Key moments, in order
The vast majority of people asking about ADHD are not med-seeking. They have a genuine problem.
Inattention is a symptom, like a cough. Having a cough does not mean you have cough disorder. Do not go straight for ADHD: rule in or out the other conditions you have evidence for.
Be okay with losing a few patients. Not handing over a treatment just to keep someone is not a missed diagnosis.
If you invest too much of yourself in every intake and grip clinical success too firmly, you burn out, and the patients suffer for it.
It is a disorder of attention, which does not only mean being unable to keep attention. It can mean being unable to let go of an activity or change focus when needed.
Media has waged a war on attention, from newspapers and radio to five-hour binges, and culture sells ever more salient and rewarding things, from bright colors to sugary food.
True ADHD is not just responsive to medication. It is treatable with medication, psychotherapy, skills and changes in what you do, and every mental condition responds to some degree to habits, skills and training.
'I can't go to this thing because of my mental illness' is a very dangerous, self-fulfilling prophecy.
The ADHD TikToks are fun, but consuming them has a cost: ideas like I can't listen, I can't motivate.
The most common mimic in outpatient work is a mood and anxiety problem: sometimes major depression, bipolar disorder, adjustment disorder or a primary anxiety disorder, often just a fuzzy mix of anxious, self-punitive reaction to not doing well. Anxious people lean on avoidance of tasks.
The wider differential: substances, the sleep-wake cycle, depressive, anxiety and trauma disorders, OCD, personality traits and disorders, and social stress, including the situation at work and how someone handles stress.
A specific learning disorder can explain the problem and will not respond as well to a stimulant.
It does not mean you assume the condition at the top of the hierarchy is present. It means that if you have evidence for both, you must treat the one higher up before the lower one.
At the top are organic disorders: medical and biological conditions such as brain problems, thyroid problems and cortisol, depending on the disorder in question.
True OCD sits in the diagnostic hierarchy between schizophrenia and bipolar disorder and depression, and severe OCD can be biological enough to sit at the same level as psychosis and bipolar disorder.
Ages 18 to 25 are when many serious mental illnesses begin, often with a prodrome of inattention. Several patients with a childhood ADHD diagnosis developed bipolar disorder in their early twenties, and a stimulant makes that worse.
Your setting shapes your hierarchy. Child psychiatrists rightly rank ADHD higher because the other conditions are much rarer before 17, and an expert can find their expertise in anyone.
Childhood diagnoses overlap so much on a Venn diagram that they are not nailing the underlying problem.
Poor concentration is in the core criteria of every depressive disorder, from dysthymia to major depression with psychotic features.
The zoned-out patient often has depressive withdrawal, a shutdown of seeking and enjoyment, and you do not hear a longitudinal history of attention problems.
Depression disrupts attention through persistent negative thoughts, slowed thinking, talking and moving, or psychomotor agitation.
Take a longitudinal history of the person's life, not just of symptoms. With anxiety, depression and adjustment disorders you will often hear that things were going really well before.
It is very easy to miss trauma without a good CAPS-5 style screen, and even then patients may forget to tell you. They are not hiding it: talking about it is upsetting and dysregulating, and part of the memory seems dissociated.
If someone believes poor concentration means ADHD, pull up the PTSD criteria and read criterion E with them, so it is not just you saying it is probably trauma.
Doctor and patient can easily disagree on the tasks or goals without knowing it, thinking they are working together on how to treat the problem or on what the problem is when they are not. A mismatch in conceptualization has to be addressed directly and specifically.
Much of what social media calls ADHD symptoms, though present in many people with true ADHD, is better attributed to depressive disorders, trauma disorders and personality. Patients arrive believing ADHD explains their emotional dysregulation and relationship conflicts too.
Ages 18 to 25 are when the more serious mental illnesses start, and the prodrome can show up first as inattention.
Some patients with true childhood ADHD develop stimulant-induced psychosis around 18 or in their twenties. You know it because the psychotic symptoms stop when you pull the stimulant.
Depressive episodes (95 percent of bipolar disorders have them), mania and hypomania all impair concentration, attention and task switching.
For true bipolar disorder with lingering attention problems, seek mood stabilization first, even without clear remaining mood symptoms.
People who have not fully accepted a bipolar diagnosis sometimes decide they were misdiagnosed. Shop around enough and you will eventually find someone who diagnoses whatever you prefer to report.
Say why you are holding back: I know you can get Adderall elsewhere, but I'm worried about you. It may help today and tomorrow, but these things have consequences.
When patients say "my sleep's good, I sleep five hours," trust your gut. People who function great on five hours are rare, rare exceptions.
Move the phone charger out of the bedroom. People go to bed swiping, wake at 3 a.m., can't fall asleep and go back on the phone. That one change has cured insomnia and made drastic improvements in many other areas of patients' lives.
In every patient, consider substances, herbs, supplements, natural remedies, energy drinks, caffeine, medical conditions and other psychiatric conditions.
Take a non-authoritative stance. You are not wagging a finger or making it a moral issue: they are saying they have a problem, and you can see the problem.
It is easy to medicalize a social problem. Pushing someone through a life that does not suit them on amphetamine, at the cost of their health, is a detriment to their life.
Collaborate with the patient, but do not let their justification of a situation end the inquiry. Trust your formulation.
Don't take yes for an answer. Go beyond the patient's conclusion or affirmation.
Much of what social media calls ADHD (present in many with true ADHD) is better attributed to depressive disorders, trauma disorders and personality; many of those conceptualizations are describing a personality disorder and calling it ADHD.
The DSM itself says that in adolescents and adults ADHD may be hard to distinguish from borderline, narcissistic and other personality disorders. Older editions named it explicitly as an explainer, and the DSM-5-TR still lists it in the differential.
ADHD does not explain every characteristic of a person. Anxious ways of relating to yourself that grew out of it are an anxiety or interpersonal problem, not ADHD itself, and over-reading personality as Axis I takes away control.
Checklists and disorder-specific interviews confirm whatever you asked about. A motivated patient can answer yes to every structured question, which makes the criteria almost useless used that way.
There is no biomarker, no diagnostic test and no psychological test that is diagnostic of ADHD. It is a clinical syndrome. Neuropsych testing can confirm learning disorders and intellectual functioning, but it cannot confirm ADHD.
As a chief complaint, ADHD has become a general marker of psychosocial distress. All it tells you is that the person is not functioning as they want at work or school.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.