Burnout looks remarkably like ADHD on a self-report symptom checklist.
Physicians have misdiagnosed four of my clients with ADHD over the past several years. These individuals have big jobs. They carry a lot of responsibility and work huge hours. They can’t take a break when they get tired, and so they burn out. By the time I meet them, their burnout has been running for years.
In all four cases, I haven’t been able to see any symptoms of ADHD. I have looked because I don’t want to recommend someone come off ADHD medication without a firm basis. But after six months of working with two of these clients, and a couple years of knowing the other two, I have seen no evidence of ADHD in these individuals.
I’m not suggesting that high achieving people do not sometimes have ADHD. Of course they do. What I’m talking about in this post is that sometimes physicians diagnose people with ADHD when they haven’t got it.
ADHD meds can feel like a godsend when you’re tired and your mind isn’t working clearly.
When you’re in burnout, your concentration is shot. You can’t remember details. You can’t sustain your attention. If you’re given ADHD meds, you may magically have better focus. Who wouldn’t appreciate that when you are exhausted, and your success depends on your ability to keep going?
University students use ADHD meds to cram for exams. When I was a teaching assistant in an undergraduate university course, I surveyed the class to see how many students used ADHD meds to study for finals. Seventy out of seventy hands went into the air. Every single student had used ADHD meds off-script to help them absorb information they needed to retain.
When your brain is exhausted, it’s not healthy to falsely prop yourself up.
Shouldn’t you call uncle when you are in burnout? ADHD meds can make it possible to push yourself beyond reasonable limits. Your body is drained. The energy the meds summons isn’t real. They’ll take you further into burnout.
A client’s physician recently asked him to complete an ADHD self-report checklist.
A month ago, a client told me that his physician wanted to put him on ADHD meds. I was flummoxed. I have known this man for a year. He has shown no symptoms of ADHD.
He had answered most of the questions on the checklist in the affirmative. His score was high enough to suggest he has ADHD, if his results weren’t interpreted carefully.
I had an epiphany. Perhaps this experience explains why my other clients were misdiagnosed? The answer turned out to be, yes.
Checklists are used to diagnosis ADHD without considering the possibility of a false positive.
A symptom checklist shouldn’t be used to make a diagnosis without further investigation because the checklist might be picking up something it wasn’t designed to measure. The checklist may accurately measure ADHD, but it may also falsely suggest that people in burnout have ADHD, too. In technical language, this means the test might not be valid outside its intended use.
As my client and I reviewed the questions on the checklist together, the lights really went on for me. My client had endorsed questions in the affirmative because he is in burnout, and not because he has ADHD.
If a physician is moving quickly, she may hear a patient complain about not being able to focus and think ADHD and not burnout.
Physicians have to reach conclusions quickly. They can’t practice like psychologists, who can interview a client for an hour to get to the root of an issue.
As I pondered the other four cases of misdiagnosed ADHD that clients have brought to my practice, I remarked that all four individuals had been in burnout when they were diagnosed.
What does burnout look like?
Someone in burnout has difficulty concentrating. You read four times slower than normal but struggle to absorb the information. You can’t follow a group discussion. You forget where you put your house keys and where you parked your car. You need to write everything down. You miss appointments. You forget commitments. You’re sleep deprived. The sleep you get isn’t restorative. You lose interest in things you normally care about. You stop exercising. Grocery shopping overwhelms you. You stop cooking. You disengage socially. You become depressed.
Consider how someone in burnout will respond to questions designed to identify the presence of ADHD on a self-report checklist.
I downloaded a stack of ADHD self-report checklists from the internet and looked at the questions being asked. I selected the ASRS-v1.1 Symptom Checklist to take a closer look at because you can easily find a copy on the internet.
After you’ve read the discussion that follows, you will be able to review the ADHD screening tool that your physician asks you to complete with a critical eye. Think about whether the test will accurately catch ADHD, or whether it might erroneously quantify your burnout instead.
When I was in my post-doc year as a psychologist, I was taught to ask patients to verbally respond to questions on symptom checklists, rather than have them complete the test using a pencil. This is not standardized procedure for how to administer a test, so it’s not widespread practice. But the novel approach of verbally going through a test with a patient can give a psychologist — or a physician — insight into why the patient gives a particular response to a question, and thus can yield much more information than if the patient simply ticks boxes on a form.
Analyze the responses that someone in burnout would give to questions asked in Part A on the ASRS-v1.1 Symptom Checklist.
Possible responses to the six questions in Part A of the ASRS-v1.1 Symptom Checklist are Never, Rarely, Sometimes, Often, and Very Often. To appear as though you have ADHD, you have to respond Often or Very Often to at least four of the six questions below.
The instructions for scoring Part A of the ASRS-v1.1 state, “If four or more marks appear in the darkly shaded boxes with Part A (i.e., if you respond Often or Very Often to least four questions), then the patient has symptoms highly consistent with ADHD in adults and further investigation is warranted.”
These instructions are important to the proper administration of the test. The authors clearly state that the checklist should not be used to diagnose a patient. Rather, the authors direct practitioners that further investigation is warranted when a person achieves a high score.
Have you been diagnosed with ADHD but question whether you have it?
If you’ve been diagnosed with ADHD but question whether you have it, the following section of this post may shed light on your situation. I hope, if it’s appropriate, that this post can help you determine whether to stop taking an inappropriate medication and allow yourself to heal from burnout.
Text reproduced directly from Part A of the ASRS-v 1.1 Symptom Checklist appears in italic font below.
Question 1. How often do you have trouble wrapping up the final details of a project once the challenging parts have been completed?
Someone in burnout will endorse a response of Often or Very Often to Question 1. You have trouble wrapping up everything. You can’t remember what you read. Your focus is shot. You can’t concentrate.
I anticipate you can see where we are heading. Remember that the validity of a test is important. The ASRS-v 1.1 Symptom Checklist is good at capturing symptoms of ADHD. But so far, it appears that the ASRS-v 1.1 is vulnerable to also capturing symptoms of burnout.
Question 2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
Someone in burnout will respond Often or Very Often to Question 2. You misplace your phone. Your car keys go missing. You miss appointments. You absolutely have difficulty getting things in order.
It’s also unlikely you will say, “Wait, that’s my burnout talking,” as you complete the checklist. Instead, you will feel relieved that someone is aware of your problem and is going to help you.
Question 3. How often do you have problems remembering appointments or obligations?
Someone in burnout will respond Often or Very Often to Question 3. Difficulty remembering appointments or obligations is a symptom of burnout.
Question 4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
Someone in burnout will respond Often or Very Often to Question 4. When you’re in burnout, you can’t initiate tasks. You find it difficult to simply buy groceries, so you avoid or delay going to the store. If a task requires a lot of thought, you’re going to be hard pressed to get started.
Question 5. How often do you fidget or squirm with your hands or feet when you have to sit for a long time?
My client who was given an ADHD questionnaire to complete a month ago answered Question 5 by marking Very Often. I had to think about his response for a minute, but you do fidget or squirm when you’re in a meeting and you’re burned out. You’re trying to stay awake, so you doodle, or you bounce around in your chair.
Question 6. How often do you feel overly active and compelled to do things, like you are driven by a motor?
When I was writing my doctoral dissertation, I was in heavy burnout. I had to complete the project within a three-month window or leave campus ABD (all but dissertation). I pushed myself hard. I felt compelled to finish the project. I completed the statistical analysis. I wrote like a fiend. If you had approached me during this period and asked me to respond to Question 6, I would have responded Often or Very Often because I felt overly active and compelled to do things.
Analyze the responses that someone in burnout would give to questions asked in Part B on the ASRS-v1.1 Symptom Checklist.
Part B of the checklist isn’t used in the scoring. However, the Instructions page states, the frequently scores on Part B provide additional cues and can serve as further probes into the patient’s symptoms.
Possible responses to the eleven questions in Part B of the ASRS-v1.1 Symptom Checklist are Never, Rarely, Sometimes, Often, and Very Often. Let’s look at these questions to see whether burnout can continue to masquerade as ADHD on the checklist.
Text reproduced directly from Part B of the ASRS-v 1.1 Symptom Checklist appears in italic font below.
Question 1. How often do you make careless mistakes when you have to work on a boring or difficult project?
When you’re in burnout, you will endorse Often or Very Often in response to Question 1 of Part B. You make a lot of careless mistakes because you’re exhausted. You misfile documents. You forget to reply to emails. You pour coffee in your cereal bowl in the morning.
Question 2. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
When you’re in burnout, you will endorse Often or Very Often in response to Question 2. You have difficulty keeping your attention on anything, let alone boring or repetitive tasks. You let the kettle boil dry on the stove. You run the dishwasher without adding soap or you add soap but don’t turn on the dishwasher.
Question 3. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
When you’ve in burnout, you will endorse Often or Very Often in response to Question 3. You have difficulty concentrating on what people say to you. Following a conversation that involves more than two people is crazy hard. You avoid seeing your friends so you won’t have to track what they say.
Question 4. How often are you distracted by activity or noise around you?
When you’re in burnout, you will endorse Often or Very Often in response to Question 4. Distractions aren’t your friend when your ability to focus is compromised. It’s difficult to focus on a complicated argument when a television is playing in the background at the best of times, let alone when you’re in burnout.
Question 5. How often do you leave your seat in meetings or in other situations in which you are expected to stay seated?
I immediately recalled that the burned out client who inspired me to download a copy of the ASRS-v 1.1 shared that he walks out of meetings because he can’t focus. He gets up and moves to try to refocus his attention. Based on this vignette, when you are in burnout, you will endorse Often or Very Often in response to Question 5.
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So far, this analysis confirms that someone in burnout will masquerade as having ADHD based on their responses to questions asked in Part B of the ASRS-v1.1.
In a similar way, people in chronic pain endorse symptoms of depression on questionnaires designed to identify the presence of depression. I learned this when I worked at a chronic pain clinic. New patients entering the day treatment program appeared to warrant a diagnosis of Major Depressive Disorder, Episode Severe, if you looked only at their scores on the depression inventory. But after interviewing them, the vast majority turned out to not be depressed.
This happened because chronic pain and depression share a number of overlapping symptoms. Someone with chronic pain has difficulty sleeping, has difficulty getting moving, and doesn’t participate in activities they used to enjoy, just like someone with depression.
This is why the Chief Psychologist asked me to verbally go through the answers to questions posed on symptom checklists with patients when I was in my post-doc year. She wanted me to learn to not take the results of checklists at face value.
Results from the ASRS-v 1.1 can similarly lead to a misdiagnosis if the results are interpreted at face value. Without further investigation, if a diagnosis is made based on your written responses to the questions posed in the checklist, then you will likely be told you have ADHD when you are in burnout.
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Let’s finish going through the questions in Part B of the ASRS-v1.1.
Question 6. How often do you feel restless or fidgety?
Question 6 requires more thought to interpret. If you have a developmental trauma history, and/or are in a high-pressure situation in which things aren’t going well, then fidgeting can be your body’s natural attempt to help you regulate your nervous system. All five of my clients had developmental trauma backgrounds and were in high pressure situations when they were assessed for ADHD.
Question 7. How often do you have difficulty unwinding and relaxing when you have time to yourself?
When you’re in burnout, you will likely endorse a response of Often or Very Often in response to Question 7. You are sleep deprived. Your sleep isn’t restorative. You can’t unwind or relax.
Question 8. How often do you find yourself talking too much when you are in social situations?
When you’re in burnout, your social skills are not optimal. If you are naturally chatty, you will likely endorse a response of Often of Very Often in response to Question 8. Remember, however, that you don’t need to receive a perfect score to appear to have ADHD on the checklist.
Question 9. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to before they can finish them themselves?
Because your social skills are impaired when you are in burnout, you may endorse Often or Very Often in response to Question 9.
The five clients I have written about in this post are all gifted adults. I share this because a characteristic of gifted adults is that they finish the sentences of the people they are talking to. If you are like one of these five clients because you are gifted, you will endorse Often or Very Often in response to Question 9.
Question 10. How often do you have difficulty waiting your turn in situations when turn taking is required?
When you are in burnout, you have little energy and thus little patience. You need to get things done and so you struggle when you are kept waiting. You will endorse Often or Very Often in response to Question 10.
Again, difficulty waiting your turn is a characteristic of gifted adults.
Question 11. How often do you interrupt others when they are busy?
You have no energy when you are in burnout. You need to get things done, however, so you likely find yourself interrupting others when they are busy. You will endorse Often or Very Often in response to Question 11.
Again, interrupting others is a characteristic of gifted adults.
Two mental health practitioners agree on a diagnosis 27% of the time.
If you ask two mental health practitioners to give a diagnosis, their responses agree only 27% of the time. This often comes down to what questions the mental health practitioners ask the patient, and what biases they carry with them. For example, a colleague with expertise in autism diagnoses autism much more frequently than other mental health practitioners. On occasion, she has been found to be found.
If you’re looking for ADHD, then you’re going to find it more often than someone who isn’t looking for it.
If, like me, you have a lot of experience working with people in burnout, then you’re going to look for burnout in your clients, in addition to possible ADHD.
I hope you have found the content of this post helpful. I am personally in a better position to help the next client who enters my practice with a questionable diagnosis of ADHD because I completed this thought exercise with you.
— Dr Patricia Turner, PhD, Registered Psychologist in Private Practice in Calgary, Alberta