Adult ADHD Is the Wild West of Psychiatry
theatlantic.com
theatlantic.com
ADHD wasn't identified as a disorder until recently because it wasn't a disorder until recently. For most of human history, the traits associated with ADHD would have been at worst a wash and in many cases advantageous to have in small numbers within a community. The adults that I know with ADHD are disproportionately likely to be the movers and shakers in their worlds—they work well under pressure and make things happen. You don't want everyone to be that way, but having a portion of the population that can't sit still has huge advantages.
That only changed when we moved into the 20th century and started expecting 100% of the population to be okay with sitting quietly in a chair for 6 hours a day for 12 years of their lives and then, if they had any kind of ambition, to do more sitting in chairs working a white collar job until retirement.
The people with ADHD aren't a problem, the unnatural world we've created is the problem, and we risk losing an important part of the larger organism that is civilization if we force these people to conform.
It's definitely not all upside, especially in modern contexts. But I do believe what I said—he would have thrived in the more Wild West academia of Isaac Newton and John Locke. The things he struggled to do were the accidental complexities of the job of professor, not the truly important aspects of that role.
This sounds horrific for both the individuals and their families. Talented individuals with so much to offer not finding their place.
> He would have thrived in the more Wild West academia of Isaac Newton and John Locke.
Yes, I agree. I just don't know how to create a system where the strengths of such individuals are leveraged. If an organization of 100 people is trying to build a bridge and the tasks required are challenging for the 1-5 ADHD individuals in the group, the persons will struggle and the organization will struggle. Both individuals and organizations need to get better at routing those individuals to the right places to leverage their strengths. This is true of anyone but 10x more important for ADHD or other disabilities.
> The things he struggled to do were the accidental complexities of the job of professor, not the truly important aspects of that role.
I have mixed feelings about this because sometimes I have heard people dismiss aspects of work they're not good at as not important. E.g I have had sw engineers claim they solved the problem in their head and writing it down and communicating it to others is not important. At large organizations is just as important unfortunately.
Yeah, I get that. I guess when I say "important" I mean that we have hundreds of years' worth of examples of people doing great research and teaching without doing the kind of bookkeeping tasks that my dad couldn't keep up with (I honestly don't remember what they were, but it wasn't communicating—he's an avid writer).
There's no question that that part of the job isn't an inherent part of the researcher skillset, and to the extent that we need it to happen there's no reason it couldn't be either automated or done by a different group of people who have that skillset. For example, I often wonder how much we lost when having a secretary or executive assistant stopped being a available to anyone but the highest level employees.
This is pretty much what the social model of disability pushes: if society changed with a thought for all some of us wouldn't be as disabled - in my specific case reducing bright lighting, reducing noise pollution, and reducing specific smells would help me a stupendous amount.
Then a friend gave me some of his pills. I took them for a few days and for the first day of my life I understood how everybody else was feeling, how everybody else could be so confident, behaving confident, just being and feeling normal. I knew that feeling from rare occasions, the absence of all that struggle you are constantly feeling in your body. I had my first normal workday ever. Just going to work, doing work, having a break, later going home. I had never experienced that ever before. And still I didn't believe I had ADHD, never slipped my mind, lol. But then COVID hit and we went into lockdown and homeoffice and I could not work at all and I suffered immensly. I knew that feeling of "I want to do it SO hard, but I just CAN'T" very well, but this time it hit me very hard, for weeks. She convinced me to get diagnosed and here I am, it feels like a distant past already. It was like an instant switch, even though it's a journey to retrain my brain after for decades it had to come up with mechanics to deal with the disorder.
I know there many out there that are/were like me and I know there are many out there that had a quite different experience with their ADHD. Please don't walk around saying society is the problem. Society is not the problem when it comes to depression and it's not the problem when it comes to ADHD. A lot of people would benefit from a different society for sure, but for me and many others it's nothing more than a disorder. It was a miracle I could start a PhD to begin with (and of course getting my Master's was a constant struggle, just as my whole life had been miserable and a struggle). Many others end up drug addicted, dropping out ot school, having a clinical depression, and other nasty stuff. As all mental disorders, we do not know too much about it, but as a matter of fact the medication helps greatly and I am so glad I got finally diagnosed. Some that have ADHD do not suffer that much as I did, but a lot of do. I only wish that my disorder does not get misrepresented as "wouldn't be a big deal in a more open society".
However, what you describe feels to me like validation of my point, not a contradiction. Undiagnosed ADHD overwhelmingly becomes manifest in times exactly like what you describe—you were working on a PhD! You were overwhelmed by Excel. You hated repetitive tasks. COVID lockdowns were impossible for you.
The depression and anxiety associated with ADHD are not inherent to the ADHD traits, they're the result of feeling incapable to cope with the modern world. All of the things that you described as overwhelming are accidental complexity that we can and should get rid of. Being a great researcher shouldn't require all of the overhead that we impose on modern PhD candidates. Just living in the modern world shouldn't require all that overwhelming bookkeeping—as just one example, taxes and bills can be and should be mostly automated, but they're not. If you didn't have to keep track of a million tiny things in your life, would you have been anxious and depressed?
Again, in the present reality medication is hugely important for a lot of people like you. But that doesn't mean that the world shouldn't also change to not require keeping track of so many things that add so little value.
As already said, going for a walk was very difficult. Social interactions were very difficult and they can still be difficult when medication wears off in the evening. In general, all my life I wanted to do all kind of stuff, but couldn't. There's nothing society can do about that. It's not all about work either. So, to answer your question: Yes, I still would be anxious and depressed, because I was not able to do what made me relief stress and feel good in general.
I could've learned to be totally fine with ADHD, I was just too stubborn to build my life around that disorder. I kept doing what I wanted to do, not what I could do. I bet your father could've been a perfectly fine sports instructor or carpenter or find another fitting job. I certainly could've, but it luckily never slipped my mind. So we wouldn't need to adapt society, just teach people better what they can and cannot do. That's also much more realistic than "make jobs easier". I don't think, anyone should build his or her life around that disorder and I don't think society should. I did learn how to deal with it though and society should as well, of course. As often, it comes down to balance. A simpler life would've helped definetely.
I oppose your perspective in particular because it's mostly shared by people who deny that ADHD is a disorder, which is just wrong and terrible to think for many that are affacted.
The constant hope that "tomorrow I will go out and do the thing!" followed by the self imposed guilt of "why can I not just go out and do the thing."
For those of you afflicted with this curse, lookup Dr Russell Barkley’s videos on YouTube. He’s retired now, but was a great ADHD researcher. Really helped me understand what was going on.
You should look up other prominent ADHD experts like Ed Hallowell who have a more positive take.
Richard Feynman famously wrote "Science is the Belief in the Ignorance of the Experts". He meant, and explained that "science - a.k.a. research - is in the making, belongs to the (unknown, yet to be discovered) future, while expertise is based on the past, with in-built obsolescence".
My psychiatrist recommended Gabor Maté for what it's worth, but I prefer a really reductionist "it's all about dopamine" model. It might be simplistic, but it has the advantage of being concrete.
As a preface, just so you don't think I don't understand what you're talking about—my dad struggled to hold down a job for most of my childhood and finally got diagnosed with ADHD and started medication after he turned 50. I'm intimately familiar with the impairments that ADHD can cause and the real harm that is possible.
That, said, what you're describing is exactly the kind of modern overhead that I'm talking about—the modern world imposes a million little things to keep track of that ultimately shouldn't be required, which leaves us chronically falling behind on menial tasks. That leads to anxiety and depression that makes things even worse.
In the present reality, medication may be an appropriate patch to quickly restore sanity to people who need it, but I'm unconvinced that we should treat medicating a full 5% of the population for ADHD as a reasonable end goal. There are huge social movements for making accommodations for a portion of the population much smaller than that. There's no reason we can't make substantial changes to accommodate ADHD, especially given that said accommodations would really benefit everyone.
I've got no problem with the OXO Good Grips argument ("accommodations help everyone"). The only thing I'll take issue with is laying the blame at the feet of the modern world, because I know I'd be just as much of a flake if I lived in a village of 75 people and grew turnips for a living.
In fact, here's a quote from Chapter 1 of Hallowell's book:
>In the decades since that time, research has ballooned. Probably the most up-to-date and definitive account of the history and current state of the field is to be found in a book written by one of the great researchers in the area, Russell Barkley; currently in its third edition, his book is entitled, simply, Attention Deficit Hyperactivity Disorder
Maybe their tone is slightly different, but their descriptions of what ADHD is (not a society problem) and the solution they offer (lifestyle changes and medication) are pretty much the same.
This is the problem. Just because he is an expert doesn't mean ALL of his views are correct. For instance Dr. Russell Barkley believed earlier in his career that having sugar in the diet will make ADHD symptoms worse. Years later after much more research he found out that he was wrong and that people with ADHD should sip in a bit of sugared water to focus better.
This is the problem with building a cult around a personality. Science is basically built off of hypothesis. Some of which will be proven wrong by much further research.
There is this thing called Constraint-Induced Movement Therapy (CIMT) developed by Edward Taub, a behavioral neuroscientist. There was extreme skepticism and resistance from the established medical and scientific communities. Taub's work challenged the prevailing belief that little could be done to improve function in limbs affected by neurological damage. At the time, it was widely believed that once certain neural pathways were damaged, they could not be repaired or compensated for effectively. Over time, however, through persistent research and clinical trials, CIMT gained evidence-based support and has become a recognized therapy in neurorehabilitation.
My point is that we should not build a cult of personality and take everything an "expert" is saying as absolute truth. He is right about many things. He could be wrong about some things as well. That's not a bad thing. That is how progress is made.
There is research being done by those who have analyzed nomadic tribes and they found high levels of ADHD like characteristics in those tribe members. The study noted that the traits associated with ADHD, such as impulsivity and a short attention span, which are often seen as challenges in modern structured environments like schools and workplaces, might have been beneficial in the unpredictable and varied challenges of a nomadic lifestyle.
Just like when you are blind or lost an arm. It's not a problem because society is build around the assumption that people have two arms, it's not a problem because society is build around the assumption that you can see. We should help people to deal with this issues, but saying society is the problem is the wrong way to think about it.
If you can't provide something more substantial than vague insults then you're never going to persuade anyone of anything.
Maybe the medication is just scrutinized too much?
if kids can have ADHD surely adults can too. i feel that these types of critical pieces often embolden critics of mental health and i dont quite understand why these people feel so aggrieved by allowing people to participate fully in the modern world
ADHD is a real condition. People who have it suffer immensely from it. They don't have a sense of time. They don't have a sense of priority. They procrastinate tremendously. They are extremely forgetful and tend to get stuck in an unproductive rut. The moment they swallow a pill.. i.e Adderall, they stop being late. They turn in their assignments completely finished. They can remember better. They won't lose their jobs. They stop procrastinating that much. Basically, they get to be a functional human being.
But, someone who doesn't have ADHD only has their own frame of reference to judge ADHD. People without ADHD also have a tendency to procrastinate. They also tend to be late if they are don't care about being on time. They don't feel the motivation to show up for work etc. And yet, despite not having the motivation they FORCE themselves to show up for work. Despite having a tendency to procrastinate they FORCE themselves to not procrastinate because they know the payoff. They won't be late because they CARE and they know it is DISRESPECTFUL to make the other person wait. Why can't you use a reminder on your iPhone, Google Calendar etc? is their retort. If you are forgetful why don't you write stuff down?
Discipline is a muscle. The more you force yourself to use it the easier it gets the next time. ADHD isn't special. Even I feel like not doing things BUT I FORCE MYSELF TO DO IT.
Why can't you? Instead, you are choosing to take the easier route by swallowing a pill. This is the equivalent of someone choosing to take steroids to build muscle instead of putting in the hard work at the gym.
This is how a nonADHD person thinks. They are proud of working hard and they are proud of their accomplishments. Of doing hard things. Overcoming obstacles etc. But, when they see someone with ADHD struggle they just chalk it down to them being lazy. They don't understand that the ADHD brain is wired differently.
Again, this is not their fault. Human beings cannot relate to anything that is outside of their direct experience.
I don't think it's fully settled what percent of this increase is due to more ADHD in the population versus a change in standards (the second is not inherently bad).
Without reading it, you already know what to expect in terms of an opinion. I think it's probably more constructive to say that what we're calling ADHD is more likely several different though very similar disorders. Also worth noting is the comorbidity with autism and how many people have dual diagnoses.
I wish this was more common knowledge. I consider myself to be an incredibly voracious reader and I didn't learn this until recently (relatively speaking).
Why shouldn't healthy people have access to long-acting stimulants under the supervision of their doctor? Why limit healthcare to interventions that restore health to a minimal baseline? If as Dr. Goodman says, a pill can make the average adult happier, sharper, and more productive, why shouldn't everyone have access to it?
Amphetamines make everybody better. And if you take too much, they make everybody worse. Look at WWII soldiers, 1950s housewives or 21st century undergrads for examples.
I presume Adderall was approved based on tests that lasted a couple years at most. It definitely seems like there is a class of medicine that can be beneficial in the short-term but be likely to produce bad results over decades.
I assume opioids could fall into this category too. In the short-term they could make people happier and more productive, but also their is chance of developing a dependency that may not be noticeable in the data until much later.
If drug X was found to benefit 100% of people for the first 2 years of taking it, but 5% of people developed a dependency that landed them in rehab or worse after 5 years, would we want the FDA to approve it?
I have a lot of libertarian leanings so I am mostly fine with it, but it does seem like the boundaries for what we consider beneficial or not are pretty arbitrary.
In the case of Adderall, amphetamine was sold over the counter between the mid-1930s and 1964 (in the UK. Other countries, other dates) so there must have been a fair amount of additional research to take into account.
Interestingly, the first report of amphetamine being a treatment for what we would now call ADHD was 1937. We should have had this sorted out three generations ago; instead I coasted straight on through the school system in the 1980s without attracting a second glance.
I'm not saying I"m acutely worried about adderall, just the possibility there are drugs that take decades to show negative effects. It doesn't seem like the testing system we have in place would have any way to detect that.
You can replace 'stimulants' with 'alcohol' in the quote above and it will still be true.
Reading through the article, it definitely highlighted concerns I had about my process: lack of available providers (to the point that many wouldn't even accept a call from a new patient), essentially forced to use online services, relatively short discussions before treatment, and ultimately being prescribed stimulants.
Overall, I'm glad I started this process. I definitely feel better on the medication, to the point where I'm able to effectively track my daily tasking, keep cohesive notes, drastically reduce my unintended verbal interruptions of others, and churn work out without context switching so often. I obviously can work without the medication, but it's absolutely a night and day difference to me. Ultimately, I just hope that the progression of the adult ADHD diagnosis and discovery continues to mature, and online services aren't completely cut off from the space.
That said, the answer to "what is the solution" is that it takes time to figure out what the best treatment plans are and feedback success and failure into diagnostics. It is a process of never-ending improvement. For example depression was known to Hippocrates and despite that multiple thousands of years of history we still don't have a 100% success rate diagnostics and treatment for it. Adult ADHD is only about 10 years old. Odds are by the time it grows up the current symptoms will lessen. But in the meantime, people seeking treatment for it should be aware that they are part of an ongoing experiment, i.e. they are in the Wild West.
Takeda (who manufacture Elvanse in Europe) are being very coy about what "manufacturing issues" means. Their latest estimate for a return to full production is Q2 2024, but it's slipped before.
/r/adhduk is quite good at tracking updates around shortages.