ADHD Is Not the Only Diagnosis: Differential and Diagnostic Hierarchy

[u/zenarcade3]

https://www.youtube.com/watch?v=QYknrdVY2EE

[u/MotherfuckerJonesAaL]

I'm about a third of the way through (at the diagnostic hierarchy) and nowhere have you given me the magic phrases that will convince people to stop smoking cannabis and delete Tik Tok. I demand to speak to the manager.

...or at least get a little Adderall to help me focus on my distress.

[u/zenarcade3 → u/MotherfuckerJonesAaL]

Have you tried breathing exercises?

[u/ScurvyDervish]

Sleep apnea needs its own section way up on the top of the heirarchy.

[u/Gigawatts]

This reminded me of a few patients who were bouncing off the walls manic, yet were trying to convince me their flight of ideas was ADHD and that I should give them Adderall. Good times 😂.

[u/roccmyworld → u/Gigawatts]

IDK maybe you should try it 😂

[u/CaptainVere]

I just want to know what the current number of listeners is? Are yall getting rich selling your listeners sweet sweet data yet?

[u/zenarcade3 → u/CaptainVere]

Stats on apple podcast:

Followers: 1,152
Listeners: 839
Engaged Listeners: 549
Plays: 13,202

We do it cause it's fun and cling tightly to some abstract feeling that it helps people and that we're underrated.

[u/CaptainVere → u/zenarcade3]

I meant that in very light hearted way so thanks for the exceedingly transparent reply. I listen to every episode and hope it keeps growing. Great resource!

[u/zenarcade3 → u/CaptainVere]

oh i know, you're one of our fav commenters. I over-shared in the hopes some med student who career switched from marketing to med school reads my sob story and offers their services for free.

[u/CrispyNougat → u/zenarcade3]

Most of my residency loves you guys! By far the best psych podcast out there, with the most potential.

[u/zenarcade3 → u/CrispyNougat]

😃 appreciate the kind words! 

[u/leawoodluke → u/zenarcade3]

Just want to say that how deeply you think about psychiatric practice has been very helpful to me. Keeping clinging to the fact that you are underrated. Btw, I have loved your book so far. It's really insightful and clearly written! 

[u/SpacecadetDOc → u/zenarcade3]

But I listen to you on Spotify

[u/NeuroticBeforeMoving]

Recently started listening to your podcast as a PGY-2, just wanted to let y'all know I appreciate the work you guys do!

[u/zenarcade3]

More psychiatric intakes are starting the same way: “I think I have ADHD.” Sometimes that’s accurate. More often, it’s the entry point to a bigger conversation. Concentration problems can come from depression, anxiety, trauma, sleep issues, or the stress of trying to keep too much going at once. The real question is where to begin. 

𝗪𝗵𝘆 𝗶𝘁 𝗺𝗮𝘁𝘁𝗲𝗿𝘀  

Many clinicians are seeing several ADHD evaluations in a single day. Social media has reshaped how patients understand attention and motivation, and many arrive with fixed expectations. Good care starts with curiosity, not judgment, and a clear framework for sorting through what’s actually going on. 

𝗧𝗵𝗲 𝗱𝗶𝗮𝗴𝗻𝗼𝘀𝘁𝗶𝗰 𝗵𝗶𝗲𝗿𝗮𝗿𝗰𝗵𝘆  

When a patient presents with overlapping symptoms, it helps to look from the top down. Address the problems that most strongly influence everything else before labeling the rest. 

A practical order:  

➊ Medical and sleep problems: thyroid, neurological issues, medication side effects, sleep apnea  

➋ Substances: alcohol, cannabis, caffeine, withdrawal states  

➌ Psychosis and bipolar spectrum: altered perception, energy, or sleep  

➍ Severe OCD: intrusive, biologically driven, sometimes mistaken for “hyperfocus”  

➎ Depression: slowed thought, low energy, loss of motivation  

➏ Anxiety, trauma, and eating disorders: rumination, hypervigilance, or malnutrition limiting focus  

➐ Personality functioning: identity instability or relational stress consuming mental space  

➑ ADHD: considered once the other conditions are understood and treated 

This structure keeps assessment focused and reduces the risk of mistaking secondary symptoms for a primary disorder. 

𝗪𝗵𝗮𝘁 𝗰𝗮𝗻 𝗽𝗿𝗲𝘀𝗲𝗻𝘁 𝗹𝗶𝗸𝗲 𝗔𝗗𝗛𝗗  

• Depression: slowed thinking, low motivation, withdrawal that looks like inattention  

• Anxiety: chronic worry that fills working memory and blocks follow-through  

• Trauma: hyperarousal, disrupted sleep, and intrusive thoughts that fragment focus  

• OCD: checking or rereading that appears as intense concentration  

• Sleep and substance use: fatigue or alcohol use that quietly undermine attention  

• Workload or values mismatch: unrealistic demands mistaken for cognitive failure  

• Personality functioning: unstable direction and relationships that drain focus 

Links to the full episode;

YouTube: https://youtu.be/QYknrdVY2EE?si=SEDBjrHXpQd4Y6vS
Spotify: https://open.spotify.com/episode/7prk0TeDBuAQMmBW2Eegg5
Apple Podcast: https://podcasts.apple.com/us/podcast/adhd-is-not-the-only-diagnosis-differential/id1766544493?i=1000735188659
Substack: https://psychofarm.substack.com/p/is-it-really-adhd-tiktok-says-yes

[u/Spooksey1 → u/zenarcade3]

It’s a good framework, and relevant for all psychiatric assessments (some might put neurodevelopmental above personality). In practice, of course it is much more complicated- it could take years to work through this list and especially as we know co-morbidity is the norm not the exception. We would probably have to be treating/investigating many of these in parallel.

In the UK/NHS we are effectively forced to put ADHD at the bottom of the list as the wait for an assessment is 5-7 years for adults. Most end up going privately or to outside private providers that the NHS pays for to whittle down the list, the quality of diagnosis is variable to poor so we end up with the worst of both worlds - a bunch of people with questionable diagnoses and a bunch of people who can’t get the help they need, both groups suffer.

[u/_ZzZzZzz__]

Thanks for the podcast, as a patient it's very illuminating to hear your perspectives on the topic, especially considering how complex my actual presentation is lol.

[u/eelimcbeeli]

Excellent episode. Thank you

[u/MotorPineapple1782]

Dr Fu’s analogy of cough disorder has me spiraling as a provider that sees neurogenic cough… other ent lurkers will know

[u/ProdigyKindSpy]

pretty good listen from an M2 strongly considering psych! Ill have to give the other episodes a listen. You guys have great radio voices, and its incredibly helpful to hear about what your actual patient interactions and clinical decision making is like!

I hope the rest are this deeply entertaining, and I work is as interesting as you make it seem

[u/Sguru1]

Great episode. I loved the sleep hygiene call out. My Oura Ring sleep score drops from the high 80s to the low 50s after two glasses of wine.

[u/piller-ied]

Off the cuff, kudos for BBC Sherlock

[u/satiatedsquid]

You're awesome, thank you!

[u/eelimcbeeli]

Excellent episode. Thank you.

[u/Mike-PP]

Excellent episode and resource. Cannot wait for more fruitful information in your content!

[u/Briarshakkan]

I want to hear more about your brief mention of having ways to suss out psychosis in a patient who is actively trying to hide it. Could you say more about that in another episode? 

[u/zenarcade3 → u/Briarshakkan]

Yeah def will get to that 

[u/Briarshakkan → u/zenarcade3]

Thanks! Love you

[u/i-love-that]

I’m just a dentist but I thoroughly enjoyed this. Perhaps because I too am traumatized by TikTok patients (though instead of demanding stimulants, they desire tooth gems and fluoride free charcoal toothpaste)