simulated_transcript.txt

Background: The patient is a male artist in his 30s presenting for evaluation of ADHD. He took an ADHD screening questionnaire online out of curiosity. He decided to seek treatment on his own because of a vague sense that work and personal life are not going well. He has completed a second questionnaire to assess ADHD symptoms as part of the psychiatrist’s required intake paperwork.

Psychiatrist: Now I’m going to ask about some of your symptoms related to ADHD. Some of these questions sound kind of similar but they point to different aspects of inattention and hyperactivity. Tell me if you think you have the symptom and then tell me kind of your life story of having the symptom. When did it begin? What have the consequences been for the symptom over the course of your lifetime? And we’ll discuss things like that.

Patient: Sure.

Psychiatrist: Do you feel like you struggle with attention to details compared to other people?

Patient: Oh yeah haha that has been my whole life…

Psychiatrist: What was your earliest memory of this issue?

Patient: I guess probably third grade.

Psychiatrist: What was happening then?

Patient: I kept making mistakes on my math homework.

Psychiatrist: Did these culminate in any consequences for you?

Patient: My parents had to hire a tutor. They got on to me about having to spend the money.

Psychiatrist: How was this discussed by the family?

Patient: I mean… my mom and dad were frustrated with me. They had to meet with my teachers who got them all worried I would fail.

Psychiatrist: Was your attention to detail an issue at home too?

Patient: I guess when I’d do chores like clean my room I’d do a bad job and then sometimes they would make me go back and do it again.

Psychiatrist: What about over the years? Has the problem continued?

Patient: I had to drop three classes in college and eventually change my major. I didn’t want to study math or foreign language. So I got into visual art and design.

Psychiatrist: Did the symptom follow you into your career? Or your relationships?

Patient: I make commissioned projects but I have a lot of autonomy in how they come out. People know how my art looks and they kind of want things to look that way. So they give me a few details but not many and then I kind of let the project go where it goes. I guess I misspell things in emails.

Psychiatrist: And your personal relationships?

Patient: I’ve had friendships end because I couldn’t remember peoples’ birthdays.

Psychiatrist: We’ll talk about forgetfulness in a moment. Right now we’re talking specifically about your attention to details. 

Patient: I’d have to think about it more… I don’t know.

Psychiatrist: All right. Let’s talk about your ability to focus. Are you able to focus your attention when you need to?

Patient: I get distracted like all the time.

Psychiatrist: We will talk about distractibility separately. I know this feels like a similar problem, but what I’m wondering is essentially, when you’re supposed to be paying attention and maybe you start to feel strained. Does that happen?

Patient: Um… Can you say that again?

Psychiatrist: I am not asking you about your distractibility. That will come later. When you are paying attention to things, are you able to focus or does it feel like you’re straining? To the point you might as well not be trying to focus in the first place.

Patient: Oh yeah, I couldn’t focus to save my life.

Psychiatrist: When did you first notice that?

Patient: I guess in college. When I was taking classes that I ended up having to drop.

Psychiatrist: Did you have the symptom in childhood?

Patient: I don’t know. Probably…

Psychiatrist: Does anything come to mind?

Patient: I’d have to think about it more. 

Psychiatrist: What about after college? In your career or relationships?

Patient: I work discontinuously. I have a schedule where I start working in the morning making visual art and I kind of work until I get bored or tired then I stop. I guess I get behind submitting my projects to galleries.

Psychiatrist: And in your relationships?

Patient: I’m not sure.

Psychiatrist: Are you able to sustain focus on other things? Like movies? Or outdoor activities?
Patient: Sometimes. I have to stop movies halfway through a lot.

Psychiatrist: Do you start to feel strained and lose track of the plot?

Patient: Yes! But not when I watch comedies.

Psychiatrist: Haha. What about when people are speaking to you directly? Do you notice that you’ve stopped listening as they are speaking? Or, does anyone tell you that you’re not listening to them?

Patient: My parents have been saying that to me my whole life. 

Psychiatrist: Do you notice when it happens?

Patient: Sometimes.

Psychiatrist: When do you remember it starting?

Patient: I definitely remember my parents saying that when I was about 5 or 6 years old. I’m not sure what it was about.

Psychiatrist: Did it cause any problems in school?

Patient: I think so but I can’t point to anything for sure. I guess when I saw the math tutor they had to repeat things a few times for me to pick them up.

Psychiatrist: What about in your relationships?

Patient: I’ve had girlfriends break up with me because they thought I was too wrapped up in my career. They’ve said I was unavailable.

Psychiatrist: But was there anything you missed explicitly because you were a poor listener?

Patient: Yes.

Psychiatrist: Like what?

Patient: One girlfriend I had. I didn’t remember plans we’d made. I was supposed to join her for a banquet. She said she had told me but it wasn’t like we had any significant conversation about it. I thought it had never happened but she swore she told me. But I planned a trip I didn’t want to cancel.

Psychiatrist: What about starting and completing tasks? Are you able to kind of get started and then follow through on things?

Patient: I have developed some systems of reminders over the years to help me get through my projects at work but this is why. Yes. It was a real problem in the past but not so much now.

Psychiatrist: When did it start?

Patient: Definitely when I was a kid. Maybe in middle school when assignments started to get more complicated. I’d misread instructions and write a paper that was somehow off topic. 

Psychiatrist: So you did the wrong thing? Were you turning in incomplete work?

Patient: I did the wrong thing. Oh. I guess I turned in incomplete work a time or two as well. In college I learned not to do that because there wasn’t partial credit.

Psychiatrist: What about at home when you were a kid? Did you get sidetracked there too?

Patient: One time my parents sent me to the grocery store and I came back home with half of the grocery list missing. They stopped sending me to pick things up for them.

Psychiatrist: They felt like they couldn’t trust you to see things through.

Patient: Yeah…

Psychiatrist: You mentioned systems to keep you on task. Why do you need them now?

Patient: If I’m not careful I could start making a project and never finish because here I’ve started another project and have gotten more interested in the new thing than the old one. I have a few projects that I never finished and maybe I’ll pick them back up when I have the time or interest. My current girlfriend likes to joke that our home is in shambles because of all the remodeling projects we have going on. I start a new project before finishing the old one.

Psychiatrist: It sounds like you have developed some organizational skills over the years?

Patient: Well I have systems now. I have a calendar and a system of reminders that I put into effect. It prompts me a couple times a day with the day’s goal and the project deadline. But I have to put everything into the calendar. It’s like, if it isn’t in the calendar it doesn’t happen. It definitely played a role in me changing majors in college.

Psychiatrist: When did that start to become an issue?

Patient: As soon as we started getting homework in school. Maybe second or third grade. Definitely by the time the science fair was a thing. I couldn’t straighten out what I wanted to do or what I needed to do to get it done. And when I had writing assignments like essays I’d just get started and wouldn’t kind of keep track of where I wanted things to go so there would be undeveloped ideas or loose ends.

Psychiatrist: Did your parents say anything about it at home?

Patient: Maybe when I’d try to go to school and I’d forget my books at home or I’d lose my key to get inside.

Psychiatrist: We’ll talk about your forgetfulness and the things you’ve lost in just a bit. Did your parents feel like you did things out of order?

Patient: They joked that I’d mop the floor before sweeping up all the dirt. That I was sweeping with the mop. Or when I tried baking a cake once I did some of the steps out of order and it turned out terrible. My mom had to step in and help. I avoid cooking to this day because I hate making a list of what I need, doing the shopping, doing the prep work, doing the cooking, and then doing the cleaning afterwards. I’ll cook but not clean. Then I’ve got dirty dishes next time I want to cook. I spend a lot of money eating out haha.

Psychiatrist: That brings me to my next point. Are there things you avoid because the effort just doesn’t seem possible?

Patient: When I was a kid I wanted to be an astronaut but it seemed like too much work. I learned in college that there was no way I’d become an engineer because I couldn’t handle the math classes.

Psychiatrist: When did you first feel like things were too much work?

Patient: I quit my first job working at a sandwich shop because I didn’t want to count money and give people change.

Psychiatrist: Anything before then? 

Patient: Well… I was held back in third grade. Because I put my head down and stopped doing the work my teacher asked me to do.

Psychiatrist: Goodness, I’m sorry. That must have felt overwhelming.

Patient: It was at the time. But it’s all right now.

Psychiatrist: Tell me more about the things you’ve lost over the years. Like physical things.

Patient: Jeez. Homework assignments. Action figures. Video games. Magazines. Car keys. I’ve had to pay pop a lock to come get me in my home at least three times. I’ve had to have doors re-keyed at old apartments because we didn’t know where the keys ended up. I’ve lost two phones. One was brand new. I can’t keep air pods around so I have to buy a couple sets at a time. I just let a pair go through the washing machine. If I didn’t have an accountant I don’t know what I would do in a tax audit.

Psychiatrist: Some big losses there for sure. We’ve kind of spoken about this in a few ways so far but what kind of things do you find distracting?

Patient: Light and sound. I have to work in a quiet place. A little ambient noise is fine. But I couldn’t ever study in the library in college. And it took years but I learned I couldn’t have music or the TV on while I was studying.

Psychiatrist: What about in childhood?

Patient: I would always stare out the window in school. Or when we did group projects I’d get us off topic by goofing off with my friends. We couldn’t even sit by each other or we’d get in trouble. The teacher was always calling my mom to let her know.

Psychiatrist: What would you say has been the biggest consequence of your distractibility?

Patient: Hm… I’m not real sure. There has been a lot. I kind of had to choose a life where I could be distracted without big consequences.

Psychiatrist: I see. And what about your forgetfulness in general?

Patient: I’ve always been forgetful. 

Psychiatrist: What’s the first thing you remember forgetting? Haha!

Patient: Probably forgetting to do my homework or forgetting to bring things to school. I’d get bad grades for not turning things in. Or be “home at this time” and I’d forget. My parents would remind me over and over. I could tell they were getting pissed off at me. They still remind me about things when I call them and it makes me not want to talk to them on the phone.

Psychiatrist: It has kind of colored that relationship in a way.

Patient: For sure. I’m always reminded that I’m a person who needs reminders. I wish they’d treat me like a grown up.

Psychiatrist: You mentioned your other relationships being affected earlier.

Patient: Yeah. I’d forget friends’ birthdays. I’d forget plans I’d made. Girlfriends have left me and friends have stopped returning my calls.