Polina:
0:14
Hello and welcome to Smart and Well, a podcast supporting mental health and well-being for students and early career researchers. Today we are talking about Attention Deficit Disorder in Adulthood, or short adult ADHD. When we hear the term ADHD, most of us probably think of restless kids in medication like Ritalin. But what exactly is ADHD, and is this diagnosis actually meaningful for adults? The prevalence rate for adult ADHD ranges between 2.6 to 7.8%. This difference emerges because some studies only report the prevalence of people that were already diagnosed in childhood. It is important to know that two-thirds of children with ADHD diagnosis will also have associated problems in adulthood. Other studies acknowledge that a diagnosis might only be granted in adulthood, and thus their prevalence rates are higher. But how is it possible that people get their first diagnosis when they are already adults? There are different possible answers. First diagnostics were not always as established as there are nowadays. Therefore, chances of having missed diagnosis in childhood are not so rare. Oftentimes, especially female children and adolescents were misdiagnosed with anxiety or depression, which were seen as just side effects of the underlying ADHD. What happens now is that individuals seek out help for these other problems in adulthood and with more elaborate diagnostic tools that we have nowadays, the underlying ADHD can actually be uncovered. First, ADHD has a very high genetic component. It might happen that, for example, parents seek help for the diagnosis or treatment of their child. During the diagnostic process it becomes apparent that one of the parents, or maybe even both, are actually affected themselves. Third, it might be that other compensation mechanisms or support networks which worked very well in the past changed. For example, if you lived with your parents and they took over all of their organization tasks, you might just realize now that you actually have big problems organizing and keeping track of everything on your own. Obviously, this was just meant as a relatable example, because adult ADHD is much more severe than just having problems with organizing. The diagnostic criteria of adult ADHD are not different for childhood ADHD. These different criteria are subsumed under bigger categories, targeting inattention and hyperactivity, and impulsivity. To be diagnosed in adulthood, at least five criteria in one of these categories need to be present longer than six months, with some of them already being present under the age of 12. Even though the diagnostic criteria are the same, the clinical phenotype of ADHD in adulthood might look rather different. Fidgety behaviour becomes less during adolescence, but feelings of restlessness or urges to move might be more pronounced. Importantly, just because people score with normal test results in, for instance, attention tasks does not mean that they can't have ADHD. In a clearly defined timeframe, affected individuals are often very capable of compensating their attention problems by using more cognitive resources. Therefore, a skilled and knowledgeable practitioner is very important to ensure a valid diagnosis. The practitioner will very likely also refer to insights from parents, partners, friends, and colleagues. Also, school certificates can help to unravel if somebody was always very active or easily distracted child. Our today's guest is Dr Lenka Staun. She's a medical doctor for psychosomatic medicine, a psychoanalyst, a group analyst and the head of the outpatient clinic of the International Psychoanalytic University, or IPU, in Berlin. Here we will explore some important aspects of adult ADHD, including its diagnosis and differentiation from other conditions, the impact of the environment, and its effects on academics. We will also discuss some strategies to address the challenges that come with an ADHD diagnosis. Welcome to our podcast, Dr Staun.
Dr. Lenka Staun:
4:36
Thank you for your introduction.
Polina:
4:38
So let's start exactly with this question. What are the important differential diagnosis for adult ADHD? So it coincides with other mental health concerns often. So how do we decide if it's ADHD or something else, or maybe both?
Dr. Lenka Staun:
4:56
So, first of all, there is a recent development in ADHD research that the term attention deficit syndrome is a bit too narrow and that attention deficit hyperactivity syndrome is more understood nowadays as a disorder, a neurodevelopmental disorder of emotion dysregulation. So what does this mean? It means that we do find more than just inattentiveness, hyperactivity, and impulsivity. These would be the criteria mainly in children, and in adults this plays out quite differently. So when a patient or someone comes to our department, we have a special section for the diagnostics and the treatment for ADHD in adults. We do a very, very thorough clinical interview, and we're trying to get the full picture because we need to know, is it first of all, is it really ADHD? And yes, if it is, what else is there? And because adults with ADHD also have other comorbidities such as depression, anxiety, substance abuse, so there is a whole range of other mental disorders that we need to be looking out for. So first of all, when we do the clinical interview and the testing, we are very carefully looking out for, do any of the symptoms a patient presents with, for example, inconsistent attention? Could they be explained by any other condition? So we only give the diagnosis first of all if there have been symptoms in childhood already. It doesn't have to be diagnosed in childhood, but symptoms have to be present in childhood and if no other mental disorder explains the symptom a patient presents with. So, for example, there is a big overlap with depression and often, especially women, because they don't have such strong signs of hyperactivity, they have a more internal restlessness or an internal kind of tension, but they don't look hyperactive. So, if we have a symptom like inconsistent attention, we really closely look at, could it be attributed to depressive symptoms or is a depression alone? Because symptoms like hyperactivity in attention and impulsivity can really be mimicked by many other mental disorders.
Polina:
7:37
You mentioned the importance of symptoms in childhood. So if I never had any symptoms during childhood, can I develop ADHD in adulthood, or is it than not the case?
Dr. Lenka Staun:
7:50
It's pretty unlikely. I mean, there are different schools, schools diagnostics. The strict approach would be to not give ADHD if there haven't been signs of attention deficit hyperactivity in childhood. However, often it's masked and this is the problem that, especially girls, being kind of growing up in school, they might not present with the same kind of visible and noticeable symptoms as maybe boys with ADHD do. So it's often not picked up and good performance, for example, it doesn't mean you can't have ADHD. So, often patients are not diagnosed who are very smart, who have ways of compensating for inconsistent attention, and they're not picked up in childhood. So, in later life they experience major difficulty. And then we look at the fuller picture, and then we detect the link between childhood symptoms having been mask and adult symptoms. And that's why in our department, for example, we do see patients who, you know. We recently had an architect of 50 years of age or a physiotherapist at 40 years of age who have just recently been diagnosed because they've never been, either they haven't taken their symptoms seriously and or the environment, the medical system hasn't taken their symptoms seriously. And when patients come to us, we really see a lot of suffering coming along with a diagnosis or, until the diagnosis is expressed, because it's such an effort to compensate for the symptoms an adult with ADHD suffers from.
Polina:
9:45
So if I, as an adult, for example, if I have a feeling that I might have adult ADHD, what should I do? Where can I start?
Dr. Lenka Staun:
9:55
I mean there are some kind of self-test online where you can do a screening test for ADHD to look into symptoms and then a medical professional. ADHD should only be diagnosed by experienced psychologists and psychiatrists and diagnostics take several sessions because one part is the clinical interview. Then you do executive functioning tests, testing also the attention and distractibility, and ideally also we would look into school reports or a description of partners. And then we not only test for ADHD, but the clinical interview entails looking for many other conditions such as anxiety or depression, and also personality disorder, because there's a huge overlap with personality disorder and ADHD and, unfortunately, we see many patients with borderline personality disorder who'd rather have an ADHD diagnosis but we have to disappoint them often because we see the borderline personality disorder as the leading disease, mimicking some of the ADHD symptoms.
Polina:
11:12
Right. Another interesting aspect, I think, is the interaction of ADHD with the environment. How important is our environment? For example, whether we live in a busy city or in a calm countryside, does it make a difference for someone with adult ADHD regarding the attention symptoms, or the symptoms are independent of the surroundings?
Dr. Lenka Staun:
11:35
Yes, it does, but we see it more as a kind of neurodevelopmental trajectory. So, there is a strong genetic predisposition. Adults with ADHD often have grown up in a household where their parents might have had ADHD as well, maybe not diagnosed. So, there is a genetic link, a genetic predisposition, and at the same time, the nurturing environment, mainly the attachment security, the stability in early relationships, is extremely important, whether the genetic predisposition is playing out fully or whether it's buffered. And that's maybe some new perspective on ADHD to really look at what are the early relational experiences. Because we often see patients who come from very disrupted and insecure attachments and disrupted families where they couldn't develop attachment security and hence are hyper vigilant to their external environment, being very attentive to others, watching out for what's happening next and being unable to develop the capacity to be with oneself and focus on oneself, on one's own emotions, but also on focusing on tasks. The external environment, I think, is highly important because overstimulation exacerbates ADHD symptoms and that's part of our program at the IPU. We have a 12-session psycheducational program that leads into a mentalization-based therapy, group therapy. The biggest part of it is really to help adults with ADHD explore and find out what is helping them? What kind of environment? In the workplace, but also at home. What do they need to feel less distracted or to be less distracted and to be able to focus more?
Polina:
13:39
We already mentioned that sometimes what's present, especially in children, is their school performance is different and that's often seen as some kind of indication that there might be something. So, can people in academia, if they are academically actually successful, can people in academia have ADHD? And what are maybe some misconceptions about adult ADHD in specifically academic and professional settings? So, you mentioned you had an architect or a physiotherapist. It seems like people who are successful academically still can have ADHD.
Dr. Lenka Staun:
14:16
Yes, indeed. Academic performance really doesn't mean you can't have ADHD. All the contrary, I would say the common misconceptions is that ADHD really affects professional development and academic achievement. However, we this is not the case, or it can be the case, but it's not necessarily the case. So, if someone with ADHD in academia might have developed very good coping strategies, and might have compensated a lot for attention difficulties, and might have found a good way to compensate for it. However, if you ask affected adults in academia, they often say how much of an effort it is to mask their symptoms so that nobody notices, because they fear rejection. They also fear being discriminated, and they fear consequences. So, they're trying to disguise their symptoms, which creates a lot of pain and sometimes also feelings of isolation.
Polina:
15:21
Maybe let's explore this topic a bit more. How can adult ADHD actually affect, in what ways it can affect academic and professional performance, and what we can learn from that?
Dr. Lenka Staun:
15:32
Yes. So since we are kind of embedded into an academic institution, the International Psychoanalytic University, we do see a lot of students presenting with ADHD. We also see academic professionals coming for testing and the main kind of symptoms they describe is procrastinating, not being able to finish a task, not being able to finish the master thesis, especially tasks that are associated with sustained attention, a little bit of boredom, so, repetitive tasks where you need a long span of attention, like writing your thesis. P atients do come forward often when they're about to fail their thesis or an academic achievement and that's when they want to look into what do they really have.
Polina:
16:25
Are there any instruments for them in terms of coping with that?
Dr. Lenka Staun:
16:29
Yes, I would say the ADHD treatment is really based on three pillars. One pillar are the daily essentials, which are really important. Daily essentials meaning physical activity. Adults with ADHD should be doing sports, and what kind of sports is helping them to focus better is really something you have to explore for yourself whether you need more kind of aerobic sports, such as running or cycling or swimming, or whether you need kind of more calming sports like yoga or pilates. That's really individual, what you need and what might help you. So, that's the first pillar. Daily essentials means regular sleep, having establishing routines, also looking at your diet, how much sugar do you take in, how much caffeine do you consume. So, these are the daily essentials. And the second part is psychoeducation, where the focus now in kind of recent research and that's what we're doing at the IPU as well is seeing ADHD more as an emotion, as a disorder of emotion regulation. It's really important to work on the feelings, so on regulating emotions, because the better you are at understanding and regulating your own emotions and the better you get at understanding the feelings of others, the better really. The ADHD symptoms and also one major symptom I haven't spoken about, adults come forward because of relational struggles. They struggle in their relationships, they have interpersonal difficulty because of not being able to be attentive to their partners, because the ADHD symptoms really affect close relationships, cause a lot of frustration and disappointment, and that's mainly when adults present for diagnostics. So, the emotion regulation is the major part and emotion regulation can be addressed and worked on very well in group psychotherapy because you have an environment where you're mirrored by others. You also are challenged to regulate quickly shifting emotions. It's in the best sense, group therapy is a place for training emotion regulation and learning to regulate yourself differently. So, we have to recap we have the daily essentials as one pillar, we have psychotherapy, and ideally with a focus on emotion regulation and relationships. And third, we have medication, but I would never prescribe. I think it's a bad habit. How often and how frequent stimulants and non-stimulants are prescribed without really educating patients on the daily essentials, on physical activity, and without any thorough psychotherapy that addresses emotion regulation.
Polina:
19:34
Another question I was thinking about is how important is it to actually getting an adult ADHD diagnosis if you weren't diagnosed as a child? So, for example, if someone is coping relatively well, maybe having some strategies, does it actually change much if an adult gets the diagnosis?
Dr. Lenka Staun:
19:57
Yes, it does, because often there's so much hidden. You know that people, because of being ashamed for their symptoms, their struggles as well, that often it means a huge relief to be given a diagnosis and to name what you couldn't make sense of before, where you realize it is such an effort to go through normal life. Writing a master thesis is difficult enough for a non-neurodivergent person, for an adult with ADHD it's a huge effort and a huge challenge, and the diagnosis as an adult can be a starting point also to look for how can I get better in terms of what do I need in my environment, at my workplace, to how can I structure myself better, how can I work on my emotions to then also have less symptoms. And, for example, I mentioned the relational aspect of ADHD, we often see patients who tell us, you know, I get a completely freak out when I have to do the shopping. Even with the list, with a shopping list, it's so stressful for me to be overstimulated in the supermarket, then I forgot the money or my car, then I forgot the shopping list, and even on the smartphone, you know I I'm so stimulated with everything that's around me in the supermarket, and then they start talking to their partners, and discuss maybe I can do something else in the house or, if you know, given that doing the weekly shopping is such a stressor and that's what we encourage our patients to, because ADHD is so varied and people suffer in so different ways, that we really encourage our patients to discuss with their partners, also at work, what they need to feel to be able to focus better and regulate their emotions better. And one major part is the overstimulation.
Polina:
21:55
So, as I understand, you're talking about accommodations, right? So there can be many different ways to accommodate that, different settings,. So maybe you have any ideas specifically for academic environment or for students. What is the range of accommodations?
Dr. Lenka Staun:
22:14
Some people benefit from having like a studying buddy in a way. You study together, you write your theses together, so, you're more accountable and you can't get too distracted. You also have a routine together. This can help. Also have a sports buddy. It's quite a slippery slope between not being alone, of course, being with too many people is also distracting, not being overstimulated at the same time, not feeling isolated, because often feeling isolated really contributes to more depressive feelings and then, you know, going along with procrastinating. So, having a buddy, a studying buddy, could be helpful. Also having clear breaks that you divide the day into sections where you have to focus in, sections where you do active breaks, like sports during your break, where you meet up with someone for lunch break at a certain time. Anything that establishes a pattern and a routine is helping and, for example, some people can't work in a large scale office because it's too noisy and too distracting and then a smaller, quiet work environment could be helpful.
Polina:
23:30
I'm wondering how COVID pandemic affected the symptoms in people with ADHD, because there was a lot of time when many people, especially young adults, were isolated. Did you notice any worsening?
Dr. Lenka Staun:
23:44
Yes, they were affected in a very bad way because online, like students, academics in the earlier phases they had to, everything was done online, and being able to focus online is extremely difficult when you don't see the full body of the lecture. When you can see your class, you can relate to others. So, being stuck in front of a screen for eight hours during the pandemic really didn't help and created a lot of anxiety as well, you know, of having lost your group. It's so much easier to zoom out when you're in online teaching session than when you're actually engaging, live with your teacher.
Polina:
24:27
Absolutely! I think, also having an experience of attending, for example, talks online it's different from attending talks in presence and also my first teaching experience was actually teaching online completely the entire course. So, I guess that was also more effortful for the instructors to actually engage the students, because for them it's obviously harder to pay attention for prolonged periods of time
Dr. Lenka Staun:
24:55
I think during the pandemic, many students with ADHD probably have gone missing. You know they've been lost in the course of their studies. Yeah, because the tutors can't have an eye, you know, when you're in class you can have an eye on someone. They can sit in the front row to be more attentive. You can ask questions, engage them more actively, and look after them better, and in the online format this is really difficult.
Polina:
25:23
Absolutely. I have a more practical question now. So, if I realize that I have problems focusing my attention, so let's not say that I have adult ADHD, but I notice that I have problems focusing my attention. Are there any ways, or maybe exercises, how I can work on that, for example, meditation or some kind of mindfulness practices?
Dr. Lenka Staun:
25:44
Yeah, meditation, mindfulness exercises are extremely helpful because they allow us and they enable to focus attention to how one feels, but also focusing to the environment. What do I listen to, what do I observe, what do I feel? So, meditation and mindfulness exercises are very helpful. And how we often start with ADHD adults is this body check, this quick check, where am I, how do I feel right now, how do I feel in my body? Because often patients with ADHD are not very connected with their body. Their body is really disconnected. So, before we start, checking in with our bodies, do I feel heavy, do I feel light, do I feel a sense of joy, do I feel sad? And where in the body? We work a lot on linking emotions with a body to really train our patients in where do I feel certain emotions in the body, because then ADHD has a very physical expression. And we observed, and there are studies supporting this, we observed that when you're more able to express your feelings and you're more able to read your feelings, you're more aware of your feelings, the symptoms really change and the hyperactivity, the distract ability, they really change the more you learn to express your feelings. T he body in all the physical activity and being fidgety is expressing something that the adult with ADHD can't express yet in words.
Polina:
27:33
I think it circles back nicely to the idea that you express that ADHD as an emotional regulation problem.
Dr. Lenka Staun:
27:42
Yes, and that's why often patients, you know, they come to us and they're very frustrated because they've done cognitive behavioral therapy. It hasn't worked. And they come to us and say please don't give me another checklist, another protocol, I hate these, they don't work. And then we do it with a very different approach. We do it in a way really exploring their feelings in relation to themselves and in relation to others, and to make them notice, you know, what brings about a change in the ability to focus and also in their kind of emotion disregulation. And so, we really want patients to be kind of scientists of themselves and to find out, with our help, how certain emotions are represented in their bodies. I'm still very surprised that this approach, so we're the first research group, together with a group in a research group in Geneva by Martin Debanne and Nader Perroud, we work on a multi-center study researching mentalization- based therapy for ADHD in a group setting, and I'm still surprised that ADHD, despite its high prevalence in adults and the need to develop new treatments, that the treatment options are still so limited. So, in Berlin, for example, we're the only place offering specific mentalization- based treatment for adults with ADHD in a group setting and the results so far are extraordinary because patients improve substantially in quite short time
Polina:
29:27
That's kind of very sad to know that there's definitely not enough research going on on this topic, but also quite promising that you also get quite good results from your approach.
Dr. Lenka Staun:
29:40
Yeah, and I think the whole approach has to change a little bit, from seeing it only and that's, I feel, the shortcomings of of cognitive behavioral therapy, that ADHD is not just a disorder of executive functioning. So, the treatment approach also has to change, seeing it more as a disorder of emotion regulation. This idea also that you can have a genetic predisposition, but it actually matters how your attachment, how secure your attachments have been in early childhood, that this substantially influences how you develop or to what extent you develop ADHD as a child and late in adulthood. This is really neglected in the current more CBT- based treatment approaches.
Polina:
30:32
And clearly shows the link between cognitive and affective sides of human nature. Could you think of one piece of advice that you could give to students and early career researchers?
Dr. Lenka Staun:
30:47
That's a good question. I think I would suggest to hook up with other students or researchers in early career who also have similar struggles, and there's, for example, a great website, ADD Magazine it's called, that's very thorough and there are quite good internet-based resources. I feel the most important part is to not be ashamed anymore of the diagnosis and to reach out for others who struggle with similar difficulties and To seek professional help, because there's a lot that can improve with ADHD in adults.
Polina:
31:31
That's great. Thank you very much. So we are heading towards the end of our podcast and if you were to give a little homework or maybe some kind of little cue for our listeners, what they can do until the next episode, like a little task or maybe something they can reflect on, what would that be?
Dr. Lenka Staun:
31:52
Yeah. In psycheducation education part, we do one exercise which the patients often really like. So, I would like to ask the listeners, the audience, to think about the basic emotions - anger, anxiousness, joy, disgust, surprise, and sadness and think about where in the body do I feel anger and what's the quality of anger in my body. To find adjectives, this is actually quite difficult to describe. Where in the body do I feel anger? How does it feel, what does it feel like? And then think of a recent example where I felt this way and to counterbalance it with, for example, joy. So, where in my body do I feel joy? Is it a warm feeling? Is it encompassing the whole body? Is it only related to certain body parts? And where did I recently feel this joy? In what situation did I feel the joy? And this is really important because the more we are aware of the connection between the affect and the body, the better we're able to to identify emotions and then to express emotions.
Polina:
33:03
Thank you for this insightful conversation. Before I close, I would like to invite you to check the show notes, where you can find the link to the transcript of this episode, ways to get in touch with us and other useful details, like the lin k that was mentioned. Subscribe to the Smart and Well podcast on your preferred podcast app. You're welcome to share it with your friends and colleagues. Thank you for listening. Be smart and stay well.
0:14
Hello and welcome to Smart and Well, a podcast supporting mental health and well-being for students and early career researchers. Today we are talking about Attention Deficit Disorder in Adulthood, or short adult ADHD. When we hear the term ADHD, most of us probably think of restless kids in medication like Ritalin. But what exactly is ADHD, and is this diagnosis actually meaningful for adults? The prevalence rate for adult ADHD ranges between 2.6 to 7.8%. This difference emerges because some studies only report the prevalence of people that were already diagnosed in childhood. It is important to know that two-thirds of children with ADHD diagnosis will also have associated problems in adulthood. Other studies acknowledge that a diagnosis might only be granted in adulthood, and thus their prevalence rates are higher. But how is it possible that people get their first diagnosis when they are already adults? There are different possible answers. First diagnostics were not always as established as there are nowadays. Therefore, chances of having missed diagnosis in childhood are not so rare. Oftentimes, especially female children and adolescents were misdiagnosed with anxiety or depression, which were seen as just side effects of the underlying ADHD. What happens now is that individuals seek out help for these other problems in adulthood and with more elaborate diagnostic tools that we have nowadays, the underlying ADHD can actually be uncovered. First, ADHD has a very high genetic component. It might happen that, for example, parents seek help for the diagnosis or treatment of their child. During the diagnostic process it becomes apparent that one of the parents, or maybe even both, are actually affected themselves. Third, it might be that other compensation mechanisms or support networks which worked very well in the past changed. For example, if you lived with your parents and they took over all of their organization tasks, you might just realize now that you actually have big problems organizing and keeping track of everything on your own. Obviously, this was just meant as a relatable example, because adult ADHD is much more severe than just having problems with organizing. The diagnostic criteria of adult ADHD are not different for childhood ADHD. These different criteria are subsumed under bigger categories, targeting inattention and hyperactivity, and impulsivity. To be diagnosed in adulthood, at least five criteria in one of these categories need to be present longer than six months, with some of them already being present under the age of 12. Even though the diagnostic criteria are the same, the clinical phenotype of ADHD in adulthood might look rather different. Fidgety behaviour becomes less during adolescence, but feelings of restlessness or urges to move might be more pronounced. Importantly, just because people score with normal test results in, for instance, attention tasks does not mean that they can't have ADHD. In a clearly defined timeframe, affected individuals are often very capable of compensating their attention problems by using more cognitive resources. Therefore, a skilled and knowledgeable practitioner is very important to ensure a valid diagnosis. The practitioner will very likely also refer to insights from parents, partners, friends, and colleagues. Also, school certificates can help to unravel if somebody was always very active or easily distracted child. Our today's guest is Dr Lenka Staun. She's a medical doctor for psychosomatic medicine, a psychoanalyst, a group analyst and the head of the outpatient clinic of the International Psychoanalytic University, or IPU, in Berlin. Here we will explore some important aspects of adult ADHD, including its diagnosis and differentiation from other conditions, the impact of the environment, and its effects on academics. We will also discuss some strategies to address the challenges that come with an ADHD diagnosis. Welcome to our podcast, Dr Staun.
Dr. Lenka Staun:
4:36
Thank you for your introduction.
Polina:
4:38
So let's start exactly with this question. What are the important differential diagnosis for adult ADHD? So it coincides with other mental health concerns often. So how do we decide if it's ADHD or something else, or maybe both?
Dr. Lenka Staun:
4:56
So, first of all, there is a recent development in ADHD research that the term attention deficit syndrome is a bit too narrow and that attention deficit hyperactivity syndrome is more understood nowadays as a disorder, a neurodevelopmental disorder of emotion dysregulation. So what does this mean? It means that we do find more than just inattentiveness, hyperactivity, and impulsivity. These would be the criteria mainly in children, and in adults this plays out quite differently. So when a patient or someone comes to our department, we have a special section for the diagnostics and the treatment for ADHD in adults. We do a very, very thorough clinical interview, and we're trying to get the full picture because we need to know, is it first of all, is it really ADHD? And yes, if it is, what else is there? And because adults with ADHD also have other comorbidities such as depression, anxiety, substance abuse, so there is a whole range of other mental disorders that we need to be looking out for. So first of all, when we do the clinical interview and the testing, we are very carefully looking out for, do any of the symptoms a patient presents with, for example, inconsistent attention? Could they be explained by any other condition? So we only give the diagnosis first of all if there have been symptoms in childhood already. It doesn't have to be diagnosed in childhood, but symptoms have to be present in childhood and if no other mental disorder explains the symptom a patient presents with. So, for example, there is a big overlap with depression and often, especially women, because they don't have such strong signs of hyperactivity, they have a more internal restlessness or an internal kind of tension, but they don't look hyperactive. So, if we have a symptom like inconsistent attention, we really closely look at, could it be attributed to depressive symptoms or is a depression alone? Because symptoms like hyperactivity in attention and impulsivity can really be mimicked by many other mental disorders.
Polina:
7:37
You mentioned the importance of symptoms in childhood. So if I never had any symptoms during childhood, can I develop ADHD in adulthood, or is it than not the case?
Dr. Lenka Staun:
7:50
It's pretty unlikely. I mean, there are different schools, schools diagnostics. The strict approach would be to not give ADHD if there haven't been signs of attention deficit hyperactivity in childhood. However, often it's masked and this is the problem that, especially girls, being kind of growing up in school, they might not present with the same kind of visible and noticeable symptoms as maybe boys with ADHD do. So it's often not picked up and good performance, for example, it doesn't mean you can't have ADHD. So, often patients are not diagnosed who are very smart, who have ways of compensating for inconsistent attention, and they're not picked up in childhood. So, in later life they experience major difficulty. And then we look at the fuller picture, and then we detect the link between childhood symptoms having been mask and adult symptoms. And that's why in our department, for example, we do see patients who, you know. We recently had an architect of 50 years of age or a physiotherapist at 40 years of age who have just recently been diagnosed because they've never been, either they haven't taken their symptoms seriously and or the environment, the medical system hasn't taken their symptoms seriously. And when patients come to us, we really see a lot of suffering coming along with a diagnosis or, until the diagnosis is expressed, because it's such an effort to compensate for the symptoms an adult with ADHD suffers from.
Polina:
9:45
So if I, as an adult, for example, if I have a feeling that I might have adult ADHD, what should I do? Where can I start?
Dr. Lenka Staun:
9:55
I mean there are some kind of self-test online where you can do a screening test for ADHD to look into symptoms and then a medical professional. ADHD should only be diagnosed by experienced psychologists and psychiatrists and diagnostics take several sessions because one part is the clinical interview. Then you do executive functioning tests, testing also the attention and distractibility, and ideally also we would look into school reports or a description of partners. And then we not only test for ADHD, but the clinical interview entails looking for many other conditions such as anxiety or depression, and also personality disorder, because there's a huge overlap with personality disorder and ADHD and, unfortunately, we see many patients with borderline personality disorder who'd rather have an ADHD diagnosis but we have to disappoint them often because we see the borderline personality disorder as the leading disease, mimicking some of the ADHD symptoms.
Polina:
11:12
Right. Another interesting aspect, I think, is the interaction of ADHD with the environment. How important is our environment? For example, whether we live in a busy city or in a calm countryside, does it make a difference for someone with adult ADHD regarding the attention symptoms, or the symptoms are independent of the surroundings?
Dr. Lenka Staun:
11:35
Yes, it does, but we see it more as a kind of neurodevelopmental trajectory. So, there is a strong genetic predisposition. Adults with ADHD often have grown up in a household where their parents might have had ADHD as well, maybe not diagnosed. So, there is a genetic link, a genetic predisposition, and at the same time, the nurturing environment, mainly the attachment security, the stability in early relationships, is extremely important, whether the genetic predisposition is playing out fully or whether it's buffered. And that's maybe some new perspective on ADHD to really look at what are the early relational experiences. Because we often see patients who come from very disrupted and insecure attachments and disrupted families where they couldn't develop attachment security and hence are hyper vigilant to their external environment, being very attentive to others, watching out for what's happening next and being unable to develop the capacity to be with oneself and focus on oneself, on one's own emotions, but also on focusing on tasks. The external environment, I think, is highly important because overstimulation exacerbates ADHD symptoms and that's part of our program at the IPU. We have a 12-session psycheducational program that leads into a mentalization-based therapy, group therapy. The biggest part of it is really to help adults with ADHD explore and find out what is helping them? What kind of environment? In the workplace, but also at home. What do they need to feel less distracted or to be less distracted and to be able to focus more?
Polina:
13:39
We already mentioned that sometimes what's present, especially in children, is their school performance is different and that's often seen as some kind of indication that there might be something. So, can people in academia, if they are academically actually successful, can people in academia have ADHD? And what are maybe some misconceptions about adult ADHD in specifically academic and professional settings? So, you mentioned you had an architect or a physiotherapist. It seems like people who are successful academically still can have ADHD.
Dr. Lenka Staun:
14:16
Yes, indeed. Academic performance really doesn't mean you can't have ADHD. All the contrary, I would say the common misconceptions is that ADHD really affects professional development and academic achievement. However, we this is not the case, or it can be the case, but it's not necessarily the case. So, if someone with ADHD in academia might have developed very good coping strategies, and might have compensated a lot for attention difficulties, and might have found a good way to compensate for it. However, if you ask affected adults in academia, they often say how much of an effort it is to mask their symptoms so that nobody notices, because they fear rejection. They also fear being discriminated, and they fear consequences. So, they're trying to disguise their symptoms, which creates a lot of pain and sometimes also feelings of isolation.
Polina:
15:21
Maybe let's explore this topic a bit more. How can adult ADHD actually affect, in what ways it can affect academic and professional performance, and what we can learn from that?
Dr. Lenka Staun:
15:32
Yes. So since we are kind of embedded into an academic institution, the International Psychoanalytic University, we do see a lot of students presenting with ADHD. We also see academic professionals coming for testing and the main kind of symptoms they describe is procrastinating, not being able to finish a task, not being able to finish the master thesis, especially tasks that are associated with sustained attention, a little bit of boredom, so, repetitive tasks where you need a long span of attention, like writing your thesis. P atients do come forward often when they're about to fail their thesis or an academic achievement and that's when they want to look into what do they really have.
Polina:
16:25
Are there any instruments for them in terms of coping with that?
Dr. Lenka Staun:
16:29
Yes, I would say the ADHD treatment is really based on three pillars. One pillar are the daily essentials, which are really important. Daily essentials meaning physical activity. Adults with ADHD should be doing sports, and what kind of sports is helping them to focus better is really something you have to explore for yourself whether you need more kind of aerobic sports, such as running or cycling or swimming, or whether you need kind of more calming sports like yoga or pilates. That's really individual, what you need and what might help you. So, that's the first pillar. Daily essentials means regular sleep, having establishing routines, also looking at your diet, how much sugar do you take in, how much caffeine do you consume. So, these are the daily essentials. And the second part is psychoeducation, where the focus now in kind of recent research and that's what we're doing at the IPU as well is seeing ADHD more as an emotion, as a disorder of emotion regulation. It's really important to work on the feelings, so on regulating emotions, because the better you are at understanding and regulating your own emotions and the better you get at understanding the feelings of others, the better really. The ADHD symptoms and also one major symptom I haven't spoken about, adults come forward because of relational struggles. They struggle in their relationships, they have interpersonal difficulty because of not being able to be attentive to their partners, because the ADHD symptoms really affect close relationships, cause a lot of frustration and disappointment, and that's mainly when adults present for diagnostics. So, the emotion regulation is the major part and emotion regulation can be addressed and worked on very well in group psychotherapy because you have an environment where you're mirrored by others. You also are challenged to regulate quickly shifting emotions. It's in the best sense, group therapy is a place for training emotion regulation and learning to regulate yourself differently. So, we have to recap we have the daily essentials as one pillar, we have psychotherapy, and ideally with a focus on emotion regulation and relationships. And third, we have medication, but I would never prescribe. I think it's a bad habit. How often and how frequent stimulants and non-stimulants are prescribed without really educating patients on the daily essentials, on physical activity, and without any thorough psychotherapy that addresses emotion regulation.
Polina:
19:34
Another question I was thinking about is how important is it to actually getting an adult ADHD diagnosis if you weren't diagnosed as a child? So, for example, if someone is coping relatively well, maybe having some strategies, does it actually change much if an adult gets the diagnosis?
Dr. Lenka Staun:
19:57
Yes, it does, because often there's so much hidden. You know that people, because of being ashamed for their symptoms, their struggles as well, that often it means a huge relief to be given a diagnosis and to name what you couldn't make sense of before, where you realize it is such an effort to go through normal life. Writing a master thesis is difficult enough for a non-neurodivergent person, for an adult with ADHD it's a huge effort and a huge challenge, and the diagnosis as an adult can be a starting point also to look for how can I get better in terms of what do I need in my environment, at my workplace, to how can I structure myself better, how can I work on my emotions to then also have less symptoms. And, for example, I mentioned the relational aspect of ADHD, we often see patients who tell us, you know, I get a completely freak out when I have to do the shopping. Even with the list, with a shopping list, it's so stressful for me to be overstimulated in the supermarket, then I forgot the money or my car, then I forgot the shopping list, and even on the smartphone, you know I I'm so stimulated with everything that's around me in the supermarket, and then they start talking to their partners, and discuss maybe I can do something else in the house or, if you know, given that doing the weekly shopping is such a stressor and that's what we encourage our patients to, because ADHD is so varied and people suffer in so different ways, that we really encourage our patients to discuss with their partners, also at work, what they need to feel to be able to focus better and regulate their emotions better. And one major part is the overstimulation.
Polina:
21:55
So, as I understand, you're talking about accommodations, right? So there can be many different ways to accommodate that, different settings,. So maybe you have any ideas specifically for academic environment or for students. What is the range of accommodations?
Dr. Lenka Staun:
22:14
Some people benefit from having like a studying buddy in a way. You study together, you write your theses together, so, you're more accountable and you can't get too distracted. You also have a routine together. This can help. Also have a sports buddy. It's quite a slippery slope between not being alone, of course, being with too many people is also distracting, not being overstimulated at the same time, not feeling isolated, because often feeling isolated really contributes to more depressive feelings and then, you know, going along with procrastinating. So, having a buddy, a studying buddy, could be helpful. Also having clear breaks that you divide the day into sections where you have to focus in, sections where you do active breaks, like sports during your break, where you meet up with someone for lunch break at a certain time. Anything that establishes a pattern and a routine is helping and, for example, some people can't work in a large scale office because it's too noisy and too distracting and then a smaller, quiet work environment could be helpful.
Polina:
23:30
I'm wondering how COVID pandemic affected the symptoms in people with ADHD, because there was a lot of time when many people, especially young adults, were isolated. Did you notice any worsening?
Dr. Lenka Staun:
23:44
Yes, they were affected in a very bad way because online, like students, academics in the earlier phases they had to, everything was done online, and being able to focus online is extremely difficult when you don't see the full body of the lecture. When you can see your class, you can relate to others. So, being stuck in front of a screen for eight hours during the pandemic really didn't help and created a lot of anxiety as well, you know, of having lost your group. It's so much easier to zoom out when you're in online teaching session than when you're actually engaging, live with your teacher.
Polina:
24:27
Absolutely! I think, also having an experience of attending, for example, talks online it's different from attending talks in presence and also my first teaching experience was actually teaching online completely the entire course. So, I guess that was also more effortful for the instructors to actually engage the students, because for them it's obviously harder to pay attention for prolonged periods of time
Dr. Lenka Staun:
24:55
I think during the pandemic, many students with ADHD probably have gone missing. You know they've been lost in the course of their studies. Yeah, because the tutors can't have an eye, you know, when you're in class you can have an eye on someone. They can sit in the front row to be more attentive. You can ask questions, engage them more actively, and look after them better, and in the online format this is really difficult.
Polina:
25:23
Absolutely. I have a more practical question now. So, if I realize that I have problems focusing my attention, so let's not say that I have adult ADHD, but I notice that I have problems focusing my attention. Are there any ways, or maybe exercises, how I can work on that, for example, meditation or some kind of mindfulness practices?
Dr. Lenka Staun:
25:44
Yeah, meditation, mindfulness exercises are extremely helpful because they allow us and they enable to focus attention to how one feels, but also focusing to the environment. What do I listen to, what do I observe, what do I feel? So, meditation and mindfulness exercises are very helpful. And how we often start with ADHD adults is this body check, this quick check, where am I, how do I feel right now, how do I feel in my body? Because often patients with ADHD are not very connected with their body. Their body is really disconnected. So, before we start, checking in with our bodies, do I feel heavy, do I feel light, do I feel a sense of joy, do I feel sad? And where in the body? We work a lot on linking emotions with a body to really train our patients in where do I feel certain emotions in the body, because then ADHD has a very physical expression. And we observed, and there are studies supporting this, we observed that when you're more able to express your feelings and you're more able to read your feelings, you're more aware of your feelings, the symptoms really change and the hyperactivity, the distract ability, they really change the more you learn to express your feelings. T he body in all the physical activity and being fidgety is expressing something that the adult with ADHD can't express yet in words.
Polina:
27:33
I think it circles back nicely to the idea that you express that ADHD as an emotional regulation problem.
Dr. Lenka Staun:
27:42
Yes, and that's why often patients, you know, they come to us and they're very frustrated because they've done cognitive behavioral therapy. It hasn't worked. And they come to us and say please don't give me another checklist, another protocol, I hate these, they don't work. And then we do it with a very different approach. We do it in a way really exploring their feelings in relation to themselves and in relation to others, and to make them notice, you know, what brings about a change in the ability to focus and also in their kind of emotion disregulation. And so, we really want patients to be kind of scientists of themselves and to find out, with our help, how certain emotions are represented in their bodies. I'm still very surprised that this approach, so we're the first research group, together with a group in a research group in Geneva by Martin Debanne and Nader Perroud, we work on a multi-center study researching mentalization- based therapy for ADHD in a group setting, and I'm still surprised that ADHD, despite its high prevalence in adults and the need to develop new treatments, that the treatment options are still so limited. So, in Berlin, for example, we're the only place offering specific mentalization- based treatment for adults with ADHD in a group setting and the results so far are extraordinary because patients improve substantially in quite short time
Polina:
29:27
That's kind of very sad to know that there's definitely not enough research going on on this topic, but also quite promising that you also get quite good results from your approach.
Dr. Lenka Staun:
29:40
Yeah, and I think the whole approach has to change a little bit, from seeing it only and that's, I feel, the shortcomings of of cognitive behavioral therapy, that ADHD is not just a disorder of executive functioning. So, the treatment approach also has to change, seeing it more as a disorder of emotion regulation. This idea also that you can have a genetic predisposition, but it actually matters how your attachment, how secure your attachments have been in early childhood, that this substantially influences how you develop or to what extent you develop ADHD as a child and late in adulthood. This is really neglected in the current more CBT- based treatment approaches.
Polina:
30:32
And clearly shows the link between cognitive and affective sides of human nature. Could you think of one piece of advice that you could give to students and early career researchers?
Dr. Lenka Staun:
30:47
That's a good question. I think I would suggest to hook up with other students or researchers in early career who also have similar struggles, and there's, for example, a great website, ADD Magazine it's called, that's very thorough and there are quite good internet-based resources. I feel the most important part is to not be ashamed anymore of the diagnosis and to reach out for others who struggle with similar difficulties and To seek professional help, because there's a lot that can improve with ADHD in adults.
Polina:
31:31
That's great. Thank you very much. So we are heading towards the end of our podcast and if you were to give a little homework or maybe some kind of little cue for our listeners, what they can do until the next episode, like a little task or maybe something they can reflect on, what would that be?
Dr. Lenka Staun:
31:52
Yeah. In psycheducation education part, we do one exercise which the patients often really like. So, I would like to ask the listeners, the audience, to think about the basic emotions - anger, anxiousness, joy, disgust, surprise, and sadness and think about where in the body do I feel anger and what's the quality of anger in my body. To find adjectives, this is actually quite difficult to describe. Where in the body do I feel anger? How does it feel, what does it feel like? And then think of a recent example where I felt this way and to counterbalance it with, for example, joy. So, where in my body do I feel joy? Is it a warm feeling? Is it encompassing the whole body? Is it only related to certain body parts? And where did I recently feel this joy? In what situation did I feel the joy? And this is really important because the more we are aware of the connection between the affect and the body, the better we're able to to identify emotions and then to express emotions.
Polina:
33:03
Thank you for this insightful conversation. Before I close, I would like to invite you to check the show notes, where you can find the link to the transcript of this episode, ways to get in touch with us and other useful details, like the lin k that was mentioned. Subscribe to the Smart and Well podcast on your preferred podcast app. You're welcome to share it with your friends and colleagues. Thank you for listening. Be smart and stay well.
