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A 36-year-old woman, a recently promoted senior manager, presents seeking evaluation for concentration difficulties that she attributes to work stress. She reports chronic difficulty with organization, time management, and task completion that she has 'always compensated for' using extensive lists, alarms, and rigid routines. Since her promotion 4 months ago, her compensatory strategies have become insufficient, and she is struggling significantly. On detailed history, she describes always being a 'daydreamer' in school, frequently losing belongings, difficulty sustaining attention during meetings, often starting tasks but not finishing them, and chronic difficulty with punctuality. She was an academically gifted student who 'could have done better' and was frequently told she was 'not working up to her potential.' She reports no hyperactivity but endorses internal restlessness and frequent shifting between tasks. She has no history of mood disorders, anxiety disorders, or substance use. Her mother confirms the patient has exhibited these patterns since early elementary school, describing her as 'smart but scattered.' Neuropsychological testing reveals deficits in sustained attention and executive function with a superior IQ. Which of the following is the most likely diagnosis?
Explanation
ADHD predominantly inattentive presentation is frequently missed in high-IQ women who develop compensatory strategies that mask symptoms throughout childhood and early adulthood. Diagnosis in adulthood requires documentation that inattentive symptoms were present before age 12, which can be established through detailed developmental history and collateral information. The presentation often comes to clinical attention when life demands exceed the capacity of compensatory strategies, such as after a promotion or other increase in executive function requirements.
Key Takeaway
ADHD predominantly inattentive type is commonly missed in intellectually gifted women who compensate through organizational strategies, and the diagnosis requires establishing childhood-onset symptoms through detailed developmental history even when the presenting complaint appears to be a recent-onset problem.