ADHD, autism spectrum, stimulant evaluation, and the presentations that get missed for decades.
10 cases
A 29-year-old software engineer presents with well-established ADHD-inattentive type and co-occurring generalized anxiety disorder, raising the question of which condition to treat first and how to navigate medication choices when treatments for one may complicate the other.
A 39-year-old corporate attorney and law firm partner presents with 6 months of progressive concentration difficulties, exhaustion, emotional flatness, and a sense that her brain 'stopped working.' Her PCP referred her after a positive ADHD screen she requested based on social media content. Navigate the increasingly common clinical challenge of distinguishing late-unmasked ADHD from occupational burnout and depression with prominent cognitive symptoms.
A 31-year-old high school science teacher and assistant basketball coach with ADHD predominantly inattentive presents after 10 weeks on atomoxetine 80mg with minimal response. The case navigates diagnostic verification, sleep deprivation as a confound, weight-based dose optimization, addressing stigma-driven stimulant avoidance, and the practical pharmacology of transitioning from a non-stimulant to a stimulant regimen.
A 28-year-old social media manager with a prior BPD diagnosis presents questioning whether she actually has ADHD — or both. She describes rapid mood shifts lasting minutes (not days), intense rejection sensitivity, chronic disorganization, and emotional outbursts she can't control. Navigate one of the highest-stakes differential diagnoses in young women: ADHD emotional dysregulation vs. BPD vs. comorbid ADHD + BPD, where the treatment trajectories diverge dramatically and getting it wrong in either direction causes harm.
A 26-year-old graduate student requests Adderall by name after trying a friend's prescription. The evaluation reveals a picture that is neither clearly ADHD nor clearly not — the kind of ambiguity where most of these encounters actually land. This case models the systematic approach that serves the patient regardless of which way the diagnosis ultimately falls.
A 41-year-old senior systems engineer is referred by his couples therapist after his wife describes him as 'emotionally absent.' Nathan has never had a psychiatric evaluation but has always known he was 'different.' Walk through the diagnostic reasoning for late-diagnosed autism in adult men, differentiate ASD from schizoid personality disorder, social anxiety, and alexithymia, and build a treatment plan centered on self-understanding, accommodation, and relationship repair.
A 34-year-old marketing director is referred after CBT for anxiety isn't working. She's high-functioning but unraveling — missed deadlines, 47 open browser tabs, and a lifetime of 'not living up to her potential.' Walk through the adult ADHD diagnostic workup, differential diagnosis, and stimulant prescribing.
Derek T. is a 34-year-old software developer with a childhood ADHD diagnosis and a real history of stimulant misuse in college — including snorting Adderall and recreational cocaine use. He has been sober for 6 years and is now functionally impaired at work and home. He is upfront about his history and wants help. This case explores the clinical reasoning behind risk-stratified stimulant prescribing when ADHD is genuine and substance history is real.
A 35-year-old librarian has been in treatment for anxiety and depression for 12 years with no real improvement. She's tried 4 SSRIs, 2 SNRIs, buspirone, and multiple therapists. After reading an article about autism in women, she's requesting an evaluation. Walk through the diagnostic reasoning for late-diagnosed autism in adults, unpack the masking phenomenon, differentiate ASD from look-alike conditions, and build a treatment plan that centers accommodations over medication.
A 22-year-old pre-med student requests an ADHD evaluation, citing classic symptoms and reporting that Adderall she buys from a classmate is the only thing that helps her study. Her presentation is polished and textbook-perfect — but the clinical picture is more complicated than it appears. Walk through the structured assessment that protects both patient and provider.
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