Getting The Right Diagnosis
In the practice of medicine, physicians will come across patients who present with unofficial self-diagnosis at some point in their careers. Patients who have basically identified themselves as having a certain condition. Well, who knows their own bodies better than a patient themselves, right? Well yes, and no. Not as it relates to diagnosis. Additionally, many practitioners, possibly more mental health practitioners, will come across individuals who are misdiagnosed or undiagnosed. This is not criticism of the mental health field, but more the nature of the mind being an abstract concept and behavioral and mental changes across the lifespan. And with the mainstay tool for diagnosis of mental illness being an interview, it can be a difficult endeavor. It is a less concrete specialty. This can be sometimes be seen in cases of Attention Deficit Hyperactivity Disorder (ADHD) and addiction.
On one hand, a patient recognizes “something is wrong” with their body as they present with the signs and symptoms, and on the other hand the medical practitioner properly assesses these signs and symptoms. There are many factors that need to be considered when any diagnosis is made. Appropriate history taking, physical and mental examinations, relevant diagnostic testing such as blood work or scans, the training and expertise of the clinician, the motivation and reliability of the patient, as well as many other factors need to be considered. One very important factor as it relates to substance use disorders especially, is the chronology and the context in which the signs and symptoms are occurring. This helps with both the diagnosis, as well as ruling in or out other differential diagnoses mainly due to the fact substance and alcohol use/misuse can mimic or mask many different mental health and physical conditions.
Are ADHD And Addiction Associated?
When it comes to the practice of addiction medicine, one diagnosis that appears to occur often is Attention Deficit Hyperactivity Disorder (ADHD). Studies have looked into ADHD itself to see if it is a risk factor for future substance use, and to see if undiagnosed or untreated ADHD is associated with future addiction. But often in clinical practice, ADHD is diagnosed at a time when substance use disorders are being treated. These times may be when someone is in detox or rehab, or someone intoxicated or in withdrawal ends up in the emergency room, hospitalized, jail, or they are involuntary admitted to a psychiatric unit.
Therefore, an important question arises: is it the drugs that are causing these symptoms or is it a true ADHD? This is a huge question and one that needs to be asked by both the patient and the clinical practitioner. I highlight ADHD here in this article, but this could apply to any condition which substance abuse mimics or is the result of, from depression to bipolar disorder or psychosis.
Breaking Down ADHD
Attention Deficit Hyperactivity Disorder, more commonly known as ADHD, is a neurodevelopmental disorder often diagnosed in childhood, where the prevailing symptoms of inattentiveness and/or hyperactivity cause impairment of functioning in two or more major areas of someone’s life. Often this is seen first in children, when after passing through stages of life where being hyperactive, restless, or inattentive is part of development, are subsequently identified at school as, compared to their peers, being persistently more hyperactive, inattentive, or the combination of both. And because of these features, their academic performance and subsequent success in multiple areas of life is being affected, and often is convoluted with co-occurring mental or behavioral disturbances.
What about in adults? There has been recent question as to if ADHD can, “begin or have onset in adulthood.” So far, this has not been accepted into the diagnostic criteria, so it still remains that a ADHD diagnosis still has to have some symptom onset in childhood. So, what happens when adults are struggling with inattention, having difficulty concentrating, and/or feeling restless where it is felt to be causing dysfunction in multiple areas of their lives from work to their personal relationships? This is a common question that occurs, but sadly, when it comes to those who suffer with addiction, may be inadequately treated or inappropriately diagnosed.
ADHD And Addiction
It is important for those who suffer with addiction that before they jump to any conclusion that they have ADHD, they receive a proper assessment by a professional who specializes in diagnosing such conditions. For example, psychiatrists, certain neurologists, psychologists, and clinicians proficient in mental health diagnosis. The assessment should take into consideration symptoms which occur, “while not being on the drugs of abuse” and placed in appropriate chronology and context. Criteria for the diagnosis has to be met, even unspecified diagnosis, and those symptoms which occur exclusively during or secondary to substances of abuse do not qualify. Many conditions other than ADHD can cause someone to feel or be “inattentive” as manifested by having difficulty concentrating, focusing, sustaining attention, and struggling to stay on task. Feelings of restlessness, fidgetiness, or hyperactivity may occur as well. These conditions can include depression, anxiety, bipolar disorder, thyroid and other metabolic conditions, neurological conditions, and even stress as well as substance use and addiction.
During my time in practice, I have assessed many people that report having ADHD because someone else diagnosed them or they feel they have it. After proper evaluation, their symptoms were purely secondary to their alcohol or substances of abuse. However, it becomes difficult for the patient to give up that identity. They are so accustomed to taking a “pill” to gain mental clarity or focus, they don’t want to hear that they do not have ADHD. Mind you, many patients also do have ADHD and need to be properly treated, but the caveat here is that drug and alcohol abuse screws up our brains and not taking that into consideration when diagnosing ADHD is simply wrong.
Unfortunately, addiction is hallmarked by certain characteristics, such as the inability to abstain from drugs/alcohol, behavioral loss of control, cravings, dysfunctional recognition of negative consequences, and emotional ups and downs. Additionally, those suffering from addiction often have the inability to tolerate negative situations and the inability to delay one’s self-gratification. This can be a dangerous combo when mixing an inaccurate diagnosis of ADHD with their substance use, where stimulant medication is a mainstay of treatment, yet one that is simultaneously abused. Yes, people suffering with addiction often abuse well intended medication and manipulate their presentation when drug seeking. If you get high over time, your brain gets fried, you don’t think rationally, you can’t focus, you can’t think, and you need something to fix that. It’s like speed balling. This is difficult for someone struggling with addiction as impulse control is a major problem, and if truly diagnosed with ADHD, it’s a double whammy. True ADHD is not simply symptoms caused by the substance of abuse or long-term brain deconditioning.
I would compare it to someone who historically was able to work-out, run 5 miles, lift weights, felt strong, and was eating right. Who then, after no longer following their routine, performs no exercise, gets deconditioned, eats poorly, and attempts to go back to working out and cannot lift the same weights or perform the same way. Imagine if they ask a doctor for steroids to get back in shape. Let us even consider this. It may be that the person has a true hormone deficiency or medical issue which led to their inability to perform like before and should be properly evaluated. But, most often, it is the poor nutrition, the lack of activity, and the deconditioning that has resulted in their body not performing as it did.
The same goes for problems focusing, paying attention, and concentrating like once before after using drugs. Asking for a stimulant to help focus or to be diagnosed with ADHD in the context of substance use is not correct. Don’t ask for the steroid; try and get back in shape. Get treatment, stop the drugs, get a proper assessment that takes a comprehensive history and information from multiple sources. Not just symptoms while using drugs.
If you are diagnosed with ADHD or believe you have ADHD, please speak with you doctor. Be honest to the best of your ability. Below you will find a review of the diagnostic criteria for ADHD.
Diagnostic Criteria For ADHD
According the DSM-V, Diagnostic and Statistical Manual of Mental Disorder, 5th Edition, the following criteria exists regarding ADHD:
ADHD Symptoms and/or behaviors that have persisted ≥ 6 months in ≥ 2 settings (e.g., school, home, church). Symptoms have negatively impacted academic, social, and/or occupational functioning.
In patients aged < 17 years, ≥ 6 symptoms are necessary; in those aged ≥ 17 years, ≥ 5 symptoms are necessary.
Inattentive Type Diagnosis Criteria
- Displays poor listening skills.
- Loses and/or misplaces items needed to complete activities or tasks.
- Sidetracked by external or unimportant stimuli.
- Forgets daily activities.
- Diminished attention span.
- Lacks ability to complete schoolwork and other assignments or to follow instructions.
- Avoids or is disinclined to begin homework or activities requiring concentration.
- Fails to focus on details and/or makes thoughtless mistakes in schoolwork or assignments.
Hyperactive/ Impulsive Type Diagnosis Criteria Hyperactive Symptoms:
- Squirms when seated or fidgets with feet/hands.
- Marked restlessness that is difficult to control.
- Appears to be driven by “a motor” or is often “on the go.”
- Lacks ability to play and engage in leisure activities in a quiet manner.
- Incapable of staying seated in class.
Overly Talkative Impulsive Symptoms:
- Difficulty waiting for their turn.
- Interrupts or intrudes into conversations and activities of others.
- Impulsively blurts out answers before questions completed.
Additional Requirements for Diagnosis:
- Symptoms present prior to age 12 years.
- Symptoms not better accounted for by a different psychiatric disorder (e.g., mood disorder, anxiety disorder) and do not occur exclusively during a psychotic disorder (e.g., schizophrenia).
- Symptoms not exclusively a manifestation of oppositional behavior.
Classification Combined Type:
Patient meets both inattentive and hyperactive/impulsive criteria for the past 6 months.
Predominantly Inattentive Type:
Patient meets inattentive criterion, but not hyperactive/impulse criterion, for the past 6 months.
Predominantly Hyperactive/Impulsive Type:
Patient meets hyperactive/impulse criterion, but not inattentive criterion, for the past 6 months.
Symptoms may be classified as mild, moderate, or severe based on symptom severity.