A propos of nothing in particular, I have been meaning to share my experience on this thread, as a psychiatrist recently diagnosed with ADHD. However I have been very busy and since starting vyvanse I have the capacity to resist the temptation to post until time allows. Happy to see the thread is still active!
I'm a woman over 40. Completed residency 5+ years ago. I never really considered the idea that I may have ADHD until my husband was diagnosed last year.
My husband's diagnosis was initially very confusing for me, as the person who theoretically knows him best and also happens to be a psychiatrist. I didn't want to question his therapist, who seemed decent from what I could tell, and whom he'd been seeing for a couple years. But I just didn't really see it. We've been together since we were teenagers. He was the one to whom I had always delegated (usually by default-- not taking care of it myself) all manner of necessary life tasks that were too boring or tedious or required too much sustained attention for me (though I never thought of it in those terms until recently). In the early years of our relationship I am sure I would have lost my driver's license for unpaid speeding tickets, had he not been there noticing them in the foot space of my passenger seat and reminding me to take care of them. He is an entrepreneur and has always been the primary caregiver to our kids and has run the household without a whole lot of help from me. Not particularly well, mind you, (house generally a disorganized mess, rarely a home cooked meal) a source of ongoing shame for him, but better than I would do. I always tried to stay grateful and reassure him he was doing great, life is just hard with young kids. But life was perplexingly hard for us before we had kids too, and now that the kids were getting older and generally getting to be pretty self sufficient, it was STILL REALLY HARD. And I was aware that I was like a third child to him at times, with my contributing to the chaos of the household more than the running of it. My car would always be a pitted out mess, only cleaned if I knew I was going to have to give someone a ride, or if he nagged me about it enough. His vehicle he managed to keep reasonably clean so as not to embarrass the kids when he drove their friends to school. I couldn't set good a good example for the kids--they thought it was normal to always have dirty clothes strewn across the floor in all rooms of the house. I resisted my husband's attempts to get me more involved in our finances. I bought whatever I wanted and luckily didn't have extravagant tastes, so it kinda sorta worked, though his repeated attempts to get me to follow a budget frustrated both of us. I recognize in retrospect that I was so easily overwhelmed by many tasks requiring sustained attention that I would avoid them at all costs and leave him holding the bag.
When my husband was diagnosed, I thought "well bully for him, he has a reason for why things are always so hard for him and I guess I'm just a lazy, undisciplined, careless, thoughtless, slob." I was kind of jealous he seemed to have a treatable condition vs my character flaws, but I still didn't consider the diagnosis for myself. Probably in part because NOT having a mental illness, in a family where almost everyone else did, was a weirdly central part of my identity. The fact that women are expected to do all the things I routinely failed at would have reinforced shame in a lot of women. I was able to rationalize the fact that my husband was the one who (usually) remembered to buy birthday gifts for our nieces and nephews as evidence of our progressive marriage, and spare myself a lot of the shame that way by turning my deficit into a feminist win for us both.
Slowly it started to dawn on me, maybe I didn't recognize his ADHD because I had it too, and actually mine was in many ways more severe than my husband's--or maybe l just had less experience learning coping strategies to manage it, because I had relied so much on him for so long. I had never read the criteria and had them resonate with me personally. Instead I think I often didn't recognize it in adult patients because I was using my own experiences as a barometer of what's normal, and actually, I'm not normal. This has been a jarring realization that frankly has really shaken up my professional identity and has left me wondering how many patients I have seen for whom I have not been effective at diagnosing or treating ADHD.
Practice patterns varied in my residency program around diagnosing and treating ADHD in adults, but the attendings I most respected taught that ADHD is a clinical diagnosis; while psychological testing may be useful as a way to get another opinion in tricky cases where the diagnosis is suspected but not clear, it should not generally be used as a hoop to make people jump through, or to offload responsibility for diagnosis to another clinician. That's not appropriate.
So that's how I have typically operated, doing my best good faith attempt to make a clinical diagnosis, but I am looking at patients on my panel now with fresh eyes and seeing cases I missed before. I also think back to one-off psychiatric consultations I performed on an integrated care rotation in residency, where attention problems were a common chief complaint. How many people did I send off on an ssri, saying "let's treat the anxiety first and see how you feel then" who actually had ADHD and would have had the anxiety resolve spontaneously on appropriate treatment? Even the cases where it seemed obvious they had ADHD, if there were also enough anxiety or depression symptoms to justify it I would usually say "let's try an ssri first and reevaluate once you're not feeling so depressed/anxious." Looking back on it now, I think there were times I essentially kicked the can down the road for a patient I could have helped dramatically and quickly, and it makes me sad to think about.
Once I started to suspect I had it, I talked to my psychiatrist friends who have known me since residency, and there was a general vibe of "I didn't want to be the one to say something, but yeah..." Past experiences all took on a new lens. Could I really have ADHD, when being a good student was practically my whole identity? I was a top student in my high school, but was I actually a "good student"? It wasn't that uncommon for me to miss deadlines. Not many people knew that, but my teachers all liked me and let me get away with a lot. I ended up going to a small liberal arts college where I knew the faculty well--the kind of place professors routinely invite students to their homes. I recall one professor who had a reputation for being a hard ass, who required a journal of our thoughts on all the reading assignments, to be turned in at the end of the semester. I don't know what I thought would happen not doing it, but there was always something else that was a higher priority and the end of the semester came and I didn't have anything to hand in (though I'd read all the assignments and participated actively in class discussions). I remember going to the professor's office to basically beg for mercy, and how disappointed he seemed in himself when he didn't have the heart to fail me, and offered to give me an incomplete to allow me time to do the journal. Somehow I managed to write my English thesis that was supposed to take the whole semester in a week-long writing binge fueled by caffeine and sheer panic. So...yeah. it's possible to get through high school and college and even medical school and residency and not recognize the level of dysfunction one is experiencing-- especially if the person is able to somehow escape the worst consequences of that dysfunction, as I was.
Medical school was an adaptive environment for me. I didn't love it by any means, but the high level of structure kept me doing what I needed to be doing. Studying all the time was relatively easy for me because I knew if I didn't I would probably fail, have no career prospects and be in debt forever. That was plenty motivating, especially because the consequences were not far off or vague or unpredictable. You don't study all the time, you will fail. I was an average medical student. If I had pursued a PhD I don't think I would have ever finished it.
Residency wasn't too bad in the first two years, which were all inpatient at my relatively low intensity program. I never really had to see a high volume of patients. Third year was the best of times and the worst of times. I discovered my love of outpatient, but with more patients to see daily and less pressure to get the notes done immediately, I just couldn't cope. My supervisors were not paying enough attention to my documentation habits, and I went weeks without writing notes, and then would have to fess up to my husband about how behind I was, so I could go in on a Saturday and binge write weeks' worth of notes (from my disorganized chicken scratch hand notes).
This pattern with notes continued in my attending life until I finally got a boss who was paying attention, and willing to offer support and guidance while also holding me accountable for timely documentation. Thank God! Between this boss and Vyvanse for myself and my husband, I may actually survive!
I absolutely love to read and learn and I love psychiatry. I loved majoring in English in college -most of the time it didn't feel like work, the key to success with ADHD. Someday in the not too distant future I hope to have most of my note writing automated and then I can see more patients, which I love to do. I am coming to terms with the fact that I actually learned very little about ADHD in residency, and doing a lot of self study now, both from a clinical perspective and a self help perspective. I'm starting to learn a heck of a lot of new coping strategies, which will help me and my patients with ADHD. The one I fell into by sheer dumb luck is one of the best--do what you love. It's a good idea for everyone, but I think I would have sucked at any job I tried that didn't consistently bring me as much joy and satisfaction as the study and practice of psychiatry does.
If you got this far, thanks for reading this novel. Tl;dr: yes ADHD can present for the first time in adults, especially intelligent women with inattentive subtype. There are all kinds of valid reasons it may not have been recognized before, but if it's been there all along and causing dysfunction here and now, for God's sake treat it! Not to say that people misdiagnosing themselves based on tiktok, or trying to get stimulants to sell them doesn't happen--of course it does. But please don't be one of those people who would rather fail to adequately treat a hundred people with ADHD than let one malingerer pull one over on them. And don't be like me and be afraid to pull the trigger on the diagnosis when it's staring you in the face.
One fun fact I learned from an excellent master course on ADHD at APA this year--atomoxetine works terribly on average compared to stimulants, but that's because it works about as well as a stimulant for some people and not really at all for other people. So it's reasonable to try it first if someone is up for an every single day medication, and would prefer to avoid stimulants for whatever reason, but if it doesn't work for them don't belabor it, move on.
