ADHD despite great working memory and processing speed?
May 9, 2016 8:30 PM   Subscribe

What could cause lifelong symptoms of inattentive ADHD in someone whose working memory and processing speed appear to be functioning spectacularly well? My cognitive assessment results have me baffled.

I am a female in my early 30’s who was diagnosed with ADHD-I about ten years ago. It’s pretty severe; medication helps a LOT but I’m still quite impaired. I recently completed a battery of neuropsych tests and received the results last week. It turns out that my Processing Speed and Working Memory scores were “Very Superior” - in fact, I got perfect scores on the entire Working Memory section (>99.9th percentile). None of my other results revealed any impairment whatsoever. The psychologist therefore decided not to diagnose me with ADHD at all - just Major Depressive Disorder with anxious distress. Her implication was that the “ADHD” is some kind of obsessive psychological hypochondria.

This is surprising because I assure you that in my daily life my supposedly superior working memory isn’t much help to me at all. I am extremely forgetful, especially without ADHD medication. I forget what I’m saying in the middle of saying it. I misplace and lose things constantly. I enter rooms and forget why I did so. After meeting with the psychologist I was like “Well am I just delusional?” and asked a couple family members to fill out third-party ratings about me, and they confirmed that yes, I am a spacey, scatterbrained, distracted mess (the one context when loved ones saying those things comes as a relief).

I understand the psychologist's position, but I am disappointed and frustrated that she decided that my ability to sort numbers in my head overrides my entire actual lived experience and the fact that I still actually meet the diagnostic criteria for ADHD-I. My newish psychiatrist requested this evaluation and I am concerned that he will no longer prescribe me ADHD medication based on the results (the psychologist told me that she felt the medication was a “band-aid” and a coping mechanism for my anxiety, and helps me because it helps everyone focus better - “that’s why college students use it to study”). I was also hoping to use the assessment to request graduate school accommodations for my attention problems but I obviously can’t do that now. And I just feel bad because, as if I wasn’t already hard enough on myself, it’s like “See, you have no excuse - you shouldn’t be like this. Get it together already."

In another sense, I’m glad to have the results insofar as they provide me with additional data. That I still struggle with these symptoms despite having no working memory problems per se is interesting and perplexing. Any thoughts as to what to look into next? I’ve had basic blood & thyroid tests - all normal. I’ve been on a ton of different meds, and in many different kinds of therapy, for depression, anxiety, and ADHD, and they’ve all been helpful to different degrees.
posted by anonymous to Health & Fitness (15 answers total) 19 users marked this as a favorite
Hm. I am a high functioning ADD person as well and I think I'd get a 2nd opinion on this...or just shrug it off and continue current treatment approaches. As I'm sure you know ADD/ADHD is a lot more about executive function than memory and processing speed. I'm surprised your doc didn't go into that and justify why she thought it was relevant.
posted by Miko at 8:34 PM on May 9, 2016 [5 favorites]

Huh. I have ADHD but a pretty steel-trap memory for a lot of things. Just anecdata, but I know a lot of people like myself who have ADHD but were able to coast by in school on the strength of their memory. IIRC correctly, according to the DSM, there is no one symptom that can be used to diagnose or rule out ADHD. Also, yeah, ADHD meds help everyone focus but they otherwise have pretty different effects on people without ADHD (i.e., make them feel speedy).

I would go back to your pdoc with these concerns. It sounds like the psychologist has a pretty narrow definition for ADHD, which may be fine but it's not supported by the DSM.
posted by lunasol at 8:38 PM on May 9, 2016 [4 favorites]

I just Googled up this thing that shows six clusters of impairment for ADD/ADHD, and working memory is only one. So at a minimum, it would seem like not having your issues show up in one cluster still leaves open possibilities of impairment in the other 5. Sorry I don't know more about this clinically, but I do think you are well advised to push the issue.
posted by Miko at 8:39 PM on May 9, 2016 [3 favorites]

I have an extremely strong visual and aural memory, but before Adderall, my impulse control was pretty poor. I also had trouble following directions, reading maps, and some other tasky stuff. I would get a second opinion, preferably from a neurologist (neurologist/psychiatrist is even better. Psychologist is not an MD.) ADD/ADHD is brain chemistry, not mood disorder.
posted by Ideefixe at 8:48 PM on May 9, 2016 [1 favorite]

Another high-functioning, inattentive-type ADD female here, diagnosed in my late 30s, validating everything you and the commenters above have said. Throughout my life, some facets of my ADD have made certain things really difficult, while other facets have made me really good at certain things. I've learned to hide the former and make sure people see the latter, so my struggle now is convincing people that no, really, I do have ADD, it's just not what you think of as ADD. And I think maybe your psychologist might have some pre-defined ideas of what constitutes ADD that are not helpful to you.

I recently came across some articles about how differently ADD is experienced -- and (under)diagnosed -- in girls and women. After reading one article, I searched out others, and the things they say were total light-bulb moments for me. The takeaway is that the DSM criteria for ADD fit young boys -- one of the criteria being that symptoms appear by age 7, which is not how it works in girls -- but they do not apply well at all to girls or women.

Check these articles out: 1, 2, 3. Then, maybe revisit the psychologist with that info, or find another who understands that the diagnostic criteria and the testing for ADD were designed based on, and developed for, people whose ADD doesn't look like ours.

Most of all, keep in mind that you deserve treatment as much as anyone else with ADD, and advocate like hell for yourself.
posted by mudpuppie at 9:04 PM on May 9, 2016 [11 favorites]

(schpeal about being a mental health clinician in training, but not your mental health clinician in training)

1. You did not mention taking a classic response inhibition and attention task such as the TOVA. In terms of neuropsychological data with regard to inattention and neuropsychological impulsivity, this kind of examination is the gold standard (though in and of itself needs to be contextualized by other data; if the TOVA was mixed I would want to see some converging information from e.g., the D-KEFS). While the Wechsler IQ test subscales (which I assume, perhaps incorrectly, is what you were administered based on your description) do sometimes display ancillary/downstream effects of attention problems (e.g., if your attention is super horrid, you will be too distracted to remember a set of numbers), this isn't their primary purpose. Nobody can tell on the basis of a WAIS alone whether you show neuropsychological signatures that might be expected to crop up in ADHD, the test just isn't designed to specifically examine those processes.

2. Were the above tests done on your medication? If so, I'm not sure how they're relevant to the question of whether you should continue on your medication. If you got terrible results it might suggest that they are not working or that your dose needs to be increased; but a "great" finding on meds might simply indicate that the meds are doing their job for you.

3. Your reported memory problems are somewhat perplexing at first blush; a perfect score on Working Memory is truly phenomenal and unusual to achieve. Nevertheless, sometimes Working Memory does not "hang together" or correlate well for everyone with other aspects of memory. If you believe your memory problems are notable and might not be due to inattention per se, it might be useful to do a more focused memory test, such as the Wechsler Memory Scales, which will provide a pretty comprehensive picture of different aspects of your short-term and working memory.
posted by Keter at 9:40 PM on May 9, 2016 [4 favorites]

Nthing what everyone else has said above. It's not your imagination. i was tested by someone who specializes in testing adults and several of my scores were high and yet it was clear I have ADHD (I'm a cis gal). Good luck!
posted by Bella Donna at 9:41 PM on May 9, 2016

Some psychiatrists are more comfortable taking an empirical approach to treatment than others (i.e., trying different drugs in the absence of a perfect pinpoint diagnosis, using clinically assessed function as the main measure). Also, psychologists and psychiatrists often work together, but it sometimes happens that psychologists really want you to go with psychological approaches to treatment, and psychiatrists want you to go for medical ones. There might be disciplinary bias going on, on both sides (your past psychiatrist and this psychologist).

Your current psychiatrist might not agree with the psychologist for the purposes of treatment. And you can always go somewhere for a second opinion. That said, I think some universities often ask for the full psychoeducational report to facilitate accommodations for ADXD, so, that might mean you'd have to drop another ~$2K. However, I believe you could probably also ask for accommodations on the grounds of other mental health issues, like depression / anxiety. And you would only need a psychiatrist (or GP) to document those.

Other thoughts:

- ADHD tx drugs help with executive function in general; they can also lend a boost to a depressed person.

- Memory, operationalized as a score on a particular neuropsychological / psychometric test, does not necessarily correlate perfectly to how adaptively a person uses it in life, and that can be influenced by any number of things (including interpersonal & situational factors).

- Depression can cause a lot of the cognitive symptoms you describe. So can sleep deprivation - how's your sleep been? Anxiety can also have effects that look like ADHD (e.g. hyperfocus, followed by exhaustion or confusion). If two or three are present, this can be very hard for even specialists to pick apart. Especially in an adult, who may have acquired both 1) compensation strategies and 2) less helpful adaptations, in the case of mood disorders, that look like ADHD (e.g., avoidance). (Not saying any of this is at play with you; I am coming from a very experiential place here :) ) If you are depressed (or sleep deprived), maybe addressing that first, because it's directly happening now, will clear a path towards addressing the other things, later.
posted by cotton dress sock at 10:24 PM on May 9, 2016

I test kids all the time for disabilities, and I would interpret those results as:

Under those exact circumstances of working on a single task, one to one, no other distractions, you didn't demonstrate any ADHD qualities.

Those results are accurate for those EXACT circumstances, but not necessarily true of your regular life.
posted by yes I said yes I will Yes at 3:21 AM on May 10, 2016 [2 favorites]

I think everyone above has good suggestions re: seeking a second opinion and the ADHD specifics.

One other possible explanation for your symptoms: How's your sleep? Do you wake up feeling rested, or do you feel tired? If you wake up still feeling tired, I'd suggest seeing a sleep doctor. Sleep disorders can occur in women in their early 30s (including women of normal weight), and can cause spaciness, distraction, etc., but almost nobody is going to look for them unless you ask them to. (Ask me how I know.)
posted by pie ninja at 5:08 AM on May 10, 2016

When I'm not taking medication, I basically have two modes: total trainwreck of disorganization and distraction, on the one hand, and lightening-sharp focus, on the other. When I'm in hyperfocus mode, I can concentrate more intensely than most people who don't have ADHD can. This is apparently not particularly unusual: ADHD is an inability to regulate attention, rather than a pure attention deficit. And tests send me straight into hyperfocus mode. I think I would do very well on a test of working memory, because I would hyperfocus due to it being a test, whereas my working memory in everyday life is generally pretty lousy. I don't think that's generally considered to be inconsistent with a diagnosis of ADHD, although it is sort of strange and hard to explain to lay people.
posted by ArbitraryAndCapricious at 5:11 AM on May 10, 2016 [9 favorites]

Oooh, I wish we could get a whole club together of high-functioning ADHD ladies - this conversation and the associated links are fascinating.

I've been diagnosed with ADHD and it's blazingly obvious that I have it (my third-party assessments would sound identical to yours) but I don't take stimulants for it - I take anti-anxiety medication, and it has made a world of difference. ADHD and anxiety are often deeply intertwined (I believe the technical term is 'co-morbid), and the fact that your psychologist seems to conceive of them in opposition, as though deep-down your ADHD is 'really' anxiety (casting ADHD as 'obsessive psychological hypochondria,' and talking about treatment for ADHD symptoms as a '“band-aid' and a coping mechanism for my anxiety') seems profoundly wrong-headed to me.

You almost certainly have symptoms of both anxiety and ADHD: the demands of being a high-functioning ADHD adult require an exhausting hypervigilance and overcompensation that can directly result in anxiety, and the distraction & mental exhaustion that come with clinical anxiety often manifest as symptoms of ADHD. The good news is you don't need to untangle them - treatment for one will likely ease the symptoms of the other.

For that reason, I would take the advice of the posters above when it comes to self-advocating so that you can keep being treated for ADHD, and at the same time, I wouldn't entirely shut out the clinical voices that are suggesting you may want to think about treating other issues as well. I almost laughed when I read the part where you said your clinician diagnosed you with 'just Major Depressive Disorder with anxious distress' - that is a very big deal and a major diagnosis! If, on your best days with treatment for ADHD, you are still 'quite impaired,' then there is room for improvement and I think you should pursue that.

Finally, on a totally personal and anecdotal note - when I was mainly trying to treat my ADHD, it often took the form of trying to beat & batter myself into being a normal person: to use stimulants as a way of forcing myself into a mold that was unnatural and uncomfortable for me. Since I've gotten on anxiety medication, it's been a lot easier for me to be okay with the way my wonky brain works, and to stop using self-loathing along with stimulants as a tool to make myself 'behave.' If, like a lot of women with brains like ours, you've survived this long by being massively hard on yourself, I just want to say that this isn't actually the only way to survive, and life is infinitely better on the other side.
posted by pretentious illiterate at 5:15 AM on May 10, 2016 [15 favorites]

Neuropsych trainee here. The weird thing about the diagnostic criteria for ADD is that cognitive testing isn't required, so it doesn't make sense to me that your psychologist effectively undiagnosed you (you did have an existing ADD diagnosis, correct?) based on these results. You report difficulty functioning due to a constellation of symptoms that fits with ADD, and that's the most important factor in applying this diagnosis (it helps to have collateral report from family members, so that it's not entirely based on your own perception of yourself, which is obviously biased). You also report significant improvement when taking ADD meds, which is clinically important because stimulant medications are very often not effective as attentional enhancers in healthy adults* (college students use them to study because they keep you awake, allowing procrastinators to stay up and study/write papers all night).

I have tested several very smart people with ADHD (IQs>140) and it can be very hard to detect and tease apart in smartypantses such as yourself. You could have an attentional system that handles basic tasks very well, but fails at tasks with higher cognitive demands (response inhibition, sustained/divided attention, etc.). Maybe you found it easier to concentrate and respond appropriately in a tiny sterile room with no distractions, but have a lot of trouble in your daily life that is not lived in a tiny sterile room with no distractions. Cognitive tests have limitations, and ecological validity is a big one. So those are some reasons why your testing might not match up.

I'm also curious if you were taking your medication on the day of testing. Usually, if we're trying to validate an ADD diagnosis with a neuropsych eval, we ask the patient to skip meds on the day of testing so that any legitimate dysfunction will show itself.

What to do next is tricky, because seeking multiple opinions on an ADD diagnosis is a red flag to some clinicians (it can look like doctor shopping to get meds). But in your case, I think you have a valid argument that your diagnosis could be legit** (based on self- and parent-report) and it sounds like you have a practical reason for seeking diagnostic clarity (accommodations). I would at least consider taking your results to another neuropsychologist. They may want to do more testing, using more demanding attentional measures, or they may just do a clinical interview and review your previous testing results. Either way, you could ask for a second opinion and clarification about whether or not you meet diagnostic criteria.

* the empirical findings on this are somewhat mixed, but there is no clear evidence that ADD meds enhance cognition in people without ADD

posted by Mrs.Spiffy at 5:36 AM on May 10, 2016 [7 favorites]

I'm curious what this "anxious distress" is about. Is it chronic? It's hard to pay attention when you are anxious. Do you experience yourself as anxious.
posted by Obscure Reference at 7:38 AM on May 10, 2016 [1 favorite]

IANYNeuropsychologist, either. Funny there are so many of us on MeFi though, it's not a common profession!

A few contradictory & confusing things may be at play, many of which are mentioned already.

* Prejudice against some classes of drugs: Few doctors would begrudge a malaria patient their anti-malarials, but many have been trained to be skeptical of patients wanting stimulants. Catch-22: if you want them because they make you better, then you are "drug-seeking". You can probably ameliorate this with being open to reducing (or increasing) dosages, as well as having data to back you up "well, last time I tried that, X happened."

* Shitty test norms: I would challenge your NP to explain just what the test results of a properly treated woman with ADHD and an IQ of 130+ (presumed) would be. Such norms don't exist.

* Tested while medicated. Duh! (as Spiffy explains above, the evidence of health is used to disprove the disease).

* You do complain about "spacey" behavior and that "these symptoms" are not under control, and you are asking for accommodations. The first two imply that your diagnosis may be wrong and/or your treatment may not be working, and the latter ups the stakes for having the diagnosis correct, from the point of view of the clinician. Some of this is under your control? Maybe you could de-emphasize these things?

* You say you have a long history: this is really important. If Dr. X says "let's try ZZZ" you can say "Uh, I tried that and it sucked because ABC". Good clinicians should be much happier with status quo than doing experiments on your life and mental health.

If you are watching and can follow up, I'd love to hear specifics about how/why/when you are still struggling.
posted by soylent00FF00 at 6:15 PM on May 10, 2016 [2 favorites]

« Older New rescue dog lunged at vet; how concerned should...   |   Gimme your favorite weird sci-fi/horror/etc... Newer »
This thread is closed to new comments.