Yesterday, a girl in her mid-twenties booked an appointment with me. I’d only seen her twice before, for a pap smear and follow up. (Tangent: being a general practitioner is very strange sometimes. I know more about some people’s genitals than their occupation or hobbies or politics, which seems a bit backwards. But then, in the age of Tinder perhaps this is more normal than I think.) This time she wanted an ongoing referral to her psychologist, and a new referral for a psychiatrist, because her psychologist thought she had ADHD. Here we go, I thought.
“Why do you think you have ADHD?” I asked.
“Well, we did a self-evaluation questionnaire. I procrastinate a lot. I find it hard to finish tasks- I finished high school, but I’ve tried to do a few TAFE courses, and I’m trying to do a uni degree for the second time. And I find it hard to do things I find boring.”
“I see,” I said.
Of course I gave her the referral, because if someone is convinced they have a diagnosis already, who am I to stop them? (Famous last words.) But as I typed out the brief letter, I made an attempt to gently suggest that perhaps these things didn’t need a seven hundred dollar consultation (not including medication) to be managed. She looked at me like I was stupid, and worse, judgemental. I must admit, my version of gentle (I have been told by reliable sources) is other people’s version of blunt hammer. She may or may not ever book in with me again.
*****
When I started in general practice, the mental health pandemic was in its infant stages. Destigmatisation was trending and every second person was coming out about their struggle with depression and anxiety. Studies were being published demonstrating beyond a doubt the efficacy of antidepressants and proving the neurotransmitter deficiency theory of depression. It’s harder to remember that time now, when we have more data about the various debilitating side effects of antidepressants (the medical term I like to use with patients is “zombification”) and their equivalence to placebo effect in mild-to-moderate disorder, and the benefits of social connection and daylight exposure.
I have worked long enough to start to see trends. I would still consider myself a fairly young doctor (I have seen physicians well into their seventies still powering through ward rounds and full clinic days; a doctor never retires, he just dies) but in my decade-and-a-bit in general practice I have seen the rise and fall of depression/anxiety, then autism, and now ADHD. I have seen the change to diagnostic criteria which makes it far easier to diagnose all of the above conditions. I have seen the influence of social media trends on diagnosis rates. One could say that these were a result of destigmatisation; I would say they are the result of social contagion. And I wouldn’t be the first.
I don’t have solid data, only my own experience and common sense. It’s strange though, that we live in an age where data is held as king, when we all know how easy it is to manipulate statistics. (Especially if you are a pharmaceutical company looking to get your new product on the market.)
My experience is that around 2015 (very approximately) there were more and more young women in particular presenting with a self-diagnosis of autism, and requesting referral to a psychiatrist for confirmation. There had always been children with autism. These children generally were non-verbal, or very delayed with their speech; they would be years behind their peers in school in basic reading, writing and mathematics skills; they would be unable to regulate their emotions to the point of physical aggression against their parents. Children with what used to be known as Asperger’s disorder had less delay in their development, but struggled socially- often saying or doing things inappropriate to the context, and unable to understand why these things were inappropriate. They had unusual interests and hobbies and physical behaviours and habits. These children had to work hard to fit into society and their parents worked hard to help them find a place where they would be able to function, or be cared for, after the parents were no longer around. No one wanted to hear that they had autism, or Asperger’s.
But these young people- as I said, primarily women, although there were some men- seemed to revel in the diagnosis of autism. Often they were a bit quiet and introverted, with interests tending towards the solitary. But they could hold a conversation, and often did well enough in school. There was nothing an objective third party could point to in terms of odd speech or behaviour that could support a diagnosis of autism. But you knew they had autism. It was one of the first things they would tell you. And they usually made sure it continued to come up in the conversation.
Of course there were legitimately missed diagnoses. Some adults- young men in particular, I think, although that may have been just my own population of patients- probably did have Asperger’s (although we can’t call it that nowadays, because of the Nazi connection- it’s autism, just like the version of autism where people cannot function independently because they can’t talk or safely go shopping alone or cook). But there was a widening gap between the kids, mostly three or four years of age at first presentation, who were brought in by their parents because they still couldn’t talk, and had meltdowns when routine was disrupted, and refused to eat anything except sauceless pasta- between these kids, and the young adults who appeared normal externally but felt divergent internally.
Interestingly, in the last two to three years, I haven’t had a single adult requesting referral to a psychiatrist to confirm autism. I continue to have similar rates of toddlers and children being brought in by concerned parents due to developmental delays and behavioural issues, though.
*****
Autism is a fairly harmless diagnosis to have. Funding is diverted to those diagnosed as adults for psychotherapy, away from the children who are struggling to stay in school, but otherwise, there’s no lasting damage done. You can do speech therapy and occupational therapy to reduce the developmental delay, but there’s no medication that has been proven to help. The cause is still unknown, although various genetic and environmental factors have been blamed. (My boss was convinced that screentime during childhood caused autism and used to quiz me about daily screen use when the boys were smaller.) It’s complex.
Not all diagnoses are harmless.
In the last five years, attention deficit hyperactivity disorder has become the diagnosis that’s trendy to have. Like autism, ADHD has always been around, and used to affect little boys most. The problem, as I heard one lecturer in medical school explain it, wasn’t so much that they didn’t have enough attention; it was that everything was of interest. They couldn’t channel their attention to focus only on what was in front of them. Forming thoughts into sequences that can be used for reasoning is not possible when the subject of one’s attention is constantly changing every thirty seconds. It’s not that learning the formula for the area of a circle isn’t interesting. But so is the little knob on the top of the compass you’re using to draw the circle, and so is that fly that just buzzed past- how did it get in the classroom- oh, the window is open- hey that car that just went past was yellow- and before you know it you’re getting yelled at by the teacher because you’ve gotten out of your chair to have a look at where the car went, disrupting the whole class in the process.
Ritalin helped with focus, but came with a host of problems- the most commonly complained about being a lack of appetite and insomnia. ADHD boys were skinny and tired. And often they would refuse to take their medication because of the side effects. Academic performance wasn’t worth how it made them feel, to them. Some boys did continue their medication into adulthood, but many left off and consequently found stable jobs and lives difficult.
Compare this with the symptoms experienced by adults- again, more commonly young women- who present for a referral for a psychiatric diagnosis of ADHD. They lack motivation. They procrastinate. They find it hard to focus on things they find boring.
This isn’t ADHD. This is human nature.
But they are getting diagnosed, and then prescribed legal speed to treat what is normal. Of course it makes you feel more productive. It’s speed.
Again, there are missed diagnoses. Some people genuinely have issues connecting thoughts together, and dexamphetamine can help them to keep a job. But again, many of my adult male patients who were diagnosed as children and have been off medication for years opt to stay off it, because of the side effects. They find strategies to keep their brains on task. They hold down jobs, because they have to- they have families to take care of now. Focus can be trained.
*****
Why the rise in cases? Aside from the trendiness, I think there’s another big factor, and that is the instant gratification we have trained ourselves to expect as a society.
Two hundred years ago, the fastest you could travel was by horse on land, and by ship on sea. It took months to go to another continent. Today, flying a day to get somewhere else is a long time. One hundred years ago, if you wanted music or drama or dance, you had to do it yourself or go and find someone to make some for you at a mutually convenient time. Today, a click of a button brings us a vast selection of art, from anywhere in the world. Fifty years ago, a dress took days to sew, not counting the weaving of the cloth. Today, we buy a dress and wear it once and throw it away.
Flour was ground, dough was kneaded and proofed for hours, bread was baked daily. Today we buy it pre-sliced and full of preservatives and chemicals.
A calf was fattened for months and slaughtered. The flesh was hung for weeks before steaks could be cut. Today we order meat at restaurants and complain if it takes too long.
Once upon a time, things were hard to do. They cost time and effort. No one expected anything of worth to be done quickly or easily.
But today we have grown up with the expectation that we ought to be happy, at ease, comfortable all the time. If something takes effort it is not fun. We bought the lie that convenience would give us more time for the important things, and we scroll away the time that was meant for important things. We skip the boring parts of videos. We skim headlines and react without reading the rest of the article. Students aren’t expected to read books in school now.
We want happiness, and we want it now.
*****
Let’s consider a widely used self-report ADHD questionnaire. I’m going to pick on selected questions.
How often do you have trouble wrapping up the final details of a project? If one has a dearth of attention, surely the entire project would have been troublesome- not just the final part.
How often do you have problems remembering appointments or obligations? In today’s digital age, setting reminders on a calendar app is not difficult. This question is not testing memory but organisation, neither of which is directly related to attention. One could argue that lack of attention results in not putting things in a calendar, or checking one’s calendar. Yes- but disorganisation can exist independently of ability to pay attention.
When you have a task that requires a lot of thought, how often do you avoid or delay getting started? Procrastination is not inability to pay attention. It is a weakness of the will. And good thinking requires practice, just like lifting weights, or running marathons; if one is not accustomed to using one’s mind then procrastination is inevitable- just as I would rather get eaten by zombies than run more than a hundred metres.
How often do you feel overly active and compelled to do things, like you were driven by a motor? Oddly this is exactly opposite of the previous question. This assessment covers both ends of the spectrum- demotivation and drive. But if both can be caused by lack of attention then one must conclude that attention is a rather paradoxical entity.
How often do you have difficulty keeping your attention when you are doing boring or repetitive work? This is a question that begs itself. The definition of boring is that it is hard to keep one’s attention on it. No one should be finding it easy to pay attention to something boring. That is to change the definition of boring.
How often do you feel restless or fidgety? I find this question interesting solely because the exact same question is used in the K10, a measure of depression and anxiety (strictly speaking, psychological distress- but not ADHD). One could argue that anxiety results from undiagnosed ADHD. Yes- and it could also not. Or we could simply relabel anxiety as ADHD, as seems to be fashion among psychologists now.
How often do you have difficulty unwinding and relaxing when you have time to yourself? There are so many unspoken assumptions- that one should be able to automatically relax when alone; that chronic stressors such as interpersonal conflict or financial strain won’t make alone time worse; that individual methods of relaxation make no difference (going to a dance rave to relax is one method that comes to mind that is very hard to do alone). And what if one’s loneliness is the cause of worry? Surely being alone would be worse in that situation.
*****
I wish the craze for ADHD were over, but I suspect it’s going to stick around for many years. While psychiatrists and psychologists can rake in hundreds of dollars a consultation, while dexamphetamine and various derivatives can be synthesised and sold by the pharmaceutical companies, demand will be created and it will be with us. But I can’t solely blame greed. We have done a lot of it to ourselves.
Clicking a button and expecting shopping to show up instantaneously instead of thinking ahead and planning for what we need and waiting for what we want.
Divorcing ourselves from the earth that supplies everything, not having any innate understanding of the time and work that goes into every meal and shirt and house.
Distracting ourselves from meaningless existence with half minute bites of content that we can scroll past the second that boredom sets in, instead of seeking contentment in the reality of the rhythms of flesh and soul.
Allowing ourselves to flee effort, perseverance, and discomfort instead of training ourselves in blood, sweat and tears to stand despite it all.
Believing that feeling weird is equivalent to a disease, instead of accepting that most of us have no pathology- we are just all individuals who speak and behave slightly different from everyone else.
Expecting life to be easy and pain-free, when nothing good or right has ever been easy or pain-free.
*****
I feel like I’ve had a narrow escape from this social contagion, because I’ve always been weird. I didn’t have many friends as a child, and I wasn’t very good at keeping the friends I had. (That I have any friends at all as an adult is a testament to their kindness and persistence, not to any friendliness in me.) I was clever and bookish, but not good at conversation or reading social cues. I didn’t know how to suck up to teachers and was often overlooked in class. I wasn’t interested in popular culture, but in fantasy and dragons and science (at that time, a weird combination for a girl).
I had to learn how to talk to “normal” people. I had to learn to persist in doing things I didn’t want to do. I had to learn how to filter (I now have the skill of not saying everything that I think. I am now learning the skill of not saying most things that I think). I had to learn that my feelings were not to be relied upon, and that if I got a good night’s sleep and ate proper meals my feelings would magically improve (and I also learnt how to sheepishly admit my wrong in arguments the day afterwards). I am learning now that sometimes even if people give me weird looks or don’t understand what I mean I can still say it. I had to learn how to be acceptably weird. And I am learning that the more you talk to them, the more you find out everyone is actually weird. There is no such thing as a normal, standard person.
If I had been born a few years later, I might have been diagnosed with autism, and assumed that I had an incurable disorder for my whole life. I would have had an excuse not to talk to people when I didn’t want to. I would have had an excuse not to try new things.
If I had been born a decade later, I might have been diagnosed with ADHD and medicated into social conformity.
But as it is, I am coming to terms with being weird.
*****
ADHD is a easy explanation for the restlessness of our souls. We are easily distractable because we distract ourselves from the true problem. We don’t want to finish projects and make-work because we know that in eternity these things will have been meaningless. We don’t want to think in case we have some thoughts, particularly our own, and particularly uncomfortable ones. We are driven because we want something better than what we have. We don’t want to be bored, because it’s boring. But taking drugs is not the answer.
If our souls are restless, then we need to rest our souls.
We need to find our way home.
Yeah, this all sounds like total nonsense to me. You seem to be essentially saying that as long as autism or adhd is not totally disabling for an individual there are no benefits to diagnosing it and we shouldn’t. Well, I’m very bright and I did well enough in school despite having never been able to pay attention to an entire lecture, not even when it was my favorite subject that I was passionate about and was super determined to pay attention. And yeah I’m still bitter at how hard I tried and how shitty I felt about it. And yeah I would be neither homeless not in a hospital if I didn’t have ADHD meds - I can function, I have compensatory strategies. But when I started Ritalin and it killed the noise and attention pulling that I was constantly fighting all day at work I went from having to fight my own brain every day to be a mediocre attorney to being a fantastic attorney with little effort and much happier. Before I took it the first time I couldn’t have even told you that there was that noise. So tell me, how is anyone in the world hurt by me taking Ritalin on work days? I get enough food and sleep. How does it make the world better for me to suffer and resign myself to not being able to reach for my dreams? I don’t get it.
Autism diagnosis are sought so people can feel like a normal zebra and not a defective horse - so that they can stop trying to change things that are impossible to change about themselves and focus on figuring out accommodations and how to get the life they want (including socialization) - not as an excuse for anything.
Great essay but the title is off, it sounds like rage bate. Never should you say ADHD is stupid, even when making a point. I agree social media is the cause for the rise in misdiagnoses. I've seen people making videos saying "3 signs you have ADHD" and one of the signs will be not being able to focus in class. Yes not focussing in class can be a result of ADHD, but it doesnt mean you have it. The way you wrote this piece, saying you immediately judged your patient, although you knew nothing of her mental health outside of your conversation is one reason people are scared to open up and express themselves to medical practisers. You made a good point, the idea of being mentally drained it trending, but it is a reason issue, and a disorder is never stupid