“There’s nothing wrong with you. You’re just a hunter in an agrarian society.” That’s what my college psychiatrist said when I came to him complaining that I had trouble paying attention in lectures. Questionable analogy, I thought, but I nodded along quietly. He didn’t ask much of anything at all, just prescribed me Concerta, Ritalin, and eventually Vyvanse when the first two made my heartbeat spike in disturbing ways. I stayed on Vyvanse for about two months, and then promptly forgot to refill my prescription and didn’t think much about it for the next three years.
At that point of my life I wasn’t really sure I actually had ADHD. Sure, I had the behavioral tics—my college dorm room was terrifying, I had a lifelong problem with procrastination, and I could not tune in during lectures for the life of me, but I’d always been able to turn in assignments on time, and I could spend hours reading and writing without too much effort. I was having a terrible semester, but it seemed to me that was rooted more in emotional and family turmoil than in an inability to pay attention. Well, maybe I have it and maybe I don’t, I thought to myself. Does it matter as long as I’m doing okay? Americans love to medicalize everything.
It wasn’t until years later—sometime in the middle of 2020, to be precise—that I revisited the topic again. I looked up and it seemed like literally everyone I knew had ADHD. Two of my closest friends had been diagnosed within the last six months. Three of my other close friends had been on stimulants as long as I’d known them. Several of my Twitter mutuals casually mentioned that they’d been on ADHD medications since they were children.
I evaluated myself and my ability to get things done in the past few years. One thing became pretty clear: I was very productive when I loved what I was doing, and if I hated it became an undoable chore. I was writing thousands of words per month, but I couldn’t schedule a dentist appointment or reply to emails. This seemed to be a pattern with my closest friends, too: they were generally high-achieving and did lots of work in manic bursts of productivity, but fell into spiraling guilt when they felt demotivated and blocked. They were hyperactive, needed to move around a lot, and hyperfocused on things they were obsessed with.
There was clearly a core set of traits that people close to me shared. But if this was a disorder, why were my friends mostly doing fine (or in some cases quite a lot better than fine?) Were people in tech particularly prone to therefore ADHD? Did modern society lead an increase in ADHD rates? I wanted to figure out what was going on.
There are increasing numbers of people with ADHD
Since the 1980s, ADHD has been among the most commonly diagnosed psychiatric conditions for children in the U.S. Recent studies suggest that up to 9% of U.S. children ages 4–17, and approximately 4.4% of U.S. adults have diagnosed ADHD.
ADHD diagnoses among both adults and children in the US are rising, especially among adults—diagnoses among adults are growing four times (123% vs 26.4%) faster than diagnoses among children in the US. There’s currently no consensus on whether the numbers are growing because more kids have ADHD or because more doctors are diagnosing it.
ADHD is also becoming increasingly globalized: two decades ago, the ADHD diagnosis was primarily used in North America and a few other countries; growing evidence suggests that this is changing and that ADHD is now diagnosed in many countries around the world.
The global growth is due to five trends, according to a paper on ADHD in Social Science and Medicine: “overseas lobbying efforts by drug companies; the growth of biological psychiatry; the adaptation of the American-based Diagnostic and Statistical Manual standards, which are broader and have a lower threshold for diagnosing ADHD; promotion of pharmaceutical treatments by ADHD advocacy groups that work closely with drug companies; and the easy availability of ADHD information and self-diagnosis.”
What is ADHD?
One of the most helpful ADHD books I’ve come across is Scattered Minds by Dr. Gabor Mate. He explains that the individual with ADD “experiences the mind as a perpetual-motion machine. An intense aversion to boredom, an abhorrence of it, takes hold as soon as there is no ready focus of activity, distraction or attention. An unremitting lack of stillness is felt internally … Merciless pressure in the mind impels without specific aim or direction.”
People with ADHD have visible brain differences compared to those who don’t: the EEGs of a group of preadolescent boys with ADHD were compared to non-ADHD peers, and in the ADHD group “electrical activity in the cerebral cortex, or gray matter, slowed down just when it would have been required to speed up.”
Mate explains that it may seem paradoxical that hyperactivity of mind or body can be caused by an under-activity of the cortex, and odd that hyperactivity can be stopped by a stimulant medication, but he offers a great analogy to explain why this is the case, which I have summarized below:
Imagine a busy street corner with lots of traffic and drivers who have no capacity to regulate themselves. They rely on a policeman who ensures that the cars are allowed to make turns only in an organized fashion; traffic flow is stoped in one direction while permitted in another. Imagine if the policeman falls asleep on the job. Suddenly, cars from all directions attempt to move through the intersection, and everyone is frustrated and honking. There’s little progress. Very few cars actually make it through.
The prefrontal cortex is the policeman, responsible for inhibition, selecting what is helpful and inhibiting the impulses and inputs that aren’t. ADHD can be understood as a lack of inhibition, where the cerebral cortex is not able to perform its job; the brain is flooded with too much input and cannot decide what to prioritize. That’s where stimulants come in: they arouse the inhibitory function. They wake up the policeman, alerting the underdeveloped and under-active circuitry of the prefrontal cortex.
An ADHD checklist from ADDittude Magazine:
1. I have difficulty getting organized.
2. When given a task, I usually procrastinate rather than doing it right away.
3. I work on a lot of projects, but can’t seem to complete most of them.
4. I tend to make decisions and act on them impulsively — like spending money, getting sexually involved with someone, diving into new activities, and changing plans.
5. I get bored easily.
6. No matter how much I do or how hard I try, I just can’t seem to reach my goals.
7. I often get distracted when people are talking; I just tune out or drift off.
8. I get so wrapped up in some things I do that I can hardly stop to take a break or switch to doing something else.
9. I tend to overdo things even when they’re not good for me — like compulsive shopping, drinking too much, overworking, and overeating.
10. I get frustrated easily and I get impatient when things are going too slowly.
11. My self-esteem is not as high as that of others I know.
12. I need a lot of stimulation from things like action movies and video games, new purchases, being among lively friends, driving fast or engaging in extreme sports.
13. I tend to say or do things without thinking, and sometimes that gets me into trouble.
14. I’d rather do things my own way than follow the rules and procedures of others.
15. I often find myself tapping a pencil, swinging my leg, or doing something else to work off nervous energy.
16. I can feel suddenly down when I’m separated from people, projects or things that I like to be involved with.
17. I see myself differently than others see me, and when someone gets angry with me for doing something that upset them I’m often very surprised.
18. Even though I worry a lot about dangerous things that are unlikely to happen to me, I tend to be careless and accident prone.
19. Even though I have a lot of fears, people would describe me as a risk taker.
20. I make a lot of careless mistakes.
21. I have blood relatives who suffer from ADHD, another neurological disorder, or substance abuse.
Personally, I find this checklist remarkably vague, and it’s unsurprising to me that the proliferation of content like this online would lead to more and more people believing they have ADHD. I also find Twitter ADHD culture unsettling:
I think a lot of people identify with content like this, and not necessarily because they have ADHD. I’ve heard many people across a lot of different fields who don’t have ADHD say things like “I don’t think it’s possible to get more than four hours of really high-quality work done in a day,” and I think in fact many people feel this way: that you have a few hours of really high-effort work, a few hours of task-oriented/low-level work, and then occasionally you have streaks of being able to produce significantly more output. Sure, for people with ADHD I’m sure it’s significantly more distinct (I had a friend who told me he couldn’t concentrate on any task for more than 25 min at time), but there definitely is something misleading about memetic content that makes relatively common personality traits into something diagnosable.
This, of course, isn’t to say that distinct traits for ADHD don’t exist. In fact, when I read Scattered Minds and Driven to Distraction, I was struck by the similarity between my childhood and the hallmarks of ADHD that were described. I was reactive, all my feelings on the surface. I was also inattentive, thrill-seeking, emotionally intense, and impulsive. I needed a lot of stimulation.. A quote from Driven to Distraction:
“What is my ideal fantasy?” said one adult with ADD. “To live my day in a room with three TVs going, me holding the blipper, my PC running, the fax operating, a CD playing, portable phone held to one ear, the newspaper spread out before me, with three deals about to close.”
I was particularly struck by the chapter Mate spent talking about hypersensitivity, and how people with ADHD tend to be born hypersensitive: “It is their inborn temperament. That, primarily, is what is hereditary about ADD. Genetic inheritance by itself cannot account for the presence of ADD features in people, but heredity can make it far more likely that these features will emerge in a given individual, depending on circumstances. It is sensitivity, not a disorder, that is transmitted through heredity. In most cases, ADD is caused by the impact of the environment on particularly sensitive infants”
I was definitely hypersensitive as a kid, both emotionally and physically. I often broke out in allergic rashes all over my body. I was terrified of rejection, terrified of other kids. According to Mate, “Some human beings are hyperreactive. A relatively negligible stimulus, or what to other people would seem negligible, sets off in them an intense reaction. When this happens in response to physical stimuli, we say the person is allergic. Someone allergic to, say, bee venom may choke.”
Maté explains that if individuals with ADHD are born with a high level of sensitivity, it takes less stimulation for them to feel more overwhelmed in distracting environments. The more sensitive we are, the more likely we’ll feel pain.
The desire to avoid pain can lead to disassociation. From Scattered Minds:
“In the language of psychology, mental absence, tuning out, is an example of a mind state known as dissociation. It is employed in clinical psychiatry to refer to specific syndromes such as multiple personality disorder, but I use the term in its general sense. Dissociation, including the tuning-out of ADD, originates in a defensive need—it is a form of psychological defense. Gloucester’s motive to be “distract,” in the fourth act of King Lear, is very close to the source of the “distractness” of ADD. It is a way of coping with emotional hurt. The original purpose of dissociation is to separate conscious awareness from some emotional pain we are experiencing, to dis-associate one from the other. We may think of dissociation as a psychological anesthetic.”
Of course, while dissociation may work as a short-term coping strategy, it eventually impedes long-term psychological growth. If you’re distractible and dissociated, you end up having trouble connecting with others and coping with setbacks in a positive way.
Development vs Pathology
In Hyperactive Around the World? The History of ADHD in Global Perspective, Matthew Smith explains that “As with other aspects of ADHD and its history, the closer one examines the conditions in which it flourishes, the less it appears to be a universal, fixed glitch in neurological functioning, present in 5.29 per cent of the human population, and the more it becomes a product of culture.”
It’s clear that across multiple countries hyperactivity and inattention has been observed in children, but how ADHD is diagnosed and how much of it is perceived to be genetic versus environmental is heavily contested.
Smith writes that the globalization of ADHD could not occur without the influence of American-based psychiatry: “While several of the countries we examined have their own “origin stories” about ADHD, the expanding influence of American psychiatry, especially biological psychiatry, is of great significance. Until the 1990s ADHD was mostly diagnosed in the U.S. and a few other countries. But since the 1990s we have seen a diffusion of the ADHD diagnosis and treatment more worldwide. This comes in part from more psychiatrists being trained in the U.S. and bringing these perspectives back to their countries of origin.”
Mate asserts that American psychiatry tends to explain mental conditions through deficiencies of the brain’s neurotransmitters. If you subscribe to a simple biochemical model, “depression is due to a lack of serotonin, and can be treated with SSRIs that increases serotonin levels in the brain. Attention deficit is thought to be due in part to an undersupply of dopamine, one of the brain’s most important neurotransmitters, crucial to attention and to experiencing reward states, can be treated with stimulants like Ritalin.”
Although this model of psychiatry carries some amount of truth, Mate believes that “such biochemical explanations of complex mental states are dangerous oversimplifications.” He writes that “Recognizing that ADD is a problem of development rather than one of pathology takes us in a direction completely different from that dictated by a narrowly medical approach.” He believes that since the formation of children’s brain circuits is influenced by the mother’s emotions states, ADHD originates in stress that affects the parent’s emotional interactions with the infant.
He goes onto claim that the greater prevalence of ADHD in North America is rooted in “the gradual destruction of the family by economic and social pressures in the past several decades. This process is more advanced in North America than elsewhere in the industrialized world.” Because children are less likely to get attuned, stable, one-on-one parenting in their formative years, they’re more likely to develop attention deficiency in early childhood.
“If we choose not to see ADD as medical disorder or illness, the question of causation is turned around and examined from the opposite angle. Recognizing that time sense, self-regulation and self-motivation are nature driven and necessary developmental tasks, we ask the following: What conditions are needed for human physiological and psychological maturation? What conditions would inhibit or interfere with that growth process? Instead of asking why a disorder or illness develops, we ask why a fully self-motivated and self-regulated human personality does.”
In America we tend to prioritize medicating issues over examining the social and cultural causes of our problems. Several of my friends who are prescribed or taking stimulants worry about the long-term consequences of their medication. Thankfully, Slate Star Codex did a great deep-dive into the realistic long-term affects:
My impression is that the risks of proper, medically supervised Adderall use are the following:
1. High risk of minor short-term side effects that might make you want to stop taking the medication with no long-term issues
2. Extremely low risk of serious medical side effects like stroke or heart attack, except maybe in a few very vulnerable populations
3. Maybe one percent risk, but not literally zero risk, of addiction if patients are well-targeted by their doctors and use the medication responsibly.
4. Perhaps one in five hundred risk, but not literally zero risk, of psychosis. Some anecdotal evidence suggests it is more common than this. Most of these cases will be mild and resolve quickly. Some people find a very small number of cases of stimulant-induced psychosis may be permanent, though I still find this hard to believe.
5. Some evidence for tolerance after several years, though most patients will continue to believe it is helping them. No sign of supertolerance where it actually makes the condition worse.
6. Plausibly 60% increased relative risk (+~1% absolute risk) for Parkinson’s disease with long-term use.
7. Unknown unknowns.
While there certainly are risks, it seems that the chance of serious medical effects is relatively low. Mate suggests that adults starting stimulants should have “clear and limited expectations for what medications can do for them.” Though I’ll save this topic for a later part of this series, Scott very interestingly describes how psychiatrists spend a lot of time gatekeeping Adderall, because a lot of people want stimulants for pretty obvious reasons (in college, people would refer to the “Starbucks and Adderall” diet before finals and formals).
Why does everyone I know have ADHD?
Context: a lot of my friends are startup founders (or former startup founders who now work in other areas in tech).
A few potential causes that I’ve identified:
We do have some evidence that Internet usage is linked with ADHD:
A study published in the Journal of the American Medical Association tracked 2,500 teens over two years and found that a “significant but modest” association between teens using social media sites, video games, etc, and their risk of developing symptoms of ADHD.
The mean (SD) number of baseline digital media activities used at a high-frequency rate was 3.62 (3.30); 1398 students (54.1%) indicated high frequency of checking social media (95% CI, 52.1%-56.0%), which was the most common media activity. High-frequency engagement in each additional digital media activity at baseline was associated with a significantly higher odds of having symptoms of ADHD across follow-ups (OR, 1.11; 95% CI, 1.06-1.16). This association persisted after covariate adjustment (OR, 1.10; 95% CI, 1.05-1.15). The 495 students who reported no high-frequency media use at baseline had a 4.6% mean rate of having ADHD symptoms across follow-ups vs 9.5% among the 114 who reported 7 high-frequency activities (difference; 4.9%; 95% CI, 2.5%-7.3%) and vs 10.5% among the 51 students who reported 14 high-frequency activities (difference, 5.9%; 95% CI, 2.6%-9.2%).
Similarly, a 2016 cross-sectional study that followed 4816 graduate students described the potential link between high levels of screen time and self-perceived inattention and hyperactivity:
Overall, findings suggested that symptoms of psychiatric disorders in adults were correlated with an individual’s addictive social networking and video gaming, after controlling for age, sex, and educational and marital status.
There’s a few ways we could interpret this: one, more exposure to social media actually leads to an increase in ADHD diagnoses. Two, people who have ADHD are more likely to, say, tweet compulsively and be addicted to video games. Either way, it means that the people I meet in Twitter and my real-life friends, all of whom are heavily online even relative to a generation that’s by default heavily online, are probably a biased sample.
Hyperfocus is a symptom of ADHD. It’s what I experienced as a kid when I could read for hours and hours without any desire to stop or any awareness of the outside world (actually, I guess you could say it persists today).
At its best, hyperfocus is equivalent to a flow state—a “state of mind in which you are so immersed in a task that you become (not to sound too far out) one with it. PET scans have shown that the hyperfocusing brain literally “lights up” with activity and pleasure.”
Hyperfocus is clearly really useful if you want to program for days on end to finish an app, or you’re trying to hit a deadline for your startup. It’s unsurprising that startup founders would benefit from the ability to hyperfocus and subsequently be more likely to have ADHD.
From Scattered Minds: “Men and women with ADD have about them an almost palpable intensity that other people respond to with unease and instinctive withdrawal.” From Driven to Distraction: “That intensity may in part explain why ADD is common among people in high-energy fields, from sales to advertising to commodities to any high-pressure, high-stimulus kind of work.”
I like intense people: people who have a lot of convictions and express them fluidly. Many of my friends are noticeably, alarmingly intense. It’s probably a quality I unconsciously select for.
ADHD and hypomania
I recently read a book, The Hypomanic Edge, that explored how many entrepreneurs are also hypomanic. Many people confused hypomania with mania, which is a trademark of bipolar disorder. But hypomania is a significantly milder and usually less destructive version of mania, and people can be hypomanic without being bipolar. In 2019, researchers found overlap between ADHD and hypomanic symptoms across childhood and adolescence, “which appears to reflect a genetic link between these phenotypes, according to findings from a Swedish twin cohort study published in JAMA Psychiatry.”
At age 15 years, 21% to 22% of the variance in hypomania was associated with genetic factors shared with ADHD, and at age 18 years, 13% to 29% of the genetic risk factors for hypomania were tied to ADHD. Again, Hosang and colleagues reported higher estimates for symptoms of hyperactivity-impulsivity (10% to 25%) compared with inattention (6% to 16%).
If people who are hypomanic have a significantly higher chance of also having ADHD, this further explains why lots of founders seem to possess that quality.
So, what am I going to do about it?
I saw a psychiatrist two months ago. I described my life to him and he said, “Well, you seem to be doing fine, but I agree that you meet the diagnostic criteria for ADHD.” I’m currently prescribed stimulants, and I take them roughly once a week. I don’t really like the way they make me feel, and I find that they don’t noticeably improve my ability to write or edit. What they’re most useful for is getting me on track: ordinarily I tend to fuck around for a while before focusing on whatever task I’ve assigned myself. When I’m on stimulants, I immediately feel the urge to get to work, which results in a less dysfunctional schedule.
Otherwise I mostly cope through keeping a regular schedule, working out regularly, and setting daily goals (respond to X emails, edit one chapter a day, work out at 8 PM). I remain a little queasy about the pathologization of ADHD. Scott Alexander pretty much summed up how I felt when he said:
We draw a line at some point on the far left of the bell curve and tell the people on the far side that they’ve “got” “the disease” of “ADHD”. This isn’t just me saying this. It’s the neurostructural literature, the the genetics literature, a bunch of other studies, and the the Consensus Conference On ADHD. This doesn’t mean ADHD is “just laziness” or “isn’t biological” – of course it’s biological! Height is biological! But that doesn’t mean the world is divided into two natural categories of “healthy people” and “people who have Height Deficiency Syndrome“. Attention is the same way. Some people really do have poor concentration, they suffer a lot from it, and it’s not their fault. They just don’t form a discrete population.
I worry that we focus too much on identifying symptoms and not enough on the cultural and developmental factors that lead to ADHD. At the same time, I’ve had enough friends who’ve been diagnosed as adults and seen remarkable improvements in quality of life to be happy that there’s more awareness and treatment options for people who are negatively affected.
Scattered Minds ends with a quote that confused me: “If we can actively love, there will be no attention deficit and no disorder.” This is on the tail end of a couple chapters that talk about how expectations for medication should be limited (which I agree with), and how successfully navigating life with ADHD should involve an acceptance of emotional pain (I also agree). But it’s not super clear to me what’s being said here: that if we can be mindful, that if we can learn to successfully attend, ADHD will no longer be a problem? I buy that, for non-extreme cases, but it seems quite vague. Am I a success story, as someone who meditates, exercises, and writes 4000-word essays on ADHD?
Despite all this I feel that I struggle to separate personality from pathology: I’m still cluttered and distractible. If I’m thinking hard about something and you talk to me, I probably won’t hear you. I lose keys, cards, chargers constantly. But I’ve always been like this and to be honest with you, I’m mostly fine with it. If I really wasn’t I could probably devise a way to change it. Maybe that’s all there is to it: you fall on some point in the attention bell curve, you try to understand why you are the way you are, you attempt to fix what bothers you, and you live (and maybe even thrive) with the rest.
Part 2 and 3
So, it turns out that I have a lot to say about ADHD, so I’m planning to do Part 2, where I talk to friends with ADHD and ask them about how it affects their life, and Part 3, where I do a deep-dive into Adderall, gatekeeping stimulants, and amphetamine addiction. Please let me know if this is something you’re interested in, and if you have any ADHD experiences to share, feel free to email me!
Also, you can’t do footnotes on Substack (or at least I haven’t figure out how) and I’ve referenced a lot of books/papers/articles, so please let me know if I forgot to attribute anything.