Just before Katie Marsh dropped out of university, she started worrying that she had attention deficit hyperactivity disorder.
“I felt a burning sensation of boredom inside me,” said Marsh, now 30 and living in Portland, Oregon. “I hardly went to class.” And when I did, I felt like I had a lot of pent up energy. It was like having to move around all the time. ”
So she asked for an ADHD evaluation and was surprised to learn the results were inconclusive. She never returned to school. And it wasn't until she sought help again four years later that she was diagnosed by an ADHD specialist.
“It was pretty frustrating,” she said.
ADHD is one of the most common mental illnesses in adults. However, many health care providers are unevenly trained in how to assess it, and there are no U.S. clinical practice guidelines for diagnosing and treating patients in childhood and beyond.
Without clear rules, some health care providers, while well-intentioned, are simply “making things up as they go,” said Dr. David W. Goodman, assistant professor of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine. He said that.
This lack of clarity leaves healthcare providers and adult patients in a bind.
“We desperately need something to help guide the field,” says Dr. Wendy Weitz, a psychiatrist at the online mental health company Talkiatry. “When everyone practices a little differently, it becomes difficult to know how best to approach it.”
Do ADHD symptoms continue to appear in adulthood?
ADHD is defined as a neurodevelopmental disorder that begins in childhood and is typically characterized by inattention, confusion, hyperactivity, and impulsivity. Patients are usually classified into three types: hyperactive and impulsive, inattentive, or a combination of the two.
According to the latest data, approximately 11 percent of children ages 5 to 17 in the United States have been diagnosed with ADHD, and approximately 4 percent of adults are estimated to have the disorder. But as recently as 20 years ago, most mental health providers “didn't really believe in adult ADHD,” Dr. Goodman said.
Now, in most cases, that is no longer the case. And a study published in JAMA Psychiatry in January found that prescriptions for stimulants, primarily used to treat ADHD, “rose sharply” during the pandemic, especially among young adults and women.
To diagnose this condition, medical professionals rely on the American Psychiatric Association's official manual of mental disorders, DSM-5, which includes somewhat arbitrary requirements. To meet diagnostic criteria for ADHD, significant symptoms, such as persistent forgetfulness or out-of-turn speech, must be present in at least two situations by age 12.
However, older patients may not remember their symptoms from childhood or may say they were milder.
Judy Sandler (age 62, resident of Lincolnville, Maine), She wasn't diagnosed with ADHD until her mid-50s, when she retired from her job as a teacher. For the first time in her life, she felt like she couldn't get anything done. She wanted to write, but when she sat down to concentrate, she immediately had the urge to get up and do something else. “I'll just do the laundry,” she'll think, “and then I'll walk the dog.”
During her active years, she benefited from a “super-structured” schedule until her retirement. “All of a sudden, it felt like the rug had been pulled out from under me,” she said.
Patients like Sandler fall into a gray area. She said she did not remember having any significant symptoms at school or at home; rather, the symptoms became most problematic later in life. But her husband, 33, had noticed the symptoms years earlier. For example, she was forgetful and she found it difficult to slow down.
“Making this diagnosis, especially in a high-functioning, intelligent person, requires much more subtle judgment than just a checklist of symptoms,” Dr. Goodman says.
Does the DSM have no symptoms?
The DSM lists nine symptoms of inattention and nine symptoms of impulsivity/hyperactivity that are used to assess whether an adult or child has ADHD.
The DSM does not officially include symptoms related to emotional dysregulation (difficulty managing mood). It also does not officially address deficiencies in executive functions or problems with planning, organization, or self-regulation. But research has found that these are some of the most common symptoms experienced by adults with ADHD, said Russell Ramsey, a psychologist who treats adults with ADHD.
When DSM-5 was published in 2013, there wasn't enough high-quality research to support the addition of these symptoms, Dr. Goodman said. But experts say it's still useful to consider them when evaluating people.
Dr. Goodman, in collaboration with Dr. Ramsey and other ADHD experts around the world, developed the first U.S. guidelines for diagnosing and treating ADHD in adults in collaboration with the National Association of Professionals on ADHD and Related Disorders. I am.
There is an urgent need to do so, in part due to the emergence of new research over the past decade. Additionally, ADHD in adults is often undiagnosed and untreated, and some people may be diagnosed with ADHD and given medications they don't really need, Dr. Goodman said. said.
The new guidelines, which will be submitted to public comment later this year, aim to create a more uniform process for diagnosing adults, but the DSM remains the “gold standard” for health care providers. continues to exist, Dr. Ramsay said.
“That's not a mistake,” he added. “It's just incomplete.”
Is it ADHD or something?
In adults, a proper ADHD diagnosis typically involves several things, including an interview with the patient, medical and developmental history, symptom questionnaires, and, if possible, conversations with other people in the patient's life, such as the spouse. steps are required.
“There are no shortcuts,” Dr. Leonard A. Adler, a professor of psychiatry at New York University's Grossman School of Medicine, said while speaking to hundreds of health care providers at the American Psychiatric Association conference in early May. . “This is not easy.”
Anyone can have trouble paying attention or feel restless at times, but how widespread and severe the symptoms are can help doctors determine whether a diagnosis of ADHD is appropriate. , he added, and how consistently the impairment occurs throughout the patient's life. .
However, several factors can make it difficult.
Research suggests that people who consider themselves heavy users of digital technology are more likely to report symptoms of ADHD.
There's a “chicken and egg” dilemma, says Dr. Weitz. Are people with ADHD more attracted to using digital technology than the average person, or did he develop ADHD due to the use of technology?
People with ADHD are more likely to have other medical conditions, such as substance use disorders, depression, or anxiety, and both doctors and patients may be unsure if their symptoms are related to ADHD, especially if the symptoms overlap. It can be difficult to understand what the results are.
Marsh was diagnosed with depression as a teenager and took up to 10 different medications to treat it with little success, but after visiting a local psychologist, she was finally diagnosed with ADHD. I received it. This time, the doctor took the time to talk with her parents and partner and conduct a new analysis of her test results, which were deemed inconclusive four years ago.
After Marsh began treatment and taking the stimulant Focalin, she said the difference in the way she felt was “insane.” Her depression also improved.
“I can now grasp things more easily in my head,” she added. “Now that I am motivated, I am able to do more.”
