I discussed ADHD with children and how tedious it can be with the substance abuse population. However, with adult ADHD, it’s usually ignored, undiagnosed, or hidden in other behaviors.
Insurances are covering less and the providers, patients, and facilities are getting more of the brunt of this broken health care system. I wish I could prescribe something to myself but will stop rambling to talk about ADHD 2.0. This is the new form of ADHD that is forcing people to change the way they practice and treat ADHD. For the sake of simplicity, I’m talking about previously undiagnosed adults only.
With children and substance abuse populations, many providers are lowering the bar and I get it, we just want people to be more productive. Therefore, adults shouldn’t be any different, if they’re not productive, things may get hopeless, engage in risky behaviors, or basically become a failure to thrive. I think my only saving grace was continuously handling millions of things at once, but eventually, a crash is inevitable because only robots operate like a robot.
The Problem
According to DSM5, ADHD is a disorder of EXCLUSION so other factors need to be r/o before diagnosing:
- “Symptoms don’t occur exclusively during the course of schizophrenia or another psychotic disorder & are not better explained by another mental disorder (eg, mood disorder, anxiety, dissociative disorder, personality disorder, substance intoxication or withdrawal)”
- Diagnosis must be made <12 y/o (used to be 6y/o).
- Symptoms must be constant & consistent.
The main issue is how many kids/families were neglected, didn’t know or had resources available, and things were stigmatized or a myth. A patient recently told me how growing up, ADHD was something that only “boys” got and females were being moody, dramatic, needy… Some people also believed that treatment was only for rich people because of course they’re more overwhelmed than anyone else in the world *insert extreme sarcasm here*.
Therefore, the lack of access to those who need it the most is really the true problem. Thus, substance abuse is going up, some take or use other people’s medications, etc. The part that really stings is when they basically gave up on their dreams, and stopped working or pursuing their interests altogether. So do NOT judge. You can already see the guilt and shame on their face. I’ll go over a brief case study and a plan of care that’s been helpful:
My Typical Adult Patient
KM is a 30y/o white male who works as a dispatcher 5 days/wk and on the weekend does freelance work. He has maintained employment but playing the piano and painting is his passion. Lately, he has been having difficult moods. KM reports a lack of energy, anxiety, restlessness, low ADLS, and poor focus, “I can barely clean my room”. PHQ 18, GAD 14, denies prior medical/psych history. Unk family hx, biological father wasn’t involved, mother frequently moved and KM rarely went to the doctor. He graduated from HS, dropped out of college, and has been working various jobs since. He denies cigarettes, but has been using cocaine for the past year 1-2/month but expressed it’s only at a party or with friends. Moderate ETOH use, 12-pack/week. He’s currently inquiring about getting treated for ADHD.
What’s The Big Deal?
This is my usual profile for the ADHD 2.0 population. According to the DSM, this shouldn’t occur, KM wasn’t diagnosed before and he shouldn’t even be classified because of recent cocaine use, but there’s another underlined problem going on…note the severe overcompensation. I left out a lot of details but you can get the gist, these patients have not been proactive, they don’t have the energy. You can actually see the complete opposite, like a numbing desensitization response to life or just in general. This is different from the cocaine blues, where a person wants to beam off into another galaxy.
The ADHD 2.0 population, tries to be productive and yearns for proper treatment. I’m gauging the severity based on the amount of overcompensation/mood, the quality of life/ADLS, and the amount of cooperation, but usually these patients are adherent because they truly want help. I’ve actually been doing this for a while because it’s the only thing that makes sense to me dealing with this gray area.
Rule Out Other Problems
So how do you tackle the undiagnosed adult that has obvious signs of poor attention? remain objective (unbiased) and treat the disorder. Being objective includes ruling out other disorders:
This graphic is awesome because you normally see a lot of overlap with ADHD. I’ve had patients that just get a stimulant prescribed and still have poor moods and vice versa. I don’t understand how some providers will only treat one disorder and not the others because things will get worse. However, I do have a few patients only on ADHD medications and no mood issues. Nevertheless, undiagnosed/untreated adult ADHD patients usually have multiple problems because their impairments and neurochemicals have been affecting everything for a long time.
How do I get into treatment mode?
As usual, DSM-V is vague and I have to do my own personal r/o because I pay attention to patterns and red flags:
- FREQUENT DAYDREAMING: this is huge to me, almost the biggest red flag. Daydreaming is the bare minimum effort and sometimes the patient doesn’t realize they’re doing it until I mention it. Because you can actually see these people drift away even while they’re talking. You can put it in the DSM criteria of seeming to not listen, but this is different. I’m assessing if it’s occurring at home, school/work, causing lapses of memory, and if they can control it (but usually they can’t). I’m also mentioning this because it’s almost always associated with some kind of PSTD, past abuse, or dissociation that also have to be ruled out or addressed.
- Overcompensating: as I previously mentioned, these people are trying to overcome this form of stress that often appears as laziness, fatigue, irritability, or stoned, when in actuality they really don’t have the energy. Instead of being purposeful and intentional, they’re barely engaging with the environment so you also see a lot of guilt, embarrassment…etc. Simple tasks are like climbing mountains.
- RISKY Behaviors: back to the overcompensating, I worry about these people taking someone else meds, going to the streets, or having a job that’s putting other people’s lives at risk such as caring for others i.e. police officers, healthcare, pilots, truck drivers, etc. Lastly, all these situations and stressors can lead to a failure to thrive (in society), poor ADLS, dispairing, self-harm thoughts…etc.
Plan of Care
Psychological testing isn’t usually covered for adults so most of the time, I try to avoid it and use a screening tool PDF DOWNLOAD -> (Adult ADHD Self-Report Scale) and a thorough hx, but you may still get backlash from insurance companies… They simply want to know how was this person able to function all these years until they encountered YOU. Commercial insurance shouldn’t be as difficult but state insurance is like a psychotic parole officer so who knows how they will act. In general, you have to have a consistent and reliable system. DOCUMENT
- Highlight the HX: document class or school failures, repeated/poor grades, past use of stimulants (or using other means to treat the symptoms), ACES, family history, learning/reading/comprehension disabilities, etc.
- Assess Moods: these undiagnosed people usually have mood disorders and to keep track of measures, I also frequently use the PHQ9 and GAD7 (check out more screening tools) for the intake. I’ve been doing this to also help me with PAs because if they still refuse to cover, well in the worst-case scenario, I documented how “uncovered” treatment has also affected their mood and contributed to making things worse…
- Start with Non-Stimulants: depending on the severity of the symptoms, I will start with bupropion if it’s not contraindicated. I’ve had several patients do well on it for ADHD or couldn’t tolerate stimulants so it’s still a great medication to consider. Bupropion SR 100mg-200mg is for the treatment of ADHD, I normally go to the lower dosage, especially with moderate ETOH users, or will avoid it if there’s a significant SZ hx.
- TARGET SLEEP: a lack of sleep mimics ADHD, irritability, and similar symptoms. I also usually ask patients about nightmares/night terrors. It would make a person avoid sleep or be restless at night. Clonidine and guanfacine also help with focus and intrusive dreams/thoughts.
- About Rx testing: I normally give patients a grace period before testing to give them a chance to have a clean slate…but unfortunately, it’s not mandatory. Many places I worked at don’t even have the equipment or supplies to test. I can’t just haul somebody off to the bathroom, especially via telehealth. The only way I have to counter this is by making the person so productive, that they won’t turn to any other means for treatment. If someone got employed at a decent job (they rx test the patient) then I can count that as a green light as well…Again, this is different with the substance abuse population, these people truly want to be productive and maintain their life/employment/status.
- Try to Avoid Adding EXTRA Stress: So it’s important to recognize when a person is doing things that aren’t normal. Some patients will try to literally work every day, randomly want to become a music producer, etc. and it usually leads to more problems. Certain lifestyles and unusual events will make you lose concentration/focus. You’re not crushing their dreams but helping the person be realistic and understand the difference between having hobbies and a stable/reliable income. Other lifestyle considerations include poor diet or physical activity, and nutritional deficiencies.
Follow-Up
KM is doing better, he was able to improve mood and concentration with Wellbutrin 100mg SR, and agreed to increase the dose to 100mg BID. He also limit his drinking to just the weekends and was okay (cleared) to increase the dosage but if not then I would’ve considered switching due to SZ risks. He continues to have anxiety and was prescribed 10mg propanolol QD, PRN for breakthrough/physical symptoms of anxiety. He declined therapy due to working off-hours and not having adequate time. Report no other concerns.
Final Thoughts
I’ve said in the past that I would avoid bupropion with moderate ETOH users, but lately, I’ve been using it to help people reduce drinking/smoking. It just goes with trying to avoid more problems if possible. I tell them it’s a great medication for focus, but they have to limit these recreational behaviors due to the seizure risks. If they can’t stop these activities then I’ll switch to other non-stimulants before going to the schedules.
KM also couldn’t precisely tell me how much he drinks per week so I also have to treat or even assume the “anxiety” may come from withdrawals. I’m not opposed to a stimulant with him, but it’s somewhat the last resort in general with cocaine users (because it can be triggering), whereas with others, I’ve been able to start them on something scheduled at least by the follow-up.
I normally don’t prescribe stimulants on the inital visit if there are no prior diagnoses or treatments. Again Rx testing is a hit or miss, so starting a regimen shouldn’t be based on it, I’m mainly looking at the quality of life and the patient’s cooperation whereas people who keep abusing substances, require more intensive treatment and can be hostile.
It’s why the intake is important but also developing mutual respect during in these follow-ups are also crucial. If the patient doesn’t respect me or agree with the treatment plan, then I usually let them know of the consequences, mainly how their mental health may get worse and I can’t proceed with scheduled medications until there’s more adherence…
I’ve had others who didn’t come back after the intake, which is somewhat a red flag to me i.e. they’re actively dealing with a drug problem or they could’ve gone to another provider, lost insurance, or whatever the problem, I don’t take things personally.
I simply explain to people especially the recent (<1 month) cocaine/Rx users, that these medications may help but a lack of self-control or cooperation means rehab IS the best option. However, the non-substance/undiagnosed ADHD population also needs boundaries since they’re already burnt out from life but not due to drugs. Overall, have a reliable system for yourself and these critical situations so we providers won’t get burnt out either or more frustrated.
Additional References and Information
- ADHD, Bipolar Disorder, or Borderline Personality Disorder the differences in the clinical pictures –Psychiatric TImes
- Bipolar & ADHD: infographics and resources about bipolar –Neurodivergent Insights
- Study: Patients with ADHD, Other Psychiatric Diagnoses Stop Treatment More Often: –Pharmacy Times …In conclusion, they have underline psych issues. Basically, make sure the patient is aware and also agrees with the ADHD diagnosis/plan of care.
- What’s the difference between ADHD, BPD, and Bipolar Disorder? -Inflow
