You can just refuse to prescribe stimulants. Or turn away all ADHD new patient inquiries. Lose money, keep your soul.
I think (hope!) that we are approaching a saturation point where momentum slowly stops and gradually, eventually, people look at the ADHD explosion the way we now look at the "every temper tantrum is bipolar" phenomenon.
Mostly the novel below is not a direct response to anyone on this thread, though this post did inspire me especially in regards to the bipolar disorder analogy.
I have seen plenty of adults who sought psychiatric treatment because they had convinced themselves they have ADHD when they didn't. I think of them in 2 categories
- Some had another diagnosable condition that caused symptoms that overlap with ADHD and you could see how they had honestly arrived at an erroneous diagnosis. Usually, if you can get enough buy in for the proper diagnosis and treatment plan, these people will thank you when they start feeling better.
- Others had fairly normative responses to overwhelming demands and were essentially seeking performance enhancing drugs, but didn't realize that's what they were doing. These patients seemed to respond well to psycho education, reassurance/normalization, and joint problem solving around the areas of overwhelm in their life. Sometimes I tell these patients that while I can't in good conscience prescribe them stimulants, they can probably find someone else who will disagree with my assessment, diagnose them with ADHD and prescribe them stimulants, if that is their goal. And the main reason I'm not prescribing them is that it is considered highly inappropriate in my profession to prescribe this scheduled drug without a clear indication, not because I necessarily think taking a stimulant would do more harm than good for them. This speech works with malingerers (quite rare in my experience) as well as the subset of the "honest mistake" people who still really do want a stimulant, thank you very much.
I have also seen plenty of adults who correctly self diagnosed with ADHD. Curiously though, I rarely encountered this last group prior to being diagnosed late in life myself. I wonder why...
Spoiler alert, it's because I was missing them before. Good thing I didn't treat them like malingerers, at least! Or annoying people not worth my time or attention to help. But I did miss making an appropriate diagnosis that could have helped them and I feel badly about it.
When I was a resident many of my attendings had this bias of "everyone thinks they have ADHD these days and they're wrong." The diagnostic process I underwent (structured clinical interview with a psychologist over 3 hour-long sessions, normally done in 2 but she just couldn't get me to shut up so it took us 3) helped me develop a much deeper understanding of what ADHD looks like in adults AND how to conduct a really good clinical interview assessing for ADHD. ADHD in effect got added to my differential when it hadn't really been there before. Since this experience, I have diagnosed people who had no idea they had it and had a really hard time accepting the diagnosis. I have diagnosed people who were so convinced they had it that their certainty would have pissed off many psychiatrists and put them at high risk of a psychiatrist subconsciously punishing them by denying the diagnosis. "How dare they! Who do they think they are?!" And yes, some of those people became aware of their lifelong ADHD traits because ADHD is the diagnosis du jour on tiktok--is that a crime?
I guess my point is, to expand on the analogy to rampant over-diagnosis of bipolar disorder, should we decline to evaluate people with emotional regulation problems which they mistakenly believe to be bipolar disorder, because it can be time consuming and emotionally draining to explain it's actually BPD? No. Should we not diagnose bipolar disorder in someone who genuinely seems to have it, because they have self diagnosed and that really annoys us? No. Should we make people jump through crazy hoops to receive a bipolar disorder diagnosis and start on effective treatment? No.
Some degree of caution about potential malingering is warranted since stimulants are a controlled substance here and do have a high potential for misuse. I wish we didn't have to be the gatekeepers for those seeking stimulants for recreational use or performance enhancement. I radically accept that we are.
But it's deeply disappointing to me that so many psychiatrists seem to be perfectly willing to sacrifice those people who have ADHD that was missed in childhood, essentially because of the inconvenience inherent to distinguishing them from others who want or think they need stimulants. Are difficult conversations not what we signed up for? I feel like this is what we signed up for.
People with ADHD, regardless of the age they were first diagnosed, stand to dramatically benefit from stimulant medications, which offer the largest effect size of anything we have in our armamentarium. How can we possibly justify screening these people out, denying them access to care, just to avoid being in a position of needing to have difficult conversations with some patients, or because the psychiatrist's ego can't tolerate running the risk of occasionally having someone successfully manipulate them. I find this stance quite bizarre and totally unconscionable. (I have also learned about myself that my "sensitivity to injustice" (AKA penchant for righteous indignation) is a common trait in people with ADHD, as is my overly detailed and parenthetical writing style.)
I used to routinely miss ADHD in adults who were not diagnosed as kids. (Granted, a big reason in my case was that I was using myself as the barometer for normal, not realizing how abnormal my struggles really were, and this cognitive error will not apply to most of you.). Now I don't think I do, not often anyway.
I worried for a while I was overdiagnosing it. I really don't think I am! I still see people who are convinced they have it and they don't, and I'm still able to have those conversations therapeutically. They can be draining conversations but more often than not they're rewarding and patients are grateful we figured out what was really going on. I don't pass the buck to some neuropsychologist (which I always thought was stupid) and I don't let my residents do so without a very good reason.
If anyone read this whole thing, thanks for listening to my PSA. And here's a special shout out to my PCP, who didn't make me jump through any hoops when I explained "I think I must have ADHD. I can't quite wrap my head around it fully yet, but apparently all my psychiatrist friends think I have it, and had just assumed all this time that I opted not to treat it. In reality it had literally never occurred to me that I had ADHD before a friend's offhand remark opened this conversation, but it could explain some things." And to the psychologist my PCP referred me to (at my request), who, because of my privilege as a psychiatrist, evaluated me AFTER I had started on life-changing medication, and who did a few sessions of ADHD-focused CBT with me which were almost as helpful as the medication, but which remain effective on days I forget to take my medication.
