Why Adults With Undiagnosed ADHD Often Turn To Self-Medication
This is the second story in a series exploring adult ADHD. You can read the series’ introductory post here.
For years, loved ones and coworkers would hurl similar statements at me:
“How many times do I have to tell you??”
“Just pick one thing and do it!”
“Have you even been listening to me?”
“I was surprised when you called; I didn’t think you were that into me.”
“Why are you always late?!?”
These, of course, comprise the kinds of complaints people with ADHD field all the time. Yet it took decades for the dots to be connected in my own life; I thought I was the opposite of ADHD because I couldn’t function without multiple stimuli at any given time. But it turns out my need for greater stimuli is perfectly aligned with the diagnosis — and so was the way I used substances to fulfill that need.
In the more than 10 years between graduating from college and a doctor friend encouraging me to seek an official diagnosis, I used anything and everything within reach to mitigate the intense discomfort of extreme, untreated ADHD. At the time, of course, I had no idea that’s what I was doing. I was simply trying to not be miserable by dumping available substances like caffeine and alcohol onto symptoms I assumed to be unrelated and/or the fault of my personal shortcomings. As I described in the first post of this series, I “required substances to become bigger (caffeine) or smaller (alcohol or pot or some combination of the two) to blend in with the size, or speed, of my surroundings.”
I didn’t realize I was attempting to force my brain to work counter to my neurobiology and that attempting to make my brain function in the linear way required by so many tasks in our culture was a futile effort. Such an experience, however, is typical.
Self-medicating without realizing it is fairly standard for the undiagnosed adult — and thus an examination of a person’s substance use can be an effective diagnostic tool.
Little concerted effort is made to educate the general public about neurodivergent conditions like ADHD, and so it continues to go mischaracterized. When I tell people I’m ADHD they assume that means I’m going to run literal circles around them and bounce off every available wall. But the notion that ADHD equals an inability to sit misses so many of its actual components — most of which we feel internally.
Therapist and author of Loving Someone with Attention Deficit Disorder Susan Tschudi calls ADHD “an allergy to boredom” — very much the antithesis of the colloquial and ableist offhanded remarks where, for example, being “sooooo ADD today” typically means being easily distracted, rather than lacking in adequate sensory input.
Because most people don’t know what the symptoms look like — just as I hadn’t — they don’t realize their challenges are connected. And as a result, their loved ones just think they’re frustrating or lazy or bad at communication. The interpersonal conflict reinforces the internal negative self-talk of the undiagnosed individual — “I can’t do anything right,” “I never finish anything,” “I’m just not very smart,” etc. — which often leads to heavier self-medication.
The cycle reinforces itself.
This cycle is so common and so often coupled with anxiety that Tschudi asks patients about their substance history when she screens for ADHD, and inquires about ADHD symptoms when they reveal a substance abuse history.
“When I do my initial interviews and someone mentions early involvement with drugs, I always follow up on that,” she tells me. Not only do many people with ADHD use substances to quell the internal anxieties and insecurities of living undiagnosed, but because of our differences in neurobiology, drugs have a different effect on us.
Cannabis, for example, can help address actual ADHD symptoms. Tschudi tells me, “Marijuana can really help ADD — not just by chilling out the anxiety, but actually, what I hear more often is: ‘It helps me with focus.’”
This certainly resonated. Finally getting my medical marijuana card here in California was life-changing. Sure, pot was around during my bartending years, but it was never the primary substance I sought out. I smoked it if someone was passing it around, but the illegality made it a hassle and alcohol was free in mass quantities. When you’re broke and miserable, you use what’s easiest.
Now that it’s so much more accessible and I can shop by strain for reliable, consistent effect, medical marijuana is one of my treatment tools. Some days or parts of days my symptoms spike and having a vape pen around to head off an anxiety spiral or provide backup to my ADHD meds has been crucial. It works instantly and doesn’t zone me out the way a lot of in-the-moment pharmaceuticals can; I can take it and have functionality restored.
“For me, pot is a white noise reducer,” I tell Tschudi, who says that this is typical.
“And for people without ADD, marijuana doesn’t really have that same effect,” she says. “I mean, it can mellow people out, but I never hear anybody without ADD say: ‘Yeah, marijuana helps me focus.’ Same thing with alcohol — to a certain degree.”
I tell her that I mostly used alcohol to not feel rather than to dull the white noise, which can grant someone with ADHD a greater ability to focus. But coffee was really my drug of choice when I started clawing my way toward healing and was trying to mitigate my symptoms in a way that allowed me to almost function.
“Oh, caffeine for sure — caffeine’s a stimulant,” Tschudi says. The primary medications for ADHD are stimulants, so unhealthy coffee consumption is a red flag.
“We get a little confused with marijuana because it’s not really a stimulant, per say. In fact it usually goes the other way. But, like you say, the white noise — it just kind of slows things down enough to be able to bring them into focus,” she explains.
I’d always wondered why uppers and downers seemed to have a similar effect on me; not understanding the neurobiology of what was happening in my head and which pathways different substances work on definitely contributed to my self-doubt and anger.
Tschudi points out that not everyone with ADD will have the same response to different substances. And she notes that food, too, is often used for self-medication. “Sugar! Sugar can be very addictive for some people,” she says. “Or really empty carbohydrates. All of those foods deliver energy and energy is akin to that stimulation, so that they feel better and more focused for a moment.”
For those recognizing themselves in my story and/or Tschudi’s explanation — now what?
The process of getting diagnosed sounds daunting because anyone who made it to adulthood without a diagnosis is filled with intense self-doubt. You’re worried you aren’t actually ADHD, that you’ll be brushed off, that your doctor is one of those who thinks it isn’t real, and — often the most immobilizing — that you’ll be seen as “medication seeking.”
Anyone with a history of substance abuse, or even just borderline functional over-reliance (me, for most of my life), is understandably concerned that they’ll be second guessed and shamed for seeking treatment that nearly always begins with medication. The fear I field most often from people reaching out for resources about ADHD is that they’ll be labeled in their medical records as “medication seeking” and they want to be prepared ahead of time for the call to their doctor as well as the screening appointment. We have so much stigma around medications prescribed for mental conditions of all types that people forgo seeking help for diagnoses and symptoms they think or know have medication as a primary component of treatment.
Some primary care physicians will screen for ADHD, others (like mine) want the initial screening done by a psychiatrist. I often tell people to call their doctor and just ask if they do ADHD screenings; if they say yes and you make an appointment, it’s less stressful because they’re clearly willing to have the discussion.
Tschudi also recommends doing questionnaires like the one in the back of Driven to Distraction by Edward M. Hallowell and John J. Ratey — and try not to be disappointed that they aren’t more in-depth.
“The DSM [Diagnostic and Statistical Manual] is only like 18 yes-or-no questions,” she says. “If you get more yes’s than no’s, then you’re likely ADD.”
Tschudi acknowledges the challenge of diagnosing a condition with such a short list of subjective criteria and no definitive test. “It’s a symptom-driven disorder; there’s no blood test for it,” she says. “There’s no imaging thing people go through. So, it’s really just questions and a history. I know people who don’t think that seems valid sometimes — it doesn’t seem like it’s thorough enough, but if the pieces are there they become clear very quickly.”
Tschudi’s first three questions for new patients are based on the “three hallmark pieces” of ADHD:
“Do you have trouble paying attention?”
“Do you have trouble with organization?”
“What’s your time management look like?”
“Other questions will be crafted around those,” Tschudi explained. “I often hear people ask, ‘How could they diagnose me — they only asked me like 10 questions?’ Well, they know what they’re looking for and those responses are meaningful.”
I’m still learning how to undo the auto-responses my brain has to certain situations. For example, I struggle to recognize my impulsivity as an extension of my ADHD and give myself a destructively hard time about it. I also use the word “should” far more than is healthy to shame myself for an inability to complete things when and how I think they should be done.
ADHD weaves itself into everything from your internal dialog to your relationships to co-occurring disorders in such a way that untangling it can be a long, frustrating process. For the next installment, I’m taking another piece of Tschudi’s advice and tracking a couple of my main self-talk hiccups (including “should”) through a thought journal as part of my continuing efforts toward this detangling. I’ll also tap the experts for other helpful suggestions and therapies like mindfulness exercises for those of us who have limited attention spans.