Does Adult ADD Really Exist?

Some people wonder whether the diagnosis of ADD makes any sense.  So many people have symptoms of ADD, like forgetfulness, procrastination, and disorganization.  Maybe ADD is just a faddish diagnosis of the month.  A number of observations and facts make me think otherwise.

It may be true that everyone has some symptoms of ADD.  But it is also true that everyone has had some symptoms of pneumonia: cough, fever, and headache.  The difference between pneumonia and a cold is 1) the symptoms of pneumonia are much more severe, 2) the effects of the symptoms on people's lives is much greater, and 3) patients with pneumonia respond to treatment designed to treat pneumonia.  

The symptoms of ADD include procrastination, memory problems, distractibility, reading problems, a tendency to interrupt others when they are talking, and poor organization.  They also include difficulties prioritizing, focusing, maintaining concentration, following a conversation, being on time, and completing tasks.  Having one or two of these symptoms is like having a cough;  living with nine or ten of them is more like having chronic pneumonia.

But it is not just the number of symptoms that differentiates ADD.  For a person to qualify for the diagnosis of ADD, the severity of their symptoms should rise significantly above the level at which they are commonly seen in the general population.  There should be more than just a few symptoms, and they should contribute to significant impairment in functioning in work, schooling, social life, and/or family life.  Because of their symptoms, a person with ADD may lose friends and jobs, get multiple speeding tickets, be rejected by their spouse, or engage in destructive impulsive behavior. 

While the disorder usually is first seen in childhood, people with strong intellectual skills or determination can often compensate for their symptoms by working long after others have stopped.  Often symptoms first become apparent only when the demands of school or work exceed the individual's ability to compensate.

The diagnosis requires that other explanations of the symptoms be excluded.  These include chronic tiredness from sleep apnea, medical problems, neurological problems, hearing problems, true laziness or irresponsibility, a learning disorder, thyroid problems, etc.  Sometimes the symptoms of depression and anxiety can cause ADD-like symptoms. 

But the reverse is true as well.  Failures caused by ADD can often cause depression or anxiety.  If this is the case, patients will not respond to anti-depressants or anti-anxiety medications but may feel better only when their ADD symptoms disappear after they have taken an ADD medication.

Unfortunately there is no psychological, chemical, or X-ray test that makes the diagnosis.  It can only be made on the basis of a careful examination of a person's lifelong functioning. 

The diagnosis is made more difficult by the fact that many people with ADD can operate quite normally in many circumstances, for example, when there is a imminent deadline for them to finish a task, when they have just physically exercised, when they have had a lot of caffeine, or when they find a task (or a game) particularly interesting. 

This normalizing effect of stress often occurs during a person's first visits to a doctor for an ADD evaluation.  If the doctor doesn't take this into account, he or she may dismiss the possibility that the patient has the disorder because, during those visits, the patient was quite focused and attentive.  Of course, it is true that almost everyone is more focused when there is more pressure, but the difference in ability to focus with and without pressure is much greater in patients with ADD. 

It is interesting that the situations in which people with ADD function better are ones in which their adrenalin is running high, when they feel pumped up.  And when their adrenalin is low, like when they are bored or when they are sleepy, their adrenalin levels get lower, and their symptoms get worse.   

It is no coincidence that the most effective treatments of ADD are the stimulants, which in many ways mimic the effects of adrenalin.  While they can make some people who don't have ADD somewhat more alert and focused, their effects on people with ADD is much more dramatic.  Because of this adrenalin-like effect, people sometimes feel anxious until they get used to the medication, it sometimes raises their blood pressure, and it can interfere with sleep.

Of course, medication is not a panacea: only 75% of patients with ADD have an effective response, and the response can vary from mild to dramatic.  And there is no way to predict which patient will respond well and which won't.  The medications may have side effects and very rarely seriously adverse effects, including death among a small number of people, usually those having coexisting heart disease.  (Be sure to discuss this with your doctor before you begin treatment with any medication.)

Some people with ADD can benefit from behavioral coaching.  Many can get help from mutual support and education groups for individuals with ADD.

ADD, as described above, occurs in about 1 of twenty people.  Most adults and children who have it are not diagnosed or treated for it, but it is also true that the diagnosis, or label, is often misapplied to many people, especially children, who don't have it. 

I have practiced psychiatry for over thirty years and treated a wide variety of disorders.  No disorder that I have treated has generally responded so well and so quickly to treatment as ADD has to treatment with stimulants.  And no treatment that I have used over the years has had so few side effects or has been as safe as the stimulants.  I have seen more than a few adults' eyes tear up as they described the remarkable effects of the medication has had on their lives and as they thought about how many enjoyable years and opportunities they had missed because they were not able to focus and concentrate effectively.  Only after they were treated did they become who they always felt they could be.

ADD does exist, and its symptoms usually respond well to the proper treatment.

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