“Adult” ADHD

[annoyedpsychiatrist]

Anyway, thank you for pointing this sort of stuff out. I think it's important for people to know, and understand, that functioning well with ADHD is more than just academic and work performance.

yes i look for significant detriments in social/occupational/educational settings. There is no adult onset ADHD, there is only ADHD that is undiagnosed as a child, or patient seeking performance enhancement.

If i see a significant detriment to some of the settings above, then im open to prescribing. I have a geriatric patient on vyvanse, because when he doesnt use the medication his wife threatens to divorce him because hell do impulsive things, lose his phone/wallet consistently, never finish anything around the house, bills will go unpaid, etc. And this how he has been since the marriage.

Primarily, i want to see a big detriment in the areas mentioned above. The guy applying for mental health disability who sits around all day and wants adderall TID, im unlikely to see a need for ADHD treatment, the majority of the time.

I get more skeptical when patients want very high doses of stimulants, and start to consider misuse. I see many of my patients respond adequately to moderate doses of xr formulations. Some may require a higher dose, but it does raise my alert status.

I weigh pros and cons. Low chance of diversion misuse? Significant quality life of improvement potentially through use of stimulant? No contraindications? Reasonable expectations with stimulant use?

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[futureapppsy2]

Explain the self report in light of what we know about the unreliability of recall, and the DSM instruction, "Adult recall of childhood symptoms tends to be unreliable, and it is beneficial to obtain ancillary information"

In this case, they did get informant-report to back up the self-report, though not from the parents on account of them being, well, dead.

 

[calvnandhobbs68]

I genuinely think most of the stigma of diagnosing and treating ADHD is largely due to stimulant medication. If SSRIs were the treatment, despite their questionable efficacy, people would be diagnosed and treated liberally like they are with anxiety and depression.

So people say this but no I feel this is an inappropriate way to spin it. People are careful about diagnosing it because we realize that these medications are divertible and performance enhancing in general, so there is a strong incentive on patient ends to overreport symptoms in the hopes of being legally prescribed these medication. There's also a strong push from the pharma end to make many people think that essentially any difficulty they have can be ascribed to "undiagnosed ADHD".

This has been a debate before on this forum multiple times (just look at the "similar threads" thing at the bottom of your page) so I'm not going to rehash the arguments back and forth, there's a huge thread about it.

 

[the5thelement]

They aren't prescribing because Cerebral and those places got shut down by the DEA for overprescription. Stimulant prescriptions went up by 20 percent during COVID

Looks like cerebral is alive and well. Just not prescribing stimulants anymore.

If I have ADHD, will Cerebral prescribe Adderall (amphetamine / dextroamphetamine) or Concerta (Methylphenidate)?​

No, stimulants such as Adderall (dextroamphetamine-amphetamine) or Concerta (Methylphenidate) are not offered through Cerebral at this time. While stimulants are often prescribed as first-line treatment for ADHD, we do offer alternative treatments which may also be helpful. Our prescribers are able to treat ADHD with alternative non-stimulant options such as Wellbutrin (bupropion) or Strattera (atomoxetine).

 

[allantois]

Looks like cerebral is alive and well. Just not prescribing stimulants anymore.

If I have ADHD, will Cerebral prescribe Adderall (amphetamine / dextroamphetamine) or Concerta (Methylphenidate)?​

No, stimulants such as Adderall (dextroamphetamine-amphetamine) or Concerta (Methylphenidate) are not offered through Cerebral at this time. While stimulants are often prescribed as first-line treatment for ADHD, we do offer alternative treatments which may also be helpful. Our prescribers are able to treat ADHD with alternative non-stimulant options such as Wellbutrin (bupropion) or Strattera (atomoxetine).

LOL Idk how alive and well they really are.

https://www.indeed.com/cmp/Cerebral/reviews

"As a 1099 employee, I was required to be available 20 hours per week and was paid per visit. After 9 months of honoring my commitment, Cerebral continued to be unable to fill my schedule despite three rounds of lay-offs which was supposed to funnel more patients to the remaining providers. When my average gross income fell to $13/hr, I had to leave the company."

 

[annoyedpsychiatrist]

so yeah tiktok has created this "undiagosed ADHD" fad, which has extended to other things too like autism. There is thing going around where some young women have decided "they're on the spectrum" based on tiktok videos. I had a patient present to me because she believed she had undiagnosed ASD because the criteria was invented by "white males who didnt understand female autism and females present differently". When I told her she didnt have it, she cried and blasted me on patient reviews. Used to people didnt want these labels, now they're worn on social media as a badge of honor because people want to feel like a victim, or want an easy explanation to their behavioral issues.

We have to absolutely be careful with labels, because labels follow people. Otherwise were no better than ER doctors who diagnose someone with meth induced psychosis as "schizophrenia".

 

[pittfan53]

so yeah tiktok has created this "undiagosed ADHD" fad

Love this study

https://journals.sagepub.com/doi/full/10.1177/07067437221082854

 

[confused_doc]

So people say this but no I feel this is an inappropriate way to spin it. People are careful about diagnosing it because we realize that these medications are divertible and performance enhancing in general, so there is a strong incentive on patient ends to overreport symptoms in the hopes of being legally prescribed these medication. There's also a strong push from the pharma end to make many people think that essentially any difficulty they have can be ascribed to "undiagnosed ADHD".

This has been a debate before on this forum multiple times (just look at the "similar threads" thing at the bottom of your page) so I'm not going to rehash the arguments back and forth, there's a huge thread about it.

You've basically restated what I've said. The abuse and diversion potential of the meds makes doctors apprehensive to prescribe it, so there is a lot of scrutiny on patients who think they have the condition. That's fine as long as doctors aren't prioritizing the desire to prevent diversion at the expense of actually treating the patient in front of them who fulfils the criteria.

Also you stated that patients may overreport their symptoms, the problem is this is true of all mental health conditions. As long as psychiatry relies almost completely on patient reported symptoms rather than objective biomarkers you're going to have people with a subjective experience of suffering looking for treatment. If they fulfil the criteria and you still deny them a diagnosis and treatment you're prioritizing your personal beliefs over patient care.

 

[PikminOC]

Looks like cerebral is alive and well. Just not prescribing stimulants anymore.

If I have ADHD, will Cerebral prescribe Adderall (amphetamine / dextroamphetamine) or Concerta (Methylphenidate)?​

No, stimulants such as Adderall (dextroamphetamine-amphetamine) or Concerta (Methylphenidate) are not offered through Cerebral at this time. While stimulants are often prescribed as first-line treatment for ADHD, we do offer alternative treatments which may also be helpful. Our prescribers are able to treat ADHD with alternative non-stimulant options such as Wellbutrin (bupropion) or Strattera (atomoxetine).

Yes that's what I meant to say. Not prescription of controlled subs anymore

 

[PikminOC]

You've basically restated what I've said. The abuse and diversion potential of the meds makes doctors apprehensive to prescribe it, so there is a lot of scrutiny on patients who think they have the condition. That's fine as long as doctors aren't prioritizing the desire to prevent diversion at the expense of actually treating the patient in front of them who fulfils the criteria.

Also you stated that patients may overreport their symptoms, the problem is this is true of all mental health conditions. As long as psychiatry relies almost completely on patient reported symptoms rather than objective biomarkers you're going to have people with a subjective experience of suffering looking for treatment. If they fulfil the criteria and you still deny them a diagnosis and treatment you're prioritizing your personal beliefs over patient care.

That's why neuropsych testing is helpful

 

[PikminOC]

You've basically restated what I've said. The abuse and diversion potential of the meds makes doctors apprehensive to prescribe it, so there is a lot of scrutiny on patients who think they have the condition. That's fine as long as doctors aren't prioritizing the desire to prevent diversion at the expense of actually treating the patient in front of them who fulfils the criteria.

Also you stated that patients may overreport their symptoms, the problem is this is true of all mental health conditions. As long as psychiatry relies almost completely on patient reported symptoms rather than objective biomarkers you're going to have people with a subjective experience of suffering looking for treatment. If they fulfil the criteria and you still deny them a diagnosis and treatment you're prioritizing your personal beliefs over patient care.

There's scrutiny on the physicians who prescribe it too. I see more midlevels prescriptions for controlled subs now

 

[ObsequiousAplomb]

That's why neuropsych testing is helpful

Not really. It doesn't reliably say anything meaningful except that someone is foolish / desparate enough to waste their money on it.

 

[PikminOC]

Not really. It doesn't reliably say anything meaningful except that someone is foolish / desparate enough to waste their money on it.

I think it's helpful. We will have to agree to disagree

 

[clozareal]

I learned mostly how to diagnose and treat ADHD (with and without stimulants) in my CAP fellowship. I had almost no training in adult residency on how to do this. Given the number of adults who are seeking diagnosis of ADHD (most of whom have a CC of problems concentration but some will be convinced of ADHD and seek stimulants which I will then evaluate more closely about why), I think residency programs should:

1. teach more about executive functioning. I teach my residents/fellows in my volunteer faculty appointment about 12 different executive functioning domains and how to spot deficits in them.
2. evaluating for concentration deficits through an exam, from history, and through collateral
3. learn a good broad differential for ADHD and more generally concentration concerns, both medical, neurocognitive (visual inattention, low processing speed/sluggish cognitive tempo, learning disorders, sleep disorders, hearing and vision impairment, nonverbal/pragmatic communication deficits, academic acheivement, etc), and especially important is social factors (are they in a bad fit for their job, is there trauma, is there relationship conflict, is there a lot of stress at home or work, is there a lot of social media usage, what expectations do they have for themselves and what expectations do others have for them, etc).
4. know when to refer to neuropsychological testing for stuff like learning disorders (dyslexia is extremely common in those with ADHD and even though I do diagnose this in my clinic in kids/adults, I don't do much of the other neuropsychological testing that can be helpful to see)
5. know which labs are important to get,
6. learn how to use different types of stimulants and non-stimulants. learn how to use off label medications. learn how to use supplements for those who don't want a medication or for more mild symptoms.
7. learn the different lifestyle interventions and how to recommend them to improve cognition, and
8. learn how to do some therapy for ADHD in adults (some executive functioning coaching skills go a long way but also there's CBT for adult ADHD which can be helpful).

In my private practice, I have the time and frequency of appointments to thoroughly do all the above, which makes me happy because I feel effective. I don't think I would be as effective in an insurance-based model or a high volume clinic where I wasn't able to focus on multimodal interventions. Patients in my practice are typically willing to invest resources and time into the above to help improve themselves, and when they are not they typically drop out because they're usually not motivated to pay my high rates and not put in the work and see improvement.

 

[erg923]

and performance enhancing in general

Is it though?

 

[erg923]

That's why neuropsych testing is helpful

I mean, yea sorta, could be. But mostly no. Limited to say the least. And there needs to be "a method" to the test giving madness. Not just giving a bunch of stuff until we have some positive or questionable results.

And... it needs to be done by someone quality. Which is variable in the Psychologist community. Same as in the Psychiatrist community.

I appreciate that psychiatrists, at times, recognize their limited insight/ability/time to make this diagnosis. But to think that hours upon hours of tests/testing is needed to get the response validity needed to initiate treatment is just wrong.

 

[Stagg737]

The difficulty I have with this concept is that it's probably both true and also overused as an argument for excusing lack of actual impairment. I have a bit of a hard time joining the idea that a patient has a fundamental inability to sustain attention and yet gets top marks on rigorous college/graduate school finals and standardized tests that require hours of... sustained attention.

But do they? I'm doubtful that many of these people are getting "top marks" in really rigorous courses, but keep in mind that some college courses are mind-numbingly easy. And keep in mind, for longer exams sustained attention isn't always necessary. I've talked about having ADHD here before, and I can say with 100% confidence that exams where I'm given 2+ hours are actually easier than shorter exams. I actually enjoy taking tests (yea, I'm weird) so sitting and taking one for a long time doesn't bother me. Additionally, I can go through questions in 10 minute spurts extremely effectively and then just dawdle on questions for 10-15 minutes to "refresh" my focus. Give me a 60 minute exam where one would need all 60 minutes to complete it and I'd be screwed.

I get more skeptical when patients want very high doses of stimulants, and start to consider misuse. I see many of my patients respond adequately to moderate doses of xr formulations. Some may require a higher dose, but it does raise my alert status.

100% this. I've found that most people with legit ADHD notice improvements with low to moderate doses and that they typically only ask for increased doses when some major stressor occurs and impacts their focus 2/2 increased depression or anxiety, at which time you treat the depression/anxiety and their "ADHD exacerbation" is suddenly better without adjusting their stimulants.

I've also anecdotally found that for "new" cases of undiagnosed ADHD, patients willing to try avoiding stimulants if possible and try meds like wellbutrin or strattera are more likely to actually have ADHD than those coming in saying the NEED a stimulant.

It seems that some of you believe that ADHD manifests as an inability to focus and underachievement in academic or work settings is a required symptom. In reality, ADHD manifests as extreme difficulty with self-regulating attention not an inability to pay attention at all, so it's no wonder that those with high IQs can still be successful academically. But to reach that point, they commonly endure a cycle of chronic procrastination due to extreme difficulty with task initiation and sustaining attention, leading to chronic low level anxiety and depression, but once the urgency of the deadline kicks in that's enough stimulus to drive them to complete the task. So of course these people who look successful from the outside, are still seeking treatment, because they've never been able to regulate their attention which naturally has caused downstream mental health issues, and as they gain increased responsibilities and reduced structure as they age, their IQ simply won't be able to compensate.

I genuinely think most of the stigma of diagnosing and treating ADHD is largely due to stimulant medication. If SSRIs were the treatment, despite their questionable efficacy, people would be diagnosed and treated liberally like they are with anxiety and depression.

1000% the bolded. I remember a particular UG paper where I struggled immensely for 1-2 weeks to even get the intro done and then wrote the entire thing overnight before it was due. It ended up being one of my best papers in college because I went down a hyper-focused rabbit hole.

I will say I don't completely agree with the last paragraph though. I think we're still seeing effects of the old belief that ADHD isn't a real thing, I still see patients who present with classic symptoms who don't believe it's a thing and are then shocked when they improve significantly with Wellbutrin (not talking about depressive symptoms).

 

[calvnandhobbs68]

Is it though?

This has all been argued back and forth in whole other threads on this. Not sure we need to keep revisiting. However, I should have correctly put "commonly perceived to be performance enhancing in general".

 

[erg923]

This has all been argued back and forth in whole other threads on this. Not sure we need to keep revisiting. However, I should have correctly put "commonly perceived to be performance enhancing in general".

I see. Tell me more about this.

 

[HemeOncHopeful19]

I have a geriatric patient on vyvanse, because when he doesnt use the medication his wife threatens to divorce him because hell do impulsive things, lose his phone/wallet consistently, never finish anything around the house, bills will go unpaid, etc. And this how he has been since the marriage.

Ouch, this one hits close to home. I bet he has some good qualities too!

 

[calvnandhobbs68]

I see. Tell me more about this.

If people think they will benefit from something they will attempt to obtain that thing. Idk how much more simple would you like it?

 

[docksan]

As a legit sufferer of ADHD that wasn't diagnosed until adulthood because things were easy I can attest it's possible to coast until you're faced with real challenges, which happened when I started going to college.

I hate anecdotal stuff, but I think we're venturing too far into the judgmental by linking IQ with executive capacity. I can easily breeze through an interview or intake if I'm given (or take) more time, but colleagues don't need that same prep time. I have to show up earlier to structure the day because I need that extra time.

I'm incredibly hyperactive, have all the classic symptoms, all of that. I'm guarded about stimulants and most adults I know with legit ADHD are as well. I have no shortage of patients who, like myself, weren't diagnosed as children and were just thought of as "difficult" or had parents who didn't believe in medicating children. It happens.

So like with everything else, a targeted clinical interview is probably going to be more helpful than gross assumptions and stigmatization.

I don't need another person telling me what their schizophrenia or bipolar ADHD is doing because they're referring to symptoms and not the actual illness. But someone with those legit illnesses? They often have difficulty articulating their experience because they didn't look it up on TikTok.

Instead of calling these experiences fake, we should probably go back to doing our job or assessing patients and telling them what we think is going on, making recommendarions in the process.

 

[erg923]

If people think they will benefit from something they will attempt to obtain that thing. Idk how much more simple would you like it?

I see. Tell me more about this AD/HD diagnosis and the symptoms.

 

[FlowRate]

But do they? I'm doubtful that many of these people are getting "top marks" in really rigorous courses, but keep in mind that some college courses are mind-numbingly easy. And keep in mind, for longer exams sustained attention isn't always necessary. I've talked about having ADHD here before, and I can say with 100% confidence that exams where I'm given 2+ hours are actually easier than shorter exams. I actually enjoy taking tests (yea, I'm weird) so sitting and taking one for a long time doesn't bother me. Additionally, I can go through questions in 10 minute spurts extremely effectively and then just dawdle on questions for 10-15 minutes to "refresh" my focus. Give me a 60 minute exam where one would need all 60 minutes to complete it and I'd be screwed.

I mean, it's a range. But I'm mostly talking SAT, LSAT, BAR, GMAT, GRE, MCAT, STEP exams, etc. All of those require answering about 1 q per minute for 4-8 hours straight. Maybe you think I'm questioning the entity of ADHD when I'm really questioning the dramatic increase in pressure to diagnose ADHD in likely normal adults.

I read a great book chapter today that talked about how ADHD symptoms are supposed to be compared to the average person, not some selected high performing subgroup.

The normal or typical human (average person in the general population), not some highly intelligent, high functioning, highly specialized, or highly educated peer group, is the standard against which impairment is judged. It would be clinically helpful if the DSM-5 were to specify that impairment refers to the extent of reduction in functional effectiveness and make it explicit that the general population or average person is to serve as the comparison group for making this determination, consistent with governmental regulations and judicial rulings on the subject [Reference Gordon and Keiser42].

I see. Tell me more about this AD/HD diagnosis and the symptoms.

I'm pretty sure you and calvin are on the same page so not sure why you're trying to bait him. I appreciated the paper you posted, it's making me want to get around to seeing if I can get my employer to reimburse for CAARS.

 

[PikminOC]

I mean, yea sorta, could be. But mostly no. Limited to say the least. And there needs to be "a method" to the test giving madness. Not just giving a bunch of stuff until we have some positive or questionable results.

And... it needs to be done by someone quality. Which is variable in the Psychologist community. Same as in the Psychiatrist community.

I appreciate that psychiatrists, at times, recognize their limited insight/ability/time to make this diagnosis. But to think that hours upon hours of tests/testing is needed to get the response validity needed to initiate treatment is just wrong.

I have a specific neuropsychologist I refer to. Not random places.

 

[PikminOC]

As a legit sufferer of ADHD that wasn't diagnosed until adulthood because things were easy I can attest it's possible to coast until you're faced with real challenges, which happened when I started going to college.

I hate anecdotal stuff, but I think we're venturing too far into the judgmental by linking IQ with executive capacity. I can easily breeze through an interview or intake if I'm given (or take) more time, but colleagues don't need that same prep time. I have to show up earlier to structure the day because I need that extra time.

I'm incredibly hyperactive, have all the classic symptoms, all of that. I'm guarded about stimulants and most adults I know with legit ADHD are as well. I have no shortage of patients who, like myself, weren't diagnosed as children and were just thought of as "difficult" or had parents who didn't believe in medicating children. It happens.

So like with everything else, a targeted clinical interview is probably going to be more helpful than gross assumptions and stigmatization.

I don't need another person telling me what their schizophrenia or bipolar ADHD is doing because they're referring to symptoms and not the actual illness. But someone with those legit illnesses? They often have difficulty articulating their experience because they didn't look it up on TikTok.

Instead of calling these experiences fake, we should probably go back to doing our job or assessing patients and telling them what we think is going on, making recommendarions in the process.

You've never come across drug seekers? Really?

 

[docksan]

You've never come across drug seekers? Really?

Come on now, we've all come across drug seekers.

 

[Stagg737]

I mean, it's a range. But I'm mostly talking SAT, LSAT, BAR, GMAT, GRE, MCAT, STEP exams, etc. All of those require answering about 1 q per minute for 4-8 hours straight. Maybe you think I'm questioning the entity of ADHD when I'm really questioning the dramatic increase in pressure to diagnose ADHD in likely normal adults.

I'm pretty sure you and calvin are on the same page so not sure why you're trying to bait him. I appreciated the paper you posted, it's making me want to get around to seeing if I can get my employer to reimburse for CAARS.

Maybe a little based on the last post. I still don’t think high scores on longer standardized exams should be suggestive of exclusion for ADHD. All my standardized scores before boards would make one believe I didn’t have ADHD, but med school was rough.

I’d also consider what their job/education is. Situations like med school where it’s large volumes of info requiring longer periods of sustained concentration to learn everything is a great setting to expose ADHD.

 

[PikminOC]

Come on now, we've all come across drug seekers.

I quoted the guy who said people with legit ADHD don't want stims.

 

[PikminOC]

I mean, it's a range. But I'm mostly talking SAT, LSAT, BAR, GMAT, GRE, MCAT, STEP exams, etc. All of those require answering about 1 q per minute for 4-8 hours straight. Maybe you think I'm questioning the entity of ADHD when I'm really questioning the dramatic increase in pressure to diagnose ADHD in likely normal adults.

I read a great book chapter today that talked about how ADHD symptoms are supposed to be compared to the average person, not some selected high performing subgroup.



I'm pretty sure you and calvin are on the same page so not sure why you're trying to bait him. I appreciated the paper you posted, it's making me want to get around to seeing if I can get my employer to reimburse for CAARS.

questioning the dramatic increase in pressure to diagnose ADHD in likely normal adults....
Correct 💯

 

[docksan]

I quoted the guy who said people with legit ADHD don't want stims.

You quoted me, so I assumed you were responding to me.

People with legit ADHD, in my experience, are often more hesitant to ask or will be okay with lower doses.

Drug seekers are pretty obvious to nose out, as are those who think their problems focusing aren't due to anxiety/stress/depression/trauma/sleep because they keep needing escalating doses with no improvement at all.

I do think performance pushers are a thing and I've had several in clinic. I don't think it's as commonplace as undiagnosed illness, but again I don't really pride myself on anecdotes.

 

[clozareal]

I mean, it's a range. But I'm mostly talking SAT, LSAT, BAR, GMAT, GRE, MCAT, STEP exams, etc. All of those require answering about 1 q per minute for 4-8 hours straight. Maybe you think I'm questioning the entity of ADHD when I'm really questioning the dramatic increase in pressure to diagnose ADHD in likely normal adults.

I find it largely depends on motivation and enjoyment. People with ADHD have no problem paying attention to things they enjoy for hours on end. If they really enjoy standardized tests, there might be no problem. This is why thorough clinical evaluations are necessary as the examples of effort and motivation are individualized.

Example: If I told you to pay attention to the plot of a boring movie in a language you didn't understand without subtitles, you might get distracted and not focus really easily. If I told you I was going to give you a million dollars if you could do that, your focus/distractibility will change if money was sufficiently rewarding enough for you.

I care more about sustained mental effort tasks that have low motivation/low reward but are necessary or expected of them (homework in unenjoyable classes, performance reviews at work, chores at home, engaging in social chitchat with networking, etc.).

 

[PikminOC]

You quoted me, so I assumed you were responding to me.

People with legit ADHD, in my experience, are often more hesitant to ask or will be okay with lower doses.

Drug seekers are pretty obvious to nose out, as are those who think their problems focusing aren't due to anxiety/stress/depression/trauma/sleep because they keep needing escalating doses with no improvement at all.

I do think performance pushers are a thing and I've had several in clinic. I don't think it's as commonplace as undiagnosed illness, but again I don't really pride myself on anecdotes.

I've seen many more people using it as performance enhancing than actually having it.

Like flowrate said, questioning the dramatic increase in pressure to diagnose ADHD in likely normal adults....

 

[annoyedpsychiatrist]

Ok ill throw my hat into the ring of personal stories. Never treated for ADHD because my dad thought it was an excuse to medicate kids/turn them into zombies. Was super hyperactive/impulsive. Would go to class and spend most of high school talking to various people/daydreaming. I cant remember a lecture i ever paid attention to. I survived because i had this weird savant ability to where I loved to read and could read lots of fiction/cheesy horror stuff and I think that actually helped because I would read like crazy. I remember I would watch movies as a kid and if you asked me about the movie after I would remember like 5% of it. When i would study, I would have like 5 subjects open at once and never finish one entirely. I started treatment for ADHD using vyvanse as a med student. Before using stimulants, i would have to study 12-14 hours a day in the libray because i would get out of my chair every 30 minutes to walk around, or look at youtube videos, so only half that was quality time, maybe. I skipped every single major holiday in med school and studied every christmas until late year 3 when I started vyvanse. Using vyvanse, i was able to actually have time for myself which was amazing. Things got done. I didnt endlessly procrastinate or half do tasks. The thing is, I HATE using vyvanse and I dont use it on the weekends. I would prefer not to use it all because I feel it blunts my personality and makes me more irritable/more resting male bitch face. Often i actually contemplate stopping it and in residency i would have periods where I stopped it but my documentation would get crappier and I would miss stuff more on prerounds and I felt like my work quality would decrease.

I would wager that a lot of people with real ADHD would prefer to not use the medication but feel its the only thing holding their **** together

 

[docksan]

I've seen many more people using it as performance enhancing than actually having it.

Like flowrate said, questioning the dramatic increase in pressure to diagnose ADHD in likely normal adults....

What pressure though? I just straight up tell them no unless there's a good clinical reason. "I can't focus" doesn't mean ADHD any more than "I can't sleep" means sleep apnea.

I feel more pressured to continue benzos with generalized anxiety patients than I do starting stimulants on adults who "can't focus".

 

[PikminOC]

What pressure though? I just straight up tell them no unless there's a good clinical reason. "I can't focus" doesn't mean ADHD any more than "I can't sleep" means sleep apnea.

I feel more pressured to continue benzos with generalized anxiety patients than I do starting stimulants on adults who "can't focus".

I don't continue benzos either. I didn't start it. Not my mess.

 

[smalltownpsych]

Posters seem to be focusing on different categories of patients which is a big problem with this diagnosis and the treatment. “Real“ ADHD, patients with other mental health illness that cause the difficulty (most common in my practice), patients that just like taking drugs that get you high, and patients that just want to improve performance. The latter category I haven’t really seen clinically and think it is probably more common in certain college settings.

 

[Stagg737]

Before using stimulants, i would have to study 12-14 hours a day in the libray because i would get out of my chair every 30 minutes to walk around, or look at youtube videos, so only half that was quality time, maybe.

This mirrors my personal experience. I never really needed to study in HS so never did. In college, I never studied for a test other than the night/weekend before until my 4th year because I didn't know how/couldn't focus and for the most part did alright until 3rd year. Grad school was easy, started group studying and did well with others keeping me redirected. My med school curriculum was a little different with it being a 2-pass systems based approach, so M1 year was easy as it was basically just a review of cell bio, physiology, anatomy, etc, aka all the classes I'd already taken. M2 year was crushing trying to learn all new information for every organ system. I spent 12-16 hours a day "studying" with probably 4-6 of those hours being actual quality studying and the rest being distractions/trying to remind myself what I was even trying to learn. I had been on one or 2 SSRIs for "depression" and "anxiety" (which I'm sure there was some of), but didn't help with performance at all. I started Wellbutrin in residency and within a week my functioning/performance changed dramatically. My notes were far more concise/direct, I was finishing work for the day at 2-3pm at the latest instead of 7-8pm regularly, I could also just tell I was less impulsive with conversations and some of the attendings actually felt like I was a completely different resident and said so in evals. I've never taken a stimulant and don't have a strong desire to, but I have always been curious about what it would be like as someone who has benefitted from Wellbutrin the way I have.

I would wager that a lot of people with real ADHD would prefer to not use the medication but feel its the only thing holding their **** together

This also mirrors my experience. Wellbutrin is helpful but I hate taking it and most people with ADHD I've talked to and treated prefer not to take meds but suffer without them. I've found that the people who come in demanding stimulants are usually the people who don't actually need them unless they've got something acute going on effecting their emotional regulation (aka, I'm about to get fired because I can't get my work done).

 

[docksan]

This mirrors my personal experience. I never really needed to study in HS so never did. In college, I never studied for a test other than the night/weekend before until my 4th year because I didn't know how/couldn't focus and for the most part did alright until 3rd year. Grad school was easy, started group studying and did well with others keeping me redirected. My med school curriculum was a little different with it being a 2-pass systems based approach, so M1 year was easy as it was basically just a review of cell bio, physiology, anatomy, etc, aka all the classes I'd already taken. M2 year was crushing trying to learn all new information for every organ system. I spent 12-16 hours a day "studying" with probably 4-6 of those hours being actual quality studying and the rest being distractions/trying to remind myself what I was even trying to learn. I had been on one or 2 SSRIs for "depression" and "anxiety" (which I'm sure there was some of), but didn't help with performance at all. I started Wellbutrin in residency and within a week my functioning/performance changed dramatically. My notes were far more concise/direct, I was finishing work for the day at 2-3pm at the latest instead of 7-8pm regularly, I could also just tell I was less impulsive with conversations and some of the attendings actually felt like I was a completely different resident and said so in evals. I've never taken a stimulant and don't have a strong desire to, but I have always been curious about what it would be like as someone who has benefitted from Wellbutrin the way I have.


This also mirrors my experience. Wellbutrin is helpful but I hate taking it and most people with ADHD I've talked to and treated prefer not to take meds but suffer without them. I've found that the people who come in demanding stimulants are usually the people who don't actually need them unless they've got something acute going on effecting their emotional regulation (aka, I'm about to get fired because I can't get my work done).

Adderall is a giant difference maker, even with lower doses. The difference in organizational capacity is like the difference in a full and new moon.

 

[clausewitz2]

Posters seem to be focusing on different categories of patients which is a big problem with this diagnosis and the treatment. “Real“ ADHD, patients with other mental health illness that cause the difficulty (most common in my practice), patients that just like taking drugs that get you high, and patients that just want to improve performance. The latter category I haven’t really seen clinically and think it is probably more common in certain college settings.

Whiteshoe corporate law firms, tech start-ups, and big accounting firms also have a fair amount of this. Any place where there's an expectation that you will work ludicrous hours consistently manipulating and remembering very fine details where your advancement is also a zero-sum game in competition with your co-workers will give rise to this.

 

[Ceke2002]

yes i look for significant detriments in social/occupational/educational settings. There is no adult onset ADHD, there is only ADHD that is undiagnosed as a child, or patient seeking performance enhancement.

If i see a significant detriment to some of the settings above, then im open to prescribing. I have a geriatric patient on vyvanse, because when he doesnt use the medication his wife threatens to divorce him because hell do impulsive things, lose his phone/wallet consistently, never finish anything around the house, bills will go unpaid, etc. And this how he has been since the marriage.

Primarily, i want to see a big detriment in the areas mentioned above. The guy applying for mental health disability who sits around all day and wants adderall TID, im unlikely to see a need for ADHD treatment, the majority of the time.

I get more skeptical when patients want very high doses of stimulants, and start to consider misuse. I see many of my patients respond adequately to moderate doses of xr formulations. Some may require a higher dose, but it does raise my alert status.

I weigh pros and cons. Low chance of diversion misuse? Significant quality life of improvement potentially through use of stimulant? No contraindications? Reasonable expectations with stimulant use?

100% agree with this. And yes, I also don't really believe that ADHD is something that just conveniently pops up in adulthood. If you have zero indications of ADHD in childhood, then whatever you're dealing with in adulthood is not ADHD. It gets even more annoying for me when I have acquaintances online approach me for 'coaching' in terms of what answers they should provide during an assessment for ADHD. Like, I'm sorry, what?! If you think you may genuinely have ADHD then just be honest and explain your situation to a professional as best you can, you don't need someone diagnosed with ADHD to 'coach' you through an assessment. Unfortunately there are some unscrupulous types out there, who, having seen a business opportunity, now provide course work and tutoring in how to get diagnosed with ADHD (and subsequently provided with stimulants) for a fee.

 

[Ceke2002]

Ok ill throw my hat into the ring of personal stories. Never treated for ADHD because my dad thought it was an excuse to medicate kids/turn them into zombies. Was super hyperactive/impulsive. Would go to class and spend most of high school talking to various people/daydreaming. I cant remember a lecture i ever paid attention to. I survived because i had this weird savant ability to where I loved to read and could read lots of fiction/cheesy horror stuff and I think that actually helped because I would read like crazy. I remember I would watch movies as a kid and if you asked me about the movie after I would remember like 5% of it. When i would study, I would have like 5 subjects open at once and never finish one entirely. I started treatment for ADHD using vyvanse as a med student. Before using stimulants, i would have to study 12-14 hours a day in the libray because i would get out of my chair every 30 minutes to walk around, or look at youtube videos, so only half that was quality time, maybe. I skipped every single major holiday in med school and studied every christmas until late year 3 when I started vyvanse. Using vyvanse, i was able to actually have time for myself which was amazing. Things got done. I didnt endlessly procrastinate or half do tasks. The thing is, I HATE using vyvanse and I dont use it on the weekends. I would prefer not to use it all because I feel it blunts my personality and makes me more irritable/more resting male bitch face. Often i actually contemplate stopping it and in residency i would have periods where I stopped it but my documentation would get crappier and I would miss stuff more on prerounds and I felt like my work quality would decrease.

I would wager that a lot of people with real ADHD would prefer to not use the medication but feel its the only thing holding their **** together

Sounds like you and I have a similar experience with medication. I was prescribed Dexamphetamine, and yeah it was great, like total night and day in terms of my social skills, thinking skills, organisational abilities, etc etc. Trouble was I absolutely hated the side effects, the irritability, feeling jittery, sleep disruption, personality blunting, and so on. I was only on medication for around 2-3 weeks before I made the decision to stop and decided to work on ways I could adapt to having ADHD, rather than medicating the symptoms. Not saying medication isn't useful or necessary in some cases, nor that anyone should just stop taking medication for ADHD if its working for them, just that in my case I did find it better in the long run to utilise a non medication approach. As with all anecdotal evidence though, your mileage may vary.

 

[romanticscience]

What also makes this difficult for psychiatrists is that we are not usually trained in assessing malingering or how to therapeutically handle secondary gain because it's not often a factor with other conditions we treat. Yes, there is valid ADHD that persists in adults. But, there is also factitious and malingered ADHD. How do we handle these? It takes a lot of energy to work through this discord, especially when the frame is "medication management."

I sometimes use tests of malingering (e.g., TOMM) with ADHD assessments, especially in college students where the rate is particularly high. When they are positive, I just say, "I don't think you have ADHD." If they push it and ask why, then, well, that's awkward lol.

 

[allantois]

At this point everyone needs to be forensically trained both to navigate malingering as well as medico-legal issues..

 

[TexasPhysician]

What also makes this difficult for psychiatrists is that we are not usually trained in assessing malingering or how to therapeutically handle secondary gain because it's not often a factor with other conditions we treat. Yes, there is valid ADHD that persists in adults. But, there is also factitious and malingered ADHD. How do we handle these? It takes a lot of energy to work through this discord, especially when the frame is "medication management."

I sometimes use tests of malingering (e.g., TOMM) with ADHD assessments, especially in college students where the rate is particularly high. When they are positive, I just say, "I don't think you have ADHD." If they push it and ask why, then, well, that's awkward lol.

Is the TOMM hard to learn?

 

[romanticscience]

Is the TOMM hard to learn?

It's pretty easy just takes like 20 minutes to administer. There is nowhere near the sophisticated scoring/statistics of an MMPI or PAI.

Here's a good paper discussing TOMM and other measures:

Tracy, D. K. (2014). Evaluating malingering in cognitive and memory examinations: a guide for clinicians. Advances in psychiatric treatment, 20(6), 405-412.

This paper also is interesting but I can't find which items they embedded into the Connors:

Harrison, A. G., & Armstrong, I. T. (2016). Development of a symptom validity index to assist in identifying ADHD symptom exaggeration or feigning. The Clinical Neuropsychologist, 30(2), 265-283.

 

[FlowRate]

It's pretty easy just takes like 20 minutes to administer. There is nowhere near the sophisticated scoring/statistics of an MMPI or PAI.

Here's a good paper discussing TOMM and other measures:

Tracy, D. K. (2014). Evaluating malingering in cognitive and memory examinations: a guide for clinicians. Advances in psychiatric treatment, 20(6), 405-412.

This paper also is interesting but I can't find which items they embedded into the Connors:

Harrison, A. G., & Armstrong, I. T. (2016). Development of a symptom validity index to assist in identifying ADHD symptom exaggeration or feigning. The Clinical Neuropsychologist, 30(2), 265-283.

Harrison and Armstrong would be the Connors Exaggeration Index.

Here's another interesting paper on a follow-up study to add additional symptom validity measures to the Connors, they talk about using TOMM and GET (like a computerized TOMM) in the paper:

Non-credible symptom report in the clinical evaluation of adult ADHD: development and initial validation of a new validity index embedded in the Conners' adult ADHD rating scales
Becke, Miriam ; Tucha, Lara ; Weisbrod, Matthias ; Aschenbrenner, Steffen ; Tucha, Oliver ; Fuermaier, Anselm B. M
JOURNAL OF NEURAL TRANSMISSION, 2021, Vol.128 (7), p.1045-1063

 

[PikminOC]

This mirrors my personal experience. I never really needed to study in HS so never did. In college, I never studied for a test other than the night/weekend before until my 4th year because I didn't know how/couldn't focus and for the most part did alright until 3rd year. Grad school was easy, started group studying and did well with others keeping me redirected. My med school curriculum was a little different with it being a 2-pass systems based approach, so M1 year was easy as it was basically just a review of cell bio, physiology, anatomy, etc, aka all the classes I'd already taken. M2 year was crushing trying to learn all new information for every organ system. I spent 12-16 hours a day "studying" with probably 4-6 of those hours being actual quality studying and the rest being distractions/trying to remind myself what I was even trying to learn. I had been on one or 2 SSRIs for "depression" and "anxiety" (which I'm sure there was some of), but didn't help with performance at all. I started Wellbutrin in residency and within a week my functioning/performance changed dramatically. My notes were far more concise/direct, I was finishing work for the day at 2-3pm at the latest instead of 7-8pm regularly, I could also just tell I was less impulsive with conversations and some of the attendings actually felt like I was a completely different resident and said so in evals. I've never taken a stimulant and don't have a strong desire to, but I have always been curious about what it would be like as someone who has benefitted from Wellbutrin the way I have.


This also mirrors my experience. Wellbutrin is helpful but I hate taking it and most people with ADHD I've talked to and treated prefer not to take meds but suffer without them. I've found that the people who come in demanding stimulants are usually the people who don't actually need them unless they've got something acute going on effecting their emotional regulation (aka, I'm about to get fired because I can't get my work done).

People say this

It's pretty easy just takes like 20 minutes to administer. There is nowhere near the sophisticated scoring/statistics of an MMPI or PAI.

Here's a good paper discussing TOMM and other measures:

Tracy, D. K. (2014). Evaluating malingering in cognitive and memory examinations: a guide for clinicians. Advances in psychiatric treatment, 20(6), 405-412.

This paper also is interesting but I can't find which items they embedded into the Connors:

Harrison, A. G., & Armstrong, I. T. (2016). Development of a symptom validity index to assist in identifying ADHD symptom exaggeration or feigning. The Clinical Neuropsychologist, 30(2), 265-283.

Yes that's why I like full neuropsych testing as it's more thorough in regards to this.

 

[PikminOC]

Harrison and Armstrong would be the Connors Exaggeration Index.

Here's another interesting paper on a follow-up study to add additional symptom validity measures to the Connors, they talk about using TOMM and GET (like a computerized TOMM) in the paper:

Non-credible symptom report in the clinical evaluation of adult ADHD: development and initial validation of a new validity index embedded in the Conners' adult ADHD rating scales
Becke, Miriam ; Tucha, Lara ; Weisbrod, Matthias ; Aschenbrenner, Steffen ; Tucha, Oliver ; Fuermaier, Anselm B. M
JOURNAL OF NEURAL TRANSMISSION, 2021, Vol.128 (7), p.1045-1063

Yes thank you. Romantic science hit the nail on the head regarding malingering. That's what I see a lot of. Not just for ADHD.

 

[randomdoc1]

People say this

Yes that's why I like full neuropsych testing as it's more thorough in regards to this.

unfortunately crap testing services are more prevalent and quite lucrative, and the patient often comes back proudly with their stimulant certificate...I've been trying to provide educational resources to the providers here about the importance of an accurate assessment and the strong incentive to over report to procure stimulants/get accommodations.