as adults. So many adults these days were never diagnosed because (inattentive type in particular) ADHD was not so readily recognized as it is today. Unfortunately, our hostility toward times when it is inappropriately diagnosed clouds our appreciation for the times when it is inappropriately excluded from diagnostic consideration. If you don't know what to look for, you won't find it. Because the core beliefs that stem from their illness involve self-doubt, lack of sense of mastery over the environment, and in particular related to productivity, the symptoms that people will bring to you for treatment are easily ascribed to depression, anxiety, OC-spectrum, and identity/affective regulation issues. You might even say that they might have ADHD, but you need to treat their XYZ first in order to find out if those symptoms still remain. Good luck. Do you guys actually have success often clearing away those symptoms so you can even get to the ADHD evaluation? I don't, and if I do, I never find ADHD underneath because if it was there I could never really expect to successfully treat those other problems. And that's assuming you can keep these patients in treatment. You often never realize you've made a mistake because they don't come in for follow-up consistently and aren't compliant with their meds. Why would you expect them to be? They are coming to you because of an illness that impairs their executive function, and your message to them is that you can't even begin to consider identifying much less helping with that illness until they are able to execute.

 

[wolfvgang22]

When all else fails, I pirouette to dance therapy.

 

[thoffen]

When all else fails, I pirouette to dance therapy.

Do you really think I'm trolling? I didn't exactly expect widespread agreement or even understanding. I'm not really mad, but I didn't expect to be so far off in left field.

 

[birchswing]

I don't have anything to add to your original points, @thoffen , but it was one of the more original, thoughtful things I've read on here in a while. And I too was confused at the reactions to what you wrote. Although that doesn't give you a lot of credence coming from me.

 

[FlowRate]

I understand what you're talking about but I don't have enough experience with this patient population to have any opinion. It reminds me of other disorders that are usually diagnosed late and have a behavioral aspect that typically leads to patients being blamed for failures. (Sleep disorders come to mind.)

 

[thoffen]

I understand what you're talking about but I don't have enough experience with this patient population to have any opinion. It reminds me of other disorders that are usually diagnosed late and have a behavioral aspect that typically leads to patients being blamed for failures. (Sleep disorders come to mind.)

Yeah. The dynamics certainly are neither unique nor universal in ADHD, but I do think there is something special about it's relationship here because of the specific challenges it presents at the specific time in development where identity is first formed. And that much of the challenges just look like normal (but not desired) behavior to most people most of the time.

 

[psychnpgirl]

Those who clicked on this thread are probably not going to get a discussion on what they expected coming in. There are abundant threads about adult ADHD and concerns of people seeking ADHD treatment to avoid feeling responsible for their shortcomings. While I believe that some of those people have ADHD, my experience, particularly with intelligent people from generally stable homes with more inattentive symptoms and impairment in executive function than hyperactivity/impulsivity, is decidedly opposite of this model. I have had several patients who are quite resistant to the diagnosis and treatment and quite adept at hiding the existence and severity of their symptoms from providers. I believe that hiding to be an unconscious defensive operation. I'll share some experiences how many people with ADHD develop a personality central to it, and I have intentionally left the word "disorder" out of it. I will disclaim that this affinity and understanding is largely driven by my own personal experience, and my sharing here has many aims, but among them is challenging myself to understand better where I am biased.

Firstly, the people I am talking about are not lacking in desire to take personal responsibility. They are lacking in capacity. In part, a greater pressure to take personal responsibility for things is enacted, and this can certainly be helpful in overcoming barriers at times. It can also be pathologic. When a person in this state experiences failure to execute a desire (as is normal for all but central for ADHD sufferers), the guilt over this failure is irrationally intense. It presents as a barrier to overcoming awareness of their challenges and confronting minor discrepancies in expected functioning. People with ADHD tend to be quite skilled at denial and may actually be lauded for their creative efforts to solve every other problem in the world except the one assigned to them. Much of the motivation to solve those other problems comes from defenses enacted to avoid confronting the guilt over failing to do the thing they believe they are supposed to be doing. People with ADHD have an intuitive awareness of misattributions of bad intent. This is because their failures have always been taught to them as their fault, and most spend a lot of time trying to understand their own intentions. They usually fail in that regard, but it does help them at least develop intuition into how others are motivated. Sometimes recognizing that misattribution is inappropriately recognized as projection, etc., but really it is hard to put this awareness to effect when no one teaches you what it represents and how it might be used. People with ADHD are often very sensitive to criticism. They are wanting desperately to know what motivates them, so any feedback they receive is taken personally. It is not a failure of desire for constructive criticism or capacity to adapt to feedback; there is an anticipation that they will be given absolute confirmation of the fear their life is built around: that the suffering they have experienced on behalf of their failures is their fault because they are not good enough. Of course, that confirmation never really comes because it never really was true, but we cannot expect that knowledge to be worth much just as we cannot expect PTSD patients to abandon their hypervigilance merely because they rationally learn that the threat is not real.

Hypervigilance is a good word to describe ADHD. It's just not something very often clinically observable. A person with significant attentional difficulties is always scanning their environment and making note of all the distractions that exist and actively attempting to manage them. They inherently feel powerless to remove the distractions, so much active cognitive effort is used to contain them. This pressure certainly does not help to focus on the task at hand, and even the slightest aggression toward someone's lack of attention drastically amplifies the pressure. That aggression is misguided, of course, but it is such an ingrained response in so many of us when we feel disrespected that it is difficult to contain even when we fully appreciate the need to. Scanning for that aggression (a pause in speech, a raised voice, an increase in eye contact, a tap of the foot, a minute difference in affect) becomes an art form because detecting the aggression not only signals threat of impending danger, it provides information that the person with ADHD otherwise lacks. They often do not know what is expected of them despite a strong desire to meet those expectations, and the best way to find out is often by utilizing that vigilance. Of course, as a younger child, people have not learned self-control. Children with ADHD display a lot of emotion and automatic defiance. It is communication; they are needing something from the environment that they cannot provide for themselves. Unfortunately, that communication is rarely understood for the purity of its intent. It is instead interpreted as defiance, hostility, lack of desire for the good behavior, what have you. Really, people with ADHD often have intense desire for the good behavior, but they need you to help them manage their competing desires in order to perform the good behavior, and they cannot manage those competing desires because their capacity to remove attention to these competing desires is impaired. In this way, ADHD can be thought of also as Inattention-deficit disorder. The result of that is these communications of intensity of affect, distress, and difficulty contending with competing desire is met with punishment and information that this behavior is willful. It is not, but a child does not know their own motivations. They must be taught them. So a child learns to believe that these deficits are a product of their own choice. If they ever think otherwise and choose to display them in anticipation of help, they are met with punishment and further accusations. This is why the hypervigilance becomes hidden. There is nothing to be gained in its display, and doing so puts someone at risk of further exposure of their own inadequacy and perceived responsibility for that inadequacy. People with ADHD often don't recognize their hypervigilance, in part because no one could properly name it, and in part because they are unable to appreciate the ways in which their own internal experience does not match that of others. If you ask them about it, they might even report that they do not possess enough vigilance. That is because the world has taught them that their lack of execution is a result of their lack of desire and subsequent choices. They are acutely aware of their failures to execute, so this is how they explain it to themselves. It produces a wellspring of internal distress. Resistance to diagnosis and treatment may represent that same fear. If medicine confers these abilities, then it is not they who possess them, and they really don't want it bad enough. This thinking is flawed, but it must be explored and honored to have success.

Of course, some degree of these failures and these experiences and ideas are part of all of our experiences. Normal includes attentional difficulties and misattributions of intent and malice and development of some degree of vigilance for the needs and aggressions of others. This is why I did not title my post ADHD Experience. What needs to be recognized is how early and central these challenges are to an ADHD sufferer and how it has molded their personality.

Haven’t read replied yet but OP I think you’re brilliant and I would love to have a book club on “Scattered” by Gabor Mate with you. Just as PDs are dimensional you acknowledge that many of the experiences shaping ADHD are dimensional. I feel there could be a connection between your description and shame/self-blame in depression and PTSD.

It takes a lot to question our leading paradigms and I appreciate your willingness to do that. How else do we evolve?

 

[thoffen]

Haven’t read replied yet but OP I think you’re brilliant and I would love to have a book club on “Scattered” by Gabor Mate with you. Just as PDs are dimensional you acknowledge that many of the experiences shaping ADHD are dimensional. I feel there could be a connection between your description and shame/self-blame in depression and PTSD.

It takes a lot to question our leading paradigms and I appreciate your willingness to do that. How else do we evolve?

Goodness, that sounds like an awful lot of work. I'm no good at that. But I am good at being curious and recognizing where conventional thinking isn't good enough. I would happily engage in a project with you, but you'd have to do it with awareness that I will be utterly unable to provide structure on my own, and the extent to which I will contribute depends entirely upon the ability of the project or yourself to spark my curiosity. So if you give me a compelling idea with at best an ambiguous solution, you might get something worthwhile in turn.

 

[randomdoc1]

All kidding aside, believe it or not, I seriously do sympathize with people who truly struggle from ADHD. I just feel like there is a lot of over diagnosis that it's kind of killed it for the people who legitimately have it. When I first started private practice, over 70% of the people calling to be new pts either wanted stimulants continued or were looking for a dx of ADHD. I sh** you not. I try my best to be thorough and not be dismissive. People coming with a cc of poor attention, I did the Barkley, UDS, TSH, attempted to gather collateral from parents. But not only is inattention analogous to the cough in the PCP's office as someone else as said, I found after exhaustive thorough history gathering very rarely do these people actually meet diagnostic criteria for ADHD! I have been even more jaded by people I referred for neuropsych testing for various reasons and I find they are malingering trying to get that ADHD diagnosis and their stimmies. More often than not, I found people getting angry that I wanted to gather such a thorough history but hey, chronic stimulants are not a benign thing. Frankly, I got tired of this silly wild goose chase and focused my practice on mood disorders, trauma and anxiety. There is still plenty of need for the other disorders and I just don't have the time to do all this exhaustive work up just to find it was all not ADHD after all and many patients do not appreciate it, many come with their minds made up.

For those who do have ADHD, the other aspect I have to argue is that there are therapy modalities that are highly effective. But we live in a society of convenience. I find many psychiatric patients regardless of diagnosis have unrealistic expectations of medications. Many decline therapy, lifestyle changes, CBT-I, etc. I work with a neuropsychologist who is a national leader in ADHD and she also says that even children diagnosed with ADHD, it does not always equal mandatory treatment with stimulants and she feels adjunctive treatments are highly under utilized and I agree. We do have to take some ownership of our disorder and this is true of all psychiatric and non-psychiatric illnesses (with the exception of some extenuating circumstances). Many people with depression and anxiety also go through life blaming themselves and struggle with determining how much is really disease versus a character flaw. However, we must still take ownership. On the other hand, medicine has moved to a consumer model. Overweight? Diabetes? HTN? There's a pill for all of those but no one stops to change their diet, exercise, or lose weight which would have treated just about all those disorders. Hence, the world of polypharmacy we find a lot of patients in and further iatrogenic complications. We need to be careful to not be dismissive but also be mindful of our oath of first do no harm. Stimulant prescriptions are really on the rise and as I discussed in other threads, it reminds me some of how the opiate epidemic started, which is unfortunately a problem that was in part caused by healthcare providers. We are the gate keepers after all.

 

[splik]

I did not have the attention span to read through your essay, but ADHD definitely influences personality. This is well known. I do not treat patients with ADHD but I do evaluate ADHD in forensic evals (which is nice because I can spend many hours doing evaluation, psychological testing, malingering eval, and the attorneys get me all their school records etc). Many people I see with ADHD have anankastic, narcissistic or borderline personality that is the result of untreated ADHD. Many people experience a lot of shame for their difficulties. Others still experienced emotional and physical abuse in childhood as a result of ADHD which led to their personality dysfunction in later life. Many people with untreated ADHD report having found it hard to make friends when they were younger or experiencing bullying too. untreated ADHD is common in criminals (hence my role) and so clearly exacts wider societal costs.

I hate evaluating pts coming along seeking stimulants and not wanting an actual work up of their attentional complaints (which is actually quite fun diagnostically if people are willing to play ball). But I find it quite rewarding to uncover a diagnosis of ADHD in someone who isn't coming along with that diagnosis or seeking stimulants etc, but you find it actually underlies their personality disorder, interpersonal and occupational difficulties, or the poor sense of self that they may have. there can be a lot of shame and resistance to taking stimulants. these people often don't seek psychiatric help and the only reason i see them is in the context of a forensic psychiatric evaluation.

 

[thoffen]

While I think that stimulants are critical treatment for many, this post isn't really to say we should be giving more of them. I do find that, although therapeutic intervention could be the critical or a critical intervention, for adults with ADHD it can be a very daunting expectation due to the challenges with executive functioning. If someone has a spouse, friend, etc. that can aid them in getting them off the ground and starting to implement the behavioral changes, then those barriers can be overcome.

Again, while your experience is mostly in people seeking simulants, most of which you found to not have ADHD, contending with our associations to this separate class of patients really blocks us from recognizing the people who really do need help. They are unlikely to ask for it (at least directly) and unlikely to expect it's your responsibility to fix them. I posted this in part for that reason. Not because I contend with the belief that it is over-diagnosed and fraught with drug seekers. That is a very real and common experience. But it is also under-diagnosed, with real sufferers reluctant to seek treatment and unaware of exactly what the problem is anyway. And it's not just a functional deficit. Depending on the severity of (predominantly) executive deficit and the environment a person is raised in, the suffering can be quite intense and under-appreciated by both the doctor and the sufferer. The person believes they have earned their suffering and fails to appreciate that this isn't how everyone else feels inside. That isn't unlike many with depression, anxiety, etc., but it is likely to be much more central to their personality structure.

 

[psychnpgirl]

if someone can focus when they're interested but not when they are not interested, how can that be anything but psychological in origin? based on avoidance and fear of failure makes sense... I'm not sure that's exactly what you were trying to say... but it is bizarre. We acknowledge that panic has to do with avoidance and that mindfulness and acceptance of worst outcome are viable treatment routes.

I also agree that talking about the psychological origin of ADHD doesn't preclude stimulant use.

Also, we have already acknowledged all ADHD traits are spectrum that most people are on, which your essay aligns with. how to decide if they need a stimulant? I guess if benefits outweigh risks. Which will constantly vary depending on what challenges someone is facing in their life at a given time

 

[clinicalpresentations]

As a diagnosed adult with ADHD myself I find discussions of the topic on this thread at times jaw droppingly insensitive and ignorant. What bothers me most is that I expect this kind of fluff in the outside world, but to have medical professionals be this utterly clueless really scares me. I think a lot of your ADHD patients must be suffering for this ignorance and I really hope you'll all dig deep and consider that, from personal and proffesional experience I feel that the post above is one of the most thoughtful and accurate descriptions of the impact of unmanaged ADHD on psychological development. I think you nailed it, thoffen.

To quote Linda Joy Morrison's dissertation on the topic of dissenting patient movements that breed "uppity" patients
" When a group of people are discredited precisely because they belong to a particular category, their point of view is not represented and may even be actively discounted or discredited. The dominant position of psychiatry, with its claims to scientific credibility in defining its human “objects” of study and practice, can be critiqued similarly to the way a feminist epistemology has been used to critique science."

When you develop so serious a resistance to any patient who shows a modicum of independent agency in their quest for mental health that simply showing up informed decreases their odds of being diagnosed you have a problem with your ego. We are fallible as physicians, and sometimes we simply don't know as much about our patient as our patient knows about themselves.

Whenever a doctor jumps to the conclusion that a highly informed patient seeking stimulants needs must be a drug seeker, I look at myself and I wonder what would have happened to me if I wasn't believed.

I do, after all, have precocious knowledge of my disorder. I was diagnosed by a specialist in the 80's long before diagnosing girls was even considered a thing you really can do.

I had extensive therapy and intervention, and I was prescribed Ritalin to the great displeasure of my father, but at my mother's insistence - something I am today stupidly grateful for. If at any point I had to move to another provider, one who insisted on reassessing me based on my current presentation, would I pass muster? Would he look at my encyclopedic knowledge of psychiatric drugs with distrust? Would the fact that I've learned how to use the occupational therapies I was given as a child effectively mean I didn't qualify for my diagnosis anymore?

I do really well...right up until the moment you pull my meds. And the thought of living my life like that scares the living crap out of me. I look at that description thoffen gives and there but for the grace of god go I. Even more frightening is that I would be the patient who walked in, brandishing my list of criteria and asking you directly for stimulants. What if you were MY doctor? If that was your reaction to ME I'd be as angry as a hornet, and given that I'm pretty assertive, you'd know about it there and then.

Did you not read Russell Barkley's work? Do you not understand that stimulants are under prescribed, and that ADHD is undertreated? You THINK the majority of patients seeking the drugs are abusing them...but I think that I see a different picture emerging. I see people looking for help. They show up with a suggestion to you of what's the problem.

Where you might go "Hey, ok, so this is what you think is going on. I'm not sure I'm on board, but why don't you try to convince me what it is about your experience that convinces YOU" you go "I'm sorry but I just don't feel comfortable prescribing that medication to you" and then instruct your clinic appointment clerk to tell them you're booked up for the next six weeks in the hope they'll bounce off somewhere else.

How is that medicine? How is that science?

 

[thoffen]

if someone can focus when they're interested but not when they are not interested, how can that be anything but psychological in origin? based on avoidance and fear of failure makes sense... I'm not sure that's exactly what you were trying to say... but it is bizarre. We acknowledge that panic has to do with avoidance and that mindfulness and acceptance of worst outcome are viable treatment routes.

I also agree that talking about the psychological origin of ADHD doesn't preclude stimulant use.

Also, we have already acknowledged all ADHD traits are spectrum that most people are on, which your essay aligns with. how to decide if they need a stimulant? I guess if benefits outweigh risks. Which will constantly vary depending on what challenges someone is facing in their life at a given time

There is really good neuroscience that demonstrates specific differences in the way a mind with ADHD works compared to normal. That it is biological and not psychological is indisputable. However, the discrepancy comes with clinical symptoms. As in depression, anxiety disorders, others to various degrees, all the symptoms exist within the normal spectrum as well. We feel differently about the symptoms of ADHD because of how strong the value of accountability is in our culture.

As for attending to pleasurable activities, well, first of all it's incorrect on its face. The environment, emotional state, level of fatigue, etc. may make it difficult for a person with ADHD to even find a pleasurable activity they can attend to. It may not be uncommon for someone to explain that they sit down to watch TV with a book in their hands, moving back and forth to twiddling on their phone, all while squirming in their seat and chewing on something.

But the nomenclature is also a bit leading. Everyone is always attending to something, even someone with ADHD. However, where that attention is directed is hopelessly determined by the external environment. They need significant input. Something gathers more attention if it saturates them (fidgeting can help attention if it doesn't because it amplifies the input level and is controlled by the person). Something also needs to not provide too much input or it becomes overwhelming. So, the reliable steadiness of the input is really important. If the person anticipates more input than they can handle, they become distressed in anticipation and avoid. It is not avoided simply because it is anticipated to be hard and not fun, it is because of a visceral anticipation of loss of control that is more like panic. Lastly, the input must provide immediate and constant feedback. The activity most become hostile about is video games. Clearly a person is otherwise choosing not to attend because they can play video games all day! Well, a video game provides total immersion with very predictable and constant input level and immediate and abundant interactive feedback. It is the perfect setup.

So the difference isn't so much about capacity to attend as it is about degree of dependence on external structure to dictate what is attended to.

 

[clinicalpresentations]

There is really good neuroscience that demonstrates specific differences in the way a mind with ADHD works compared to normal. That it is biological and not psychological is indisputable. However, the discrepancy comes with clinical symptoms. As in depression, anxiety disorders, others to various degrees, all the symptoms exist within the normal spectrum as well. We feel differently about the symptoms of ADHD because of how strong the value of accountability is in our culture.

As for attending to pleasurable activities, well, first of all it's incorrect on its face. The environment, emotional state, level of fatigue, etc. may make it difficult for a person with ADHD to even find a pleasurable activity they can attend to. It may not be uncommon for someone to explain that they sit down to watch TV with a book in their hands, moving back and forth to twiddling on their phone, all while squirming in their seat and chewing on something.

But the nomenclature is also a bit leading. Everyone is always attending to something, even someone with ADHD. However, where that attention is directed is hopelessly determined by the external environment. They need significant input. Something gathers more attention if it saturates them (fidgeting can help attention if it doesn't because it amplifies the input level and is controlled by the person). Something also needs to not provide too much input or it becomes overwhelming. So, the reliable steadiness of the input is really important. If the person anticipates more input than they can handle, they become distressed in anticipation and avoid. It is not avoided simply because it is anticipated to be hard and not fun, it is because of a visceral anticipation of loss of control that is more like panic. Lastly, the input must provide immediate and constant feedback. The activity most become hostile about is video games. Clearly a person is otherwise choosing not to attend because they can play video games all day! Well, a video game provides total immersion with very predictable and constant input level and immediate and abundant interactive feedback. It is the perfect setup.

So the difference isn't so much about capacity to attend as it is about degree of dependence on external structure to dictate what is attended to.

YES!

I am really surprised on a daily basis by the how little of what is actually accepted to be pretty stock standard ADHD symptoms when assessed by specialists in that field are misperceived as "Not fitting" into the criteria by those who misunderstand the disorders root causes and how that plays out in reality.

Our friends over in the research halls of behavioural science can tell you that games and social media platforms are quite deliberately designed to exploit weaknesses in the very brain systems affected most by ADHD. If you stop treating your patients with ADHD like they are flaking out on you on purpose, they make actually flake out less. Fear of flaking out makes us flake out more seriously and more often. We are literally giving these people self esteem problems through with these ableist attitudes.

I invite you all to watch a few videos on the highly popular and successful youtube channel HowToADHD. It's really entertaining, and although definitely advocating for medication as a first line treatment, it is aimed at introducing lifestyle adjustments and coping skills to those with the disorder who are novices to non-drug management of the disorder. Perhaps seeing things from the patient perspective might be good for your clinical judgment?

Do It! For SCIENCE!

 

[psychnpgirl]

Because something can be seen on a brain scan doesn't mean it is organically caused, right? sorry I don't mean to be picky. Just trying to get at what you're saying. something could be caused by a confluence of nature and nurture or environment alone (e.g. TBI) and be seen on some kind of scan. and something caused by environment may still benefit from pharmacological intervention. I mean what I'm saying here is obvious to all of us but kind of lost in the field of ADHD it seems.

 

[clinicalpresentations]

Because something can be seen on a brain scan doesn't mean it is organically caused, right? sorry I don't mean to be picky. Just trying to get at what you're saying. something could be caused by a confluence of nature and nurture or environment alone (e.g. TBI) and be seen on some kind of scan. and something caused by environment may still benefit from pharmacological intervention. I mean what I'm saying here is obvious to all of us but kind of lost in the field of ADHD it seems.

I'm not sure I'm following, but if I am what I get is this: Disorders, whether organic in nature or not, can benefit from a varied approach to intervention that tries to include elements of pharmacological intervention and other therapies like CBT or DBT or OT. Furthermore, that somehow you perceive that the field of ADHD doesn't understand this.

Correct me if I'm wrong.

 

[SeniorWrangler]

I couldn't read the wall of text.

 

[birchswing]

I couldn't read the wall of text.

It's saying that if you can't read that wall of text, you may have been conditioned to believe it's because of an inherent badness and you find ways to compensate, ever working harder, rather than solve the original problem because you are unaware of it.

It's the Hillbilly Elegy of ADHD.

[As an aside I expect and want no response to, with text that long, I have to use my computer's text-to-speech, as I did in this case. And I still couldn't listen to the entire thing without writing notes on my own thoughts about it to myself, and even then got lost by the end due to multi-tasking. I've always been a faster copy-editor than reader. I see those compensations in myself a good deal; some of them are strengths. I have no ADHD diagnosis and never have (always been told my anxiety was too high to be able to see whether I had it or not, and then told my benzodiazepine dependence made the clinical picture too murky to tell). I personally think I was misdiagnosed a long time ago. ]

 

[thoffen]

Sorry for the text wall. Sometimes I find myself reading something that I have written in the past, and, if sufficient time has passed, I have tough sledding with it. Even when I remember the words and the arguments, if the emotional context has lessened, I see different ways to understand my own words than I intended at the time.

That said, you guys need to dig in. Clearly some people read it at least in part and formed some ideas other than "WTF is that guy smoking" or "OMG that explains everything". Let's hear it.

 

[clinicalpresentations]

Sorry for the text wall. Sometimes I find myself reading something that I have written in the past, and, if sufficient time has passed, I have tough sledding with it. Even when I remember the words and the arguments, if the emotional context has lessened, I see different ways to understand my own words than I intended at the time.

That said, you guys need to dig in. Clearly some people read it at least in part and formed some ideas other than "WTF is that guy smoking" or "OMG that explains everything". Let's hear it.

I think maybe your writing is just dense and needs a bit more spacing between ideas, and whittling down to core concepts. I fall prey to this myself. I tend to have rather long rambling sentences and thick densely coded paragraphs that make a casual read impossible. When I sub edit my work for brevity it usually makes more sense to others.

That said, I thought we were in the world of "There is no such thing as TLDR" given our level of education...

 

[smalltownpsych]

That said, I thought we were in the world of "There is no such thing as TLDR" given our level of education...

Might want to use an emoticon if you are being humorous. If you are actually being serious then...

Maybe I should post my dissertation on here for some light reading or....
I could just sum up the 230 pages by saying there can be a gulf of understanding and distrust between professionals and twelve step program members and that one way to mend that is to use a cultural framework. Getting a bit off topic, but some of these posts seem to come off as a bit sanctimonious.

 

[clinicalpresentations]

Might want to use an emoticon if you are being humorous. If you are actually being serious then...

Maybe I should post my dissertation on here for some light reading or....
I could just sum up the 230 pages by saying there can be a gulf of understanding and distrust between professionals and twelve step program members and that one way to mend that is to use a cultural framework. Getting a bit off topic, but some of these posts seem to come off as a bit sanctimonious.

Can I be both serious and in jest? 😛

Dissertations are like love letters we write to our most cherished ideas. It's a pity I won't see yours as I think it is a beautiful thought.

I actually agree with your position heartily. As someone who occupies both sides of the prescription pad at times I really feel the weight of responsibility for changing our institutional culture to be more effective at helping our communities. Learning to slip into the shoes of a client from time to time would be a good place to begin.

Certainly how we communicate is core to this. I actually had rather a long and hot thread erupt after I made some suggestions to someone who inherited some patients that were on what was deemed to be a poor cocktail of meds. I felt that the most important element we should cultivate in that exchange if we hoped to be successful was to look at the relationship aspect of the work.

I apparently caused enormous offense when I likened our work to a car or cell phone salesman or IT support geek who has to persuade someone to upgrade to a better option, or convey the news that some terrible technical fault has occurred. Since my former spouse was in a computational science field I mingled much with those of that persuasion, and I admit I was struck by the similarities in tone between the way Geeks talk about Users and our in-jokes about patients.

I suggested we try to be more empathetic and less disparaging or judgmental of our clients (this was in relation to those who had developed dependencies due to poor prescription habits).

The response I got was pretty intense. There was this undercurrent of fear that in trying to be more persuasive of likeable we'd trip over ourselves and fall onto our prescription pads and accidentally start issuing questionable prescriptions on demand.

When did we become so insecure about our own ability to assert ourselves? I thought it was a little strange because to me the power dynamic always favours us to such an enormous extent that shy of the type of patient who would raise a hand to us or escalate the issue outside of the office, we are not ever in danger of being taken advantage of unless we allow it.

We truly have nothing to prove in terms of who has the authority.

I've always thought that the way we are changed by the process of obtaining our education works to make us less relatable to our patients and unless we address this it can have a negative impact on the quality of our care.

Understanding that we are the IT Crowd of the biological sciences helps me grasp why sometimes my messages to patients don't land the way I expect them to.

Or maybe I'm just an eccentric. I'll go stand in the corner over there with Freud...

 

[thoffen]

Might want to use an emoticon if you are being humorous. If you are actually being serious then...

Maybe I should post my dissertation on here for some light reading or....
I could just sum up the 230 pages by saying there can be a gulf of understanding and distrust between professionals and twelve step program members and that one way to mend that is to use a cultural framework. Getting a bit off topic, but some of these posts seem to come off as a bit sanctimonious.

I have recently started editing myself less. Mostly that's because I started studying psychoanalysis and realized there was a time that people were appreciated for that kind of writing. Even if I know I will be less understood, I will more often choose to be myself. The writing might come off as being sanctimonious, but why should me recognizing that stop me? It isn't sanctimony, but even if it were, so what?

 

[smalltownpsych]

I have recently started editing myself less. Mostly that's because I started studying psychoanalysis and realized there was a time that people were appreciated for that kind of writing. Even if I know I will be less understood, I will more often choose to be myself. The writing might come off as being sanctimonious, but why should me recognizing that stop me? It isn't sanctimony, but even if it were, so what?

I didn’t think you came off sanctimoniously and wasn’t referring to your posts. Although I didn’t read the whole thing either and thought I saw some good points. Many of us do focus on the problems with over diagnosis of this disorder or the substance users and thus could definitely miss seeing actual attention or executive function issues that could be the cause of other symptoms. Another point I gathered from what you were saying is that a patient who actually meets criteria might be more likely to not want to have the diagnosis than the ones who are feigning it or trying to use the dx in some way. I think we see this in other disorders. The people who really have Bipolar Disorder are always trying to say they don’t; whereas, many a patient with emotional regulation or behavioral problems insists that they are Bipolar.

 

[Unico]

That is a very real and common experience. But it is also under-diagnosed, with real sufferers reluctant to seek treatment and unaware of exactly what the problem is anyway. And it's not just a functional deficit. Depending on the severity of (predominantly) executive deficit and the environment a person is raised in, the suffering can be quite intense and under-appreciated by both the doctor and the sufferer. The person believes they have earned their suffering and fails to appreciate that this isn't how everyone else feels inside. That isn't unlike many with depression, anxiety, etc., but it is likely to be much more central to their personality structure.

Curious what treatment would look like for these patients? It would seem that this population would likely have dug into "self-help" regimens as they perceive themselves to be the root of their problems -- so what's next? What should be implemented in your opinion that could provide meaningful relief for these patients?

On a similar note, do you think that the personality traits/deficits provide a framework for dealing with the challenges of the ADHD pt? Or are they an impedance? If the traits are a coping mechanism, wouldn't eliminating them (or treating them) make the underlying executive dysfunction more evident?

 

[thoffen]

Curious what treatment would look like for these patients? It would seem that this population would likely have dug into "self-help" regimens as they perceive themselves to be the root of their problems -- so what's next? What should be implemented in your opinion that could provide meaningful relief for these patients?

On a similar note, do you think that the personality traits/deficits provide a framework for dealing with the challenges of the ADHD pt? Or are they an impedance? If the traits are a coping mechanism, wouldn't eliminating them (or treating them) make the underlying executive dysfunction more evident?

The personality constructs themselves are not a disorder. All of us have core beliefs and conflicts which are central to our personality, but the disorder comes from incapacity to mentalize, reality test, tolerate distress, avoid fragmentation, etc. If someone has those problems, then they need therapeutic treatment for that no different than anyone else with a personality disorder.

I don't think the treatment that we know is good for ADHD needs to be modified. I do think that a provider's empathetic understanding of their problem and recognition of conflicts they are having is really helpful. I refer people to ADDitude magazine and ask them to read the testimonials, to find others who share their experience and can finally name the distress they haven't been able to understand. None of this is any different for ADHD as it is depression, bipolar disorder, etc. People often get conflicted about their treatment and lack psychoeducation and in particular an understanding of their lived experience and not just biology or symptoms. I know I don't honor that enough for those problems, either, referring people to NAMI, etc.

 

[hallowmann]

So to be completely honest, you describe me, how I respond to things, and what I ultimately experience relatively well in your posts. I've suspected for a long time that ADHD could have been a diagnosis I carried in childhood and potentially now, but my question has always been at what point is this pathologic requiring treatment. I'm able to function with it, and I've certainly learned to mask the inattention well.

Granted, my life would certainly be happier and easier if I felt able to focus on the immediate task at hand rather than 101 other things without some external pressure, and it would certainly be easier without the associated anxiety, fear of failure, and hypervigilence for cues from others. That said, is it not something many people experience? Is my personal "ADHD experience" that much different than what most people feel? I don't know.

I guess my ultimate question is that even if we assume all of this, what's the next step? Consider ADHD treatment options for people that we'd more likely diagnose with anxiety before inattention?

 

[thoffen]

So to be completely honest, you describe me, how I respond to things, and what I ultimately experience relatively well in your posts. I've suspected for a long time that ADHD could have been a diagnosis I carried in childhood and potentially now, but my question has always been at what point is this pathologic requiring treatment. I'm able to function with it, and I've certainly learned to mask the inattention well.

Granted, my life would certainly be happier and easier if I felt able to focus on the immediate task at hand rather than 101 other things without some external pressure, and it would certainly be easier without the associated anxiety, fear of failure, and hypervigilence for cues from others. That said, is it not something many people experience? Is my personal "ADHD experience" that much different than what most people feel? I don't know.

I guess my ultimate question is that even if we assume all of this, what's the next step? Consider ADHD treatment options for people that we'd more likely diagnose with anxiety before inattention?

If we decide to treat something, we need to treat the underlying problem. Whether we decide to treat something is an entirely different matter. There are many people with ADHD as a child whose biology catches up and it is more represented as delayed development. If there are psychological sequelae, those can be treated as well. It's important to understand whether there is clear evidence that executive dysfunction and inattention persist.

 

[hallowmann]

If we decide to treat something, we need to treat the underlying problem. Whether we decide to treat something is an entirely different matter. There are many people with ADHD as a child whose biology catches up and it is more represented as delayed development. If there are psychological sequelae, those can be treated as well. It's important to understand whether there is clear evidence that executive dysfunction and inattention persist.

Fair enough. I guess I agree.

 

[thoffen]

Fair enough. I guess I agree.

Certainly would be easier if someone existed that understood you and could magically give you what you needed. Have you harbored the fantasy of a mentor for a long time? Not someone that could teach you things, but someone that could understand why you were different and teach you what to do with it.

 

[hallowmann]

Certainly would be easier if someone existed that understood you and could magically give you what you needed. Have you harbored the fantasy of a mentor for a long time? Not someone that could teach you things, but someone that could understand why you were different and teach you what to do with it.

I never really got that close to anyone to have a mentor, and I'm not sure I could become comfortable enough with a faculty member to get to that point. I've managed to use coping skills and advice/help from my SO to manage things. I'm OK with that. Its gotten me through med school and into the specialty I've wanted. I guess I'll see if it can get me through residency as well.

 

[smalltownpsych]

Another interesting comsideration about patients with legitimate and significant attention problems is that the treatment typically involves a potentially harmful and/or addictive medication and many people who aren’t flooding into our offices looking for a quick fix (pun sort of intended) are reluctant to take this medication. Another thought is who really wants to test positive for amphetamines in a workplace situation and try to explain that?

 

[justfolks]

Another interesting comsideration about patients with legitimate and significant attention problems is that the treatment typically involves a potentially harmful and/or addictive medication and many people who aren’t flooding into our offices looking for a quick fix (pun sort of intended) are reluctant to take this medication. Another thought is who really wants to test positive for amphetamines in a workplace situation and try to explain that?

Just a patient, and this is n=1/anecdata, but my spouse was diagnosed with ADD a couple of years ago, by a psychiatrist who had the opportunity to observe him over time and see the lack of focus in action, and after resisting for decades my suggestion that he really needed to get some help. He is extremely smart/high-functioning, got through multiple grad programs and has a good job, but has a really hard time getting anything done at work because he can't focus to save his life. Actually, it might be more accurate to say he over focuses on minutiae and can't see the big picture/plan anything. Everything distracts him. If directed by others (i.e., me), he can do a lot, but really struggles on his own, even with meds (currently Vyvanse), which he only takes on work days (weekends are fun! not.). When he told his parent about the diagnosis, the reaction was "Well, that's a real relief to me." Basically, the parent thought he was just a screw-up/lazy. As I said, just an anecdote, but for some people this really is a thing.

 

[aim-agm]

Another interesting comsideration about patients with legitimate and significant attention problems is that the treatment typically involves a potentially harmful and/or addictive medication and many people who aren’t flooding into our offices looking for a quick fix (pun sort of intended) are reluctant to take this medication.

What are your thoughts on this article: http://slatestarcodex.com/2017/12/28/adderall-risks-much-more-than-you-wanted-to-know/ ? It seems to be a pretty thorough review of the literature and concludes risks of harm or addiction are low.

 

[smalltownpsych]

What are your thoughts on this article: http://slatestarcodex.com/2017/12/28/adderall-risks-much-more-than-you-wanted-to-know/ ? It seems to be a pretty thorough review of the literature and concludes risks of harm or addiction are low.

It basically says everyone should be able to use adderall or other stimulants if they want to. There is a good argument for that and not sure if I would disagree. I really hate being a gatekeeper. Also, it makes the point that stimulants are generally medically safe from a physical standpoint when used as directed and I suspect that few on this board would argue with that. It does not talk much about addiction or dependency much and that is where the problem lies. The ten percent or so of people with addiction problems cause a lot of problems for the rest of us. Managing potentially addictive substances for the benefit of the population is always going to be a debatable topic.

 

[thoffen]

It basically says everyone should be able to use adderall or other stimulants if they want to. There is a good argument for that and not sure if I would disagree. I really hate being a gatekeeper. Also, it makes the point that stimulants are generally medically safe from a physical standpoint when used as directed and I suspect that few on this board would argue with that. It does not talk much about addiction or dependency much and that is where the problem lies. The ten percent or so of people with addiction problems cause a lot of problems for the rest of us. Managing potentially addictive substances for the benefit of the population is always going to be a debatable topic.

I think the aversion comes in when someone uses treatment as a way to avoid challenging themselves to grow, and provision of certain treatments feels like an alliance with the patient in covering up a problem instead of addressing it.

 

[Fan_of_Meehl]

I think the aversion comes in when someone uses treatment as a way to avoid challenging themselves to grow, and provision of certain treatments feels like an alliance with the patient in covering up a problem instead of addressing it.

As a VA provider...this really hits me in the feels.

 

[thoffen]

As a VA provider...this really hits me in the feels.

My personal belief is that everyone is actually ambivalent about growth. They both want you to help them grow and to help cover up their shame in failure to grow on their own. Some people present very much aligned one way or another, but even saying something like "you want me to help you figure out what things are your fault and what things aren't your fault" can have profound effect. A lot of these patients keep coming back to you despite you not providing what they are seemingly asking for. My experience with actual malingerers is that they give up pretty quickly when you demonstrate resistance to giving them what they want. In some systems, like the VA, limited options might get them to try harder.

 

[Fan_of_Meehl]

My personal belief is that everyone is actually ambivalent about growth. They both want you to help them grow and to help cover up their shame in failure to grow on their own. Some people present very much aligned one way or another, but even saying something like "you want me to help you figure out what things are your fault and what things aren't your fault" can have profound effect. A lot of these patients keep coming back to you despite you not providing what they are seemingly asking for. My experience with actual malingerers is that they give up pretty quickly when you demonstrate resistance to giving them what they want. In some systems, like the VA, limited options might get them to try harder.

Agreed. This is quite true and one reason I prefer outpatient psychotherapy to compensation and pension exams. I have had anecdotal experiences as a VA therapist when NOT agreeing to do something that the patient wanted but that I believed was inappropriate (e.g., a request to 'write a letter to get my service connection up to 100%') actually worked out fine and perhaps even strengthened the relationship around appropriate boundaries (mine, in this case). Someone once opined that two of the most crucial milestones of becoming a mature adult involves: a) learning how to say 'no' when appropriate; and b) learning how to accept a 'no' from others, when given.

 

[thoffen]

Agreed. This is quite true and one reason I prefer outpatient psychotherapy to compensation and pension exams. I have had anecdotal experiences as a VA therapist when NOT agreeing to do something that the patient wanted but that I believed was inappropriate (e.g., a request to 'write a letter to get my service connection up to 100%') actually worked out fine and perhaps even strengthened the relationship around appropriate boundaries (mine, in this case). Someone once opined that two of the most crucial milestones of becoming a mature adult involves: a) learning how to say 'no' when appropriate; and b) learning how to accept a 'no' from others, when given.

I had a patient last week I felt really bad about having to set a limit on time due to my error in scheduling a medical test. This person has poor boundaries and presents as helpless. She took the information swimmingly and it promoted what seemed like much more genuine boundary setting and affective regulation for herself. I think she needed to know that I could manage my end of the deal. I see her again tomorrow so we'll see how that goes.

 

[birchswing]

I may have told this anecdote before; I can't remember in which venues I've told which stories. Since responding to it might be seen as giving medical advice, please don't for my sake. So, I had been on Ativan since the beginning of 10th grade. It kind of helped in the beginning but things kept getting worse for me. I could not stay in the classroom. I had tics that I had been told were OCD and I was trying to just stop them. I wasn't 26 until I was told I had Tourette's and that trying to stop them was the wrong thing to do. I went to a school where everyone was a teacher's pet. My peers went to Harvard, Caltech, Brown, etc. By 1oth grade almost every class was AP or were taken at a college. My point in saying that is not about the challenge of the material but rather the type of student in the class: absolutely deferent and quiet to a fault. I had very little issue in "health" class where I was part of the general population because there was enough ruckus people couldn't hear my tics. But in other classes you could hear a pin drop in the bell-to-bell lectures, and I was devastatingly self conscious of the tics and would try to hold them in. I felt like I was suffocating. I would physically writhe. The school I went to bragged that they spent the least per student in the state, meaning very little support staff. I begged the guidance office for help and was told it was only for intellectually disabled students. I literally sat outside classroom doors in the hallway trying to hear the material while debating how much to leave the door open as to be able to hear the teacher but not have them hear me ticcing (what I later learned was ticcing). I would watch the clock and my goal each day was to stay in each class as long as possible. I also developed trouble reading around this time. I had been a voracious reader, but I was told my ability lessened due to anxiety. It sounded logical to me.

By 12th grade, I had gone from the identity of super student to pariah, even though I still did well enough against awful conditions. I never once sat through an entire SAT test, but fortunately they combined my verbal and math from two different sittings. I got accommodations to take tests in closets so I could tic (it wasn't called that at the time--it was called grunting). I always had a sensation of not being able to breathe enough and had phosphenes in my vision and so I would eat Altoids to make it feel like I could breathe better. I went up to a pack and a half of Altoids per day. The anxiety all started in the classroom but started spreading to other spheres of my life. I had been a great tennis player, been able to run a mile in 7 minutes, but all of that stopped as well. I would get out of breath very easily. I stopped being able to run. Again, I was told it was all due to anxiety (when I say told, most of what I was told was from my parents). I doubt that. I wasn't anxious about playing tennis. I loved playing tennis. I went from up and coming on the tennis team my freshman year to being cut the next year because I couldn't even do the warm-ups of jogging around the court. So I settled for the track team which took anyone, and there I struggled immensely and spent most of my time in the woods hiding from the track coach who would yell at me for not running. (My parents insisted I be on a team so I had to keep doing it in spite of the awfulness of barely being able to jog and being on a track team. The competitions were unbearably embarrassing. I blacked out at one. One time they tried me on hurdles and I fell over 6 out of 8 and landed on a concrete track each time, very bloodied by the end.)

By 12th grade, everything was still getting worse and my parents for various reasons never took me to a "regular" doctor (I didn't have one), and I only occasionally saw a psychiatrist. The psychiatrist wanted to test if I had ADHD. He said the only way to tell was to put me on the medication. If I got better it meant I had ADHD. If I got worse, it meant I didn't.

He took me off Ativan for a week and replaced it with Adderall. That week I happened to have two AP exams: Spanish and English literature. For many years I had not been able to sit through exams like I sat through those. It was amazing. I had embarrassed myself so badly in front of my peers for years, and they came away saying the exams had been difficult. One girl who had been on par with me but excelled as I languished with physical/mental problems did worse on the Spanish exam than me. I got 5s on both. I got a 5 on the English literature exam, a class for which my teacher frequently warned I might not pass due to my frequent leaving of the class which made me miss pop quizzes (I ended up with a B-).

I felt what had been called "anxiety" go away. But I also felt a different type of anxiety: shakiness. There was one day during this experiment where after school I walked behind my house into a meadow and sat down in the grass in the sun. It was a very unusual thing for me to do. I was aware of being at greater peace in just being able to enjoy something like that for a change, but I was still shaky feeling and concerned about that.

By the time I saw the psychiatrist again, I didn't know how I had done on the AP exams. But I could tell him how I was able to sit through them, etc. My mistake was in describing the experience in the meadow. I used the word "euphoric." It was hyperbole. But I was trying to convey how it was very different for me. He was not a native English speaker and I was only 17 years old trying to explain this. He said, "People with ADHD do not feel euphoric on Adderall. You don't have ADHD." And that was the end of the experiment and I was put back on Ativan.

I think of that moment a lot and how it might have been a turning point. As it was, I went off to college on Ativan. The college psychiatrist added Klonopin (which he claimed was not a benodiazepine). Things got worse and worse, and I dropped out.

I have had a very hard time cutting the benzos, but I have cut them by a quarter now. It's been very tough. My psychiatrist is insistent that she can't know anything about what I have (in terms of mental illness) until I am a clean slate medication wise. So for now, I am just a benzo patient on a slow taper.

I have no idea whether I have ADHD. I do know that I was intelligent enough that I probably could have compensated for having it for a long time, and it's plausible that my abilities to compensate ran up against a wall. It's hard to say. And I do know for sure that I slipped through a lot of cracks. Some of it was family, some of it was the school, and some of it was the medical system.