What should I expect from my ADHD assessment?
June 20, 2013 7:55 AM   Subscribe

Going to a specialist ADHD clinic for an assessment next week. So far I'm (blech, I'm the worst) self diagnosed. What should I expect? I'm willing to go on medication but concerned that stimulants will make me anxious and crazed.

There was no one incident that made me finally seek treatment. In hindsight, I almost definitely had clinically significant problems with attention. I was a daydreamy kid (FWIW, I'm also female), and I almost entirely mentally checked out of all of my classes. I just missed out on the great ADD panic of the early 00s, which actually makes me a little sad.

While I have a desirable job and am making progress in my career, my biggest concern is that I'm really not reaching full potential because (a) my attention span blows and (b) I just feel mentally foggy and fatigued much of the time. In terms of A, I've tried every mind hack out there - timers, blocking software like Freedom, locking myself in a room away from every electronic device. I get distracted by the Internet very, very easily. In terms of B, I just feel... tired. I walk into the office and I instantly feel exhausted. I work a fairly normal 50-60 hour week, with just a couple of weekends in the office a month; I work out; I do my best to eat a fairly clean protein-heavy diet; but I'm still foggy and fatigued. I increasingly find socialising exhausting. I often find myself fidgeting in meetings to stay awake.

I feel both are caused by some kind of ADD. I feel like I have something to add to the world in terms of my creative work, but this is stymied by my inability to pay attention, focus or sometimes to even stay awake. Obviously, this is giving my self-esteem a real hit, too. I'm hoping to find ways to, well, put on my big girl panties and get some fucking shit done and lose the fogginess and sluggishness. When I was a kid my mum used to complain that I was always unfocused and, in her words, 'duh duh' (this was said jokingly, but it was true, I was always dreamy and unfocused as a kid), and I haven't outgrown it and it's bumming me out.

FWIW, I've spent years in therapy, and the clinic combines comprehensive talk therapy with medication, so I won't just be depending on drugs to address these problems. I'm definitely nowhere near a crisis point, I just want to deal with my issues with work and focus.

So now that the backstory is out of the way, here are my questions:
  • So what should I expect from the two hour intake interview and physical?
  • What concerns should I raise?
  • Is there any way to avoid stimulants or amphetamine drugs? If a drug can give me tachycardia it will - a dose of Voltaren once put me in hospital - and while I know a racing heart isn't at all harmful it feels awful and I am prone to anxiety and jitteriness from stimulants.
  • If you're on medication for ADD, has it relieved your fatigue and sleepiness?
posted by anonymous to Health & Fitness (13 answers total) 11 users marked this as a favorite
I'm a 32 year old woman who recently started ADD meds (although I was diagnosed as a child with atypical ADD -- no drugs because I did well in school -- benefits of hyper focus!)

I didn't have as detailed of an intake as you are describing, but I was put on a low dose of amphetamine. There are other drugs if you are sensitive to those -- I had tried Strattera a few years ago and it gave me horrible nightmares which cause paranoia and that is what turned me off from meds for a long time.

For me, the meds have greatly reduced my anxiety. I think that is because I'm able to handle it better without a million thoughts going through my mind at once. Although, I was struggling with anxiety already and was considering meds for that as well.

I am much more alert (sometimes too alert) on the meds, and I have to be careful when I take my pill as sometimes I stay up way too late (when I used to be dragging at 9pm).

I would definitely share all your concerns with the psychiatrist, and don't expect the meds to solve all. I'm in therapy as well and the goal is to make it easier to do the work on myself, not to have the meds do the work.

Good luck, and feel free to memail me.
posted by hrj at 8:05 AM on June 20, 2013

As a 40-yr-old woman, I was just diagnosed with ADHD & put on adderall. I figured it would make me even more spacy (speed when I'm already hyper?) but it actually speeds up the parts of my mind that are not able to keep up so I can focus without going all SQUIRREL!

I also have a history of tachycardia caused by a prior medication but it's been long enough and I'm in good enough health that we decided to roll the dice and so far no issues.

And I don't fall asleep at my desk any more! I still get a good night's sleep like I did before; it wasn't fatigue from lack of sleep, but apparently that's something that an ADHD brain does; it gets overloaded and shuts down. And here I thought I was just not getting enough sleep.

Seconding hrj: talk with your doc about any and all concerns. There are several meds out there that can help.
posted by tigerjade at 8:33 AM on June 20, 2013

Is there any way to avoid stimulants or amphetamine drugs?

Absolutely. I took Strattera, which is neither, and supplemented with the generic form of Wellbutrin when side effects meant I had to cut back on the Strattera.

There's most likely other meds out there as well, those are just the ones I know of.
posted by telophase at 8:40 AM on June 20, 2013

You should be prepared for the possiblity that you may not receive a positive diagnosis. 50-60 hours a week (plus a commute?) and some weekends in the office is enough to exhaust most people mentally, especially if you aren't particularly engaged in your job or field. Not every impediment necessitates a medical diagnosis, so you should be prepared in case the solution is not really evident because it turns out you don't have ADD.

It can suck to be told that there's nothing medically wrong with you and you just need to pace yourself and reduce stress when you're frustrated and looking for a magic cure.
posted by WeekendJen at 8:54 AM on June 20, 2013 [3 favorites]

In my case, I'd been in therapy for depression (not a new diagnosis) for nearly a year before I self-diagnosed ADHD, and when I mentioned it to my therapist she said she'd been suspecting that too. She basically asked me 20 questions ("on a scale of 1 to 5" type stuff), then sent a referral to my GP, who said therapist recommendation was sufficient to give me the Adderall prescription.

Adderall is a great, great thing for my brain. I work super fast and get bored really easily, and while Adderall doesn't magically create more work for me, it does help the time pass faster and keeps me from just endlessly circling in my brain going "AAAGHH I'M SO BORED". I'm supposed to take 20mg twice a day but I can make a 30-day supply last over two months, both because I'm paranoid that taking it too frequently will build up a tolerance, and also I just plain forget to take my morning pill despite my calendar notifications and then by the time I remember I feel like it's too late in the day to take one without being up all night. When I do remember (like today! and I feel really good right now because it takes about 2 hrs to kick in for me and I took it 2 1/2 hrs ago!), I usually just take the morning pill and skip the lunch one unless I know there's something coming up later in the day that I definitely have to be "on" for (which isn't often).

Yes, it does relieve the fatigue/sleepiness. I had been a fatigued/sleepy person before, but I never really realized how bad/abnormal it was until after I had some Adderall days to compare to. Yesterday I took no pills and I felt so blaarghh by 5 PM and I was kicking myself for not having taken one.
posted by agress at 8:54 AM on June 20, 2013

It's great that you're getting an assessment and the chance to combine meds and coaching/therapy, because that is the combo likeliest to help you. I hope the doc will use a instrument such as the Conners or Brown ADHD Scale to help assess you rather than an informal screening. You seem to have realistic expectations of what meds can and cannot do, which is a good start. The psychiatrist who prescribes your meds should take a careful history before prescribing anything. If you start stimulant medication, they will taper you up to see what will give you maximum benefits at the lowest dose possible.

One nice thing about ADHD stimulant meds is that you can usually tell right away if they are helping. If you tolerate instant release meds well, the doc will likely put you on an extended release version, which has smoother action. Be sure and ask the doc anything you want to know. If he or she is good, no question is stupid or too small to answer.

Anecdata + snowflaky details: I was diagnosed in my late 40s. I'm medicated for my hypertension (irbesartan) and anxiety (Celexa and Buspar). I was apprehensive about taking stimulant meds for these reasons, but I tolerate Ritalin/Concerta very well after increasing them slowly and seeing the pdoc weekly for a while for vitals monitoring. I haven't tried Strattera, but I'd like to. YMMV as with all psych meds.

I have many of the same symptoms as you (especially that fogginess and sleepiness when I'm not very engaged in a task). I'm inattentive/impulsive, and before meds I often felt like I had a full tank of gas but no spark plugs. Now the spark plugs work and the motor turns over. Also, if I encounter an attention rabbit hole (e.g., internet) I can get out faster when I'm taking my medication. (Set switching is an executive function we ADDers have trouble with!)

Bonus video--I have used it with clients (I am a therapist, but not your therapist) who have adult ADHD and one said she found it "funny and kind of profound"--you may see yourself in it.

Sh*t no ADDers Say

I wish you luck!
posted by sister nunchaku of love and mercy at 9:10 AM on June 20, 2013 [1 favorite]

Your severe fog and fatigue sounds as if it could be more than just ADHD. There has been some research lately suggesting that some cases of ADHD may also involve obstructive sleep apnea or other sleep disturbances. (Please note that you can be quite young and fit, yet still suffer from apnea.)

Can you ask your doctor to book a sleep study to rule that out?

Ann Clin Psychiatry. 2011 Aug;23(3):213-24. Is obstructive sleep apnea associated with ADHD?
BACKGROUND: It has been suggested that obstructive sleep apnea (OSA) may result in symptoms similar to those experienced in attention-deficit/hyperactivity disorder (ADHD). Because this may have important public health implications, we reviewed the literature regarding this association, with a focus on interventional studies examining the effect of OSA treatment on change in ADHD symptoms.
METHODS: We performed a systematic literature search of PubMed, along with other major databases, for interventional studies published between January 1966 and June 2010 that examined the effect of OSA treatment on ADHD, which resulted in 6 studies. The literature on the prevalence of ADHD symptoms in OSA and vice versa was also reviewed.
RESULTS: Attentional deficits have been reported in up to 95% of OSA patients. In full syndromal ADHD, a high incidence (20% to 30%) of OSA has been shown. All 6 interventional studies reported improvements in behavior, inattention, and overall ADHD after treatment of OSA.
CONCLUSIONS: OSA may contribute to ADHD symptomatology in a subset of patients diagnosed with ADHD (DSM-IV criteria). Treatment of OSA appears to have favorable effects on ADHD symptoms. Controlled trials and epidemiologic investigations will be required to better understand these relationships, as well as their diagnostic and prognostic implications.
NY Times: Diagnosing the Wrong Deficit
A number of studies have shown that a huge proportion of children with an A.D.H.D. diagnosis also have sleep-disordered breathing like apnea or snoring, restless leg syndrome or non-restorative sleep, in which delta sleep is frequently interrupted. ...

Sometimes my patients have resisted my referrals for sleep testing, since everything they have read (often through direct-to-consumer marketing by drug companies) identifies A.D.H.D. as the culprit. People don’t like to hear that they may have a different, stranger-sounding problem that can’t be fixed with a pill — though this often changes once patients see the results of their sleep studies.

Beyond my day job, I have a personal interest in A.D.H.D. and sleep disorders. Beginning in college and for nearly a decade, I struggled with profound cognitive lethargy and difficulty focusing, a daily nap habit and weekend sleep addiction. I got through my medical school exams only by the grace of good memorization skills and the fact that ephedra was still a legal supplement.

I was misdiagnosed with various maladies, including A.D.H.D. Then I underwent two sleep studies and, finally, was found to have an atypical form of narcolepsy. This was a shock to me, because I had never fallen asleep while eating or talking. But, it turned out, over 40 percent of my night was spent in REM sleep — or “dreaming sleep,” which normally occurs only intermittently throughout the night — while just 5 percent was spent in delta sleep, the rejuvenating kind. I was sleeping 8 to 10 hours a night, but I still had a profound delta sleep deficit.
posted by maudlin at 9:19 AM on June 20, 2013

I've been diagnosed by both a neurologist (as a child) and a psychiatrist as an adult.

Your initial session will probably be a lot of talking about your current symptoms and about how it was growing up. If you have any recent bloodwork, bringing the results is a good idea. You will likely be sent for labs if you don't have recent ones.

Definitely mention the issues you have had tolerating stimulants in the past, that's really important. I take a stimulant (concerta) and my doctor has sent me for EKGs and every visit asks me if I am having heart palpitations, anxiety, etc. and checks my blood pressure, because medication should not be causing those things.

As others have mentioned, there are other medications that can be helpful for ADHD that are not stimulants.

I do find myself more awake and alert in the morning when I take my Concerta. My doctor told me to cut out the caffeine, so I don't have that anymore. However, since you mentioned that you want to avoid stimulants, this might not be applicable to you. I previously took Strattera and while it was somewhat helpful, it made me sleepy.
posted by inertia at 9:22 AM on June 20, 2013

You might also have your thyroid checked--brain fog is a symptom of an under-active thyroid,
posted by Ideefixe at 10:08 AM on June 20, 2013

My experience with stimulants is that I feel calmer, happier, and less anxious on them. A feeling of being "buzzed", hyper, anxious, or "sped up" would probably indicate you either do not have ADHD or you are taking too high of a dose of medication. Certainly a psychiatrist would be evaluating you regularly to make sure that you're on the right track. Sometimes you need to try a few different ones before you find the right one for you.

If you do have ADHD and you are properly medicated, the brain fog will go away. You will feel normal. It is life-changing.
posted by annekate at 10:21 AM on June 20, 2013

Yeah, all due respect, it sounds like being unfocused would be totally normal in your situation. I was diagnosed as an adult--and had trouble just holding down a job for more than a few months at a time. If fatigue is involved, it's not ADD, and I don't think anybody's really meant to handle a 60 hour week at peak performance. (I'm on a stimulant and, I mean, yeah, it wakes me up, but the ADD never made me tired in the first place, except insofar as sometimes the stress of poor coping kept me up nights. I don't think I could handle that kind of work schedule even now without abusing my medication.)

But. That said? Just go in, be honest, and be open to whatever solutions present themselves. I got a lot of help out of therapy and coaching to find better ways to deal with the things that medication was not going to fix. Some people do very well on medications that are not stimulants. You don't necessarily need this diagnosis; you need something that helps you with the specific problems you have.
posted by Sequence at 10:21 AM on June 20, 2013

So what should I expect from the two hour intake interview and physical?

They'll probably ask you a lot of questions about your childhood. Many psychiatrists won't assign a diagnosis of ADHD if the symptoms haven't been present from a young age, and frankly I'd be skeptical of one who would.

What concerns should I raise?

Mostly I would just be forthright about your history with regards to tachycardia and anxiety.

Is there any way to avoid stimulants or amphetamine drugs? If a drug can give me tachycardia it will - a dose of Voltaren once put me in hospital - and while I know a racing heart isn't at all harmful it feels awful and I am prone to anxiety and jitteriness from stimulants.

Yes, Strattera is one such medication. It is technically a stimulant (since stimulants comprise a broad and somewhat fuzzy category of drugs that achieve their effects by a wide variety of mechanisms), and so like others in its class it does have varying effects on heart rate and blood pressure, but those tend to be significantly less pronounced in the case of Strattera than in the case of amphetamine- and methylphenidate-based drugs. In general, though, I wouldn't go in to this with the resolution to take a certain drug. It is good to be aware of what your alternatives are when you go into an appointment like this, but the best result usually comes from communicating your concerns and your history clearly, and then expressing your doubts if you have any based on your knowledge of the available options.

If you're on medication for ADD, has it relieved your fatigue and sleepiness?

I take Strattera, and even given what I said above about it not being as actively stimulating as something like Adderall, yes, absolutely. It just makes me feel normal, as opposed to the feeling I used to have of slogging through cognitive molasses when it came time to focus on something. It's worth noting though that a lot of people with ADHD report paradoxical reactions to stimulant drugs, where instead of waking you up they put you straight to sleep. That happened to me on a lot of occasions when I used to take Adderall. This isn't so much something to be concerned about beforehand, but just remember down the line that it's not an unheard-of reaction to stimulants if that's the treatment you end up receiving.
posted by invitapriore at 10:51 AM on June 20, 2013

The dosage of amphetamines that most ADHD people are on is way, WAY lower than recreational doses. Caffeine affects me way more than amphetamine as far as nerves, anxiety and jitters go.

One caveat: my tolerance for caffeine went WAY down when I started taking ADHD drugs. A little goes a long way now. This can be hard to adjust to because it just feels wrong to not be wired on caffeine all the time.

And yes- let the doctor do his or her job. Relate your concerns and the problems your symptoms cause in your life and especially what you've already tried (counselling) and ask them for help. If you did not have these symptoms when you were in school, you will not get diagnosed with ADHD. It's a lifelong structural issue that isn't necessarily always obviously symptomatic, but it's always there. If it wasn't always there, you have some other issue and getting stimulants is probably not a good idea.

If the doctor does diagnose you and gives you the option to choose, start with Adderall XR. It doesn't last as long as the newer amphetamine, Vyvanse, and its quick onset and relatively quick drop off will help you be more aware of whether your symptoms are being helped or not.

If you are worried about side effects, start on a lower dose. Explain to the doctor that you'd feel most comfortable starting slow and easing into whatever treatment you may use.
posted by gjc at 8:52 PM on June 20, 2013

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