“You Couldn’t Possibly Have ADHD!”

Despite the fact that at least 20 percent of the patients being seen in mental health practice will have ADHD (due to the high level of co-existing psychiatric disorders), most doctors and mental health professionals know virtually nothing about the symptoms of attention deficit disorder. Ninety-three percent of adult psychiatry residency programs do not mention ADHD once in four years of training. There are no questions about ADHD symptoms on the board-certification examination for adult psychiatry.

More often than not, it is the patient who suspects that he has ADHD and who makes an informal diagnosis. This happens because ADHD is genetic and runs in families. A person sees someone else in his family who has been diagnosed and treated for the condition. The more he talks with family members about the symptoms, the more he recognizes ADHD impairments in himself, his siblings, or his children.

Doctors, however, hold the key to treatment. Only a clinician can write a prescription for ADHD medication, which is the first-line treatment for ADHD. But before you can receive a trial of ADHD medication, you need a diagnosis. That can be the hardest part. Unless the doctor understands what is going on with you, he will make the wrong diagnosis. You cannot bypass the diagnosis step, ever.

Here are five mistakes doctors make in diagnosing ADHD.

1. Your doctor doesn’t think that you might have ADHD.

Data from the National Comorbidity Survey Replication (NCS-R) shows that people with ADHD look for professional help, but don’t always find it. There are two reasons for this.

[Free Download: It’s Not ADHD?! Common Diagnosis Mistakes]

Clinicians are given little or no training in recognizing ADHD. ADHD is the only medical condition for which there is no textbook. Even if a doctor wants to learn how to diagnose and treat ADHD, there are few places to get the information.

Many doctors don’t consider the possibility that ADHD could be present. In a study examining which interactions between patient and psychiatrist led to the consideration that ADHD is present, not a single psychiatrist made the diagnosis. When the board-certified psychiatrists were told that they were participating in a study about adult ADHD, 60 percent of them refused to accept that attention deficit was a potential co-existing condition.

If you suspect that ADHD is not on your doctor’s radar screen, and he is not listening to you, find a new practitioner.

2. Your doctor assumes that a person who is successful can’t have ADHD.

Many of my patients who are successful professionals, spouses, and parents were not considered to have ADHD because they were successful. Doctors would say, “You graduated from college. You’ve got a good job. You couldn’t possibly have ADHD!”

[The Building Blocks of a Good ADHD Diagnosis]

This way of thinking dates back to the days when the condition was called Minimal Brain Damage, and children identified with symptoms were thought to be brain-damaged. These assumptions have continued due to the fact that children who are identified as having ADHD early in life are either severely hyperactive or have learning disabilities that prevent them from doing well in school and in life.

Most people with ADHD nervous systems compensate for their impairments. That’s why, in part, the average age of diagnosis for adults is 32. They have made it through school, established themselves in jobs, and started to raise families, but they can no longer meet the increasing demands brought about by their success. The doctor sees the “highlights reel” of a person’s life, not the hard work and sacrifice it took to get where the person is.

People with ADHD nervous systems are passionate. They feel things more intensely than people with neurotypical nervous systems. They tend to over-react to the people and events of their lives, especially when they perceive that someone has rejected them and withdrawn their love, approval, or respect.

Doctors see what they are trained to see. If they see “mood swings” only in terms of mood disorders, they will most likely diagnose a mood disorder. If they are trained to interpret excessive energy and racing thoughts in terms of mania, that is what they will probably diagnose. In the study mentioned above, all of the ADHD adults were diagnosed as having BMD. ADHD wasn’t an option. By the time most adults get the correct diagnosis, they have seen 2.3 doctors and been through 6.6 failed courses of antidepressant or mood-stabilizing medications.

You’ll need to make the distinction that mood disorders:

• Are untriggered by life events; they come out of the blue.
• Are separate from what is going on in a person’s life (when good things happen, they are still miserable).
• Have a slow onset over many weeks to months.
• Last for weeks and months unless they are treated.

ADHD mood swings:

• Are a response to something happening in a person’s life.
• Match the person’s perception of that trigger.
• Shift instantaneously.
• Go away quickly, usually when the person with ADHD becomes engaged in something new and interesting.

If you can’t get your doctor to see these important distinctions, chances are, you will be misdiagnosed and mistreated.

3. Your doctor misinterprets lifelong ADHD hyperarousal as anxiety.

Under managed care, the insurance company pays your doctor for about 15 minutes of his time, during which he is supposed to take your history, do an examination, make a diagnosis, explain the diagnosis and the risks and benefits of possible treatments, write a note in your chart, and find enough time to make a phone call or go to the bathroom. It can’t be done.

Unfortunately, people with ADHD often have a hard time accurately describing their emotional state. If a patient walks in and says, “Doc, I’m so anxious!” the doctor thinks he has anxiety. The doctor does not take the time to probe further. If he did, he might say, “Tell me more about your baseless, apprehensive fear,” which is the definition of anxiety – the constant feeling that something awful is about to happen. Most people with an ADHD nervous system would be puzzled by his request, because they are not afraid. They equate anxiety with the lifelong experience of never slowing down enough to have a moment of peace, always thinking about five things at once, being so energetic that they have never been able to sit through a movie, and being unable to shut this hyperarousal off so they can sleep.

You have to help your clinician understand by insisting that she take the time to listen to you in an open way. She needs to know the distinctions between anxious fear and internalized hyperarousal from ADHD. Unless you can get the doctor’s attention, you will get the wrong diagnosis and the wrong treatment.

4. Your doctor mistakes your need for structure as obsessive-compulsive disorder.

The more we do things by habit and structured routines, the less we need to pay attention. Many people with ADHD find that they function more efficiently if they do something the same way every time. They have a certain place where they put their wallet and keys, so that they won’t have to search the house every morning. Sometimes, this need for structure, consistency, and unchanging predictability can become excessive. Again, doctors see what they have been trained to see, and, in this case, many would interpret these behaviors as OCD. Sometimes a person has both conditions, but not always.

The distinction is that the repetitive actions of OCD are meaningless rituals. They serve no purpose, and they impair a person’s ability to lead a productive life. The structure that people with ADHD want is helpful, practical, and makes life more efficient. This is the difference between an OC trait and an OC disorder. Without their habits and routines, many people with ADHD would lead chaotic lives.

You will need to help your doctor understand that, although these habitual behaviors may look alike, their purpose and outcome are not what they appear to him.

Many doctors were taught that people outgrow ADHD in adolescence, because the disruptive hyperactivity that defined ADHD in a youngster usually diminishes in early adolescence. In fact, hyperactivity doesn’t go away; it affects one’s thoughts and emotions. ADHD is lifelong. Ninety percent of people with an ADHD nervous system will develop severe sleep disorders.

Adults with ADHD usually give their doctors the same sleep history. “Doc, I’ve always been a night owl. I know that if I get into bed at a reasonable hour, I am not going to be able to turn my brain and body off to fall asleep. My thoughts jump from one concern and worry to another.” The average time a person with ADHD lies in bed awake is two or more hours every night. For many patients, sleep deprivation from ADHD is the worst part of the condition.

Many people with ADHD start by telling their doctor that they cannot sleep due to racing thoughts. The doctor responds by prescribing lithium for mood disorders.  Most doctors never make the connection between ADHD and severe sleep deprivation.

Since the cause of the inability to sleep in ADHDers is the mental and physical restlessness of ADHD, the solution is to treat the ADHD with a stimulant or alpha agonist medication. Unless a doctor understands that a person’s sleeplessness is caused by untreated ADHD hyperarousal, he will think that stimulant medication will make the it worse instead of better.

As a patient, you need to explain the source of your chronic sleeplessness, and help your doctor understand that your hyperarousal gets worse at night and prevents you from sleeping. Since taking a stimulant to treat inability to sleep is counter-intuitive to you and your doctor, you will need to offer to do a no-risk trial to test it out. Once your ADHD stimulant has been fine-tuned and you have no side effects from it, lie down one day after lunch and try to take a nap. The majority of people with ADHD, who have never been able to take a nap in their lives, will find that they can while taking their ADHD medication. Then you and your doctor will know that the addition of another dose of medication at bedtime will treat the impairments of your ADHD through the whole day, not just the workday.

5. Your doctor thinks you are there only to get a prescription for ADHD medication.

Many doctors have a resistance to an ADHD diagnosis because ADHD is different from anything they know and it wounds their ego not to be the expert on it. Their discomfort with the diagnosis is in direct proportion to their lack of knowledge. You can hear it in the way they speak: “I don’t believe in ADHD.” When given the choice between admitting their lack of competence and undercutting the existence of ADHD, they will take the latter course.

The best medications used to treat ADHD are Schedule-II controlled substances (the most strictly controlled medications available by prescription). Even though stimulants have very low abuse potential when correctly prescribed and should be put back in Schedule IV (the least restricted category), where they were until 1978, their current controlled substance status gives most clinicians the willies. They would rather avoid the subject.

The patient has been forced to figure things out on his own, and walks in telling the doctor the diagnosis and suggesting the treatment, which involves controlled medications. Now imagine that a patient also has a recent or remote history of excessive alcohol or drug use, which is the case in up to 60 percent of people with untreated ADHD. The doctor will not be inclined to diagnose ADHD.

Before you tell the doctor the purpose of your visit, give him a history of how you concluded that ADHD has caused frustration in your life. Let him know about your family history of ADHD, if there is one. Help your doctor understand that your early misadventures with drugs and alcohol were attempts at self-diagnosis and self-medication. Tell him that you want to do things the right way.

If you can’t get through to him, get a referral to a specialist in your area who is open to hearing about your life journey with ADHD.

[The ADHD Symptoms We Misdiagnose]

William Dodson, M.D., is a member of ADDitude’s ADHD Medical Review Panel.

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