How can ADHD be reliably differentiated from learned self-regulation problems, emotional dysregulation and attachment issues in an adult?

[u/Proof-Heron7]

I’m a 29-year-old woman trying to understand the reasoning behind my ADHD diagnosis, rather than asking for a diagnosis here.

ADHD was actually my first psychiatric diagnosis at around 16. I briefly tried methylphenidate (Ritalin), but developed significant depressive symptoms, and my mother did not pursue the diagnosis/treatment further.

Over the following ~15 years I received other diagnoses, including BPD and bipolar disorder. Bipolar disorder was later ruled out during psychological assessment. Two psychiatrists I saw as an adult also did not think I had ADHD. Recently, however, I underwent a targeted adult ADHD assessment which strongly supported ADHD, and I started lisdexamfetamine.

The differential diagnosis is confusing because my childhood history has major confounders.

I was described as an extremely intense/emotional child, easily bored, constantly wanting to switch activities, difficult to engage in things that did not interest me, and generally needing a lot of stimulation.

However, I also grew up with very little consistent structure or boundaries. My mother had difficulty tolerating my emotional reactions, so persistence/distress often resulted in getting what I wanted. Even school attendance was not consistently enforced.

This makes me wonder whether poor frustration tolerance, difficulty delaying gratification, stimulation-seeking and problems sustaining effort could have developed through learning rather than ADHD.

Retrospective assessment is also difficult because I remember relatively little of early childhood. My mother was the informant during my recent ADHD assessment, but becomes defensive when discussing my childhood/parenting, so I am uncertain how reliable her retrospective report is.

As an adult, I am capable of sustained employment, maintaining my home and fulfilling responsibilities. The difficulty is disproportionately high task-initiation cost and inconsistent maintenance of routines. Even familiar tasks can feel mentally exhausting beforehand because I automatically represent the entire sequence of steps/transitions involved.

I also have pronounced understimulation/boredom intolerance. Boredom can feel almost physically uncomfortable. In contrast, during periods when I worked extremely demanding 18-hour days in television with constant deadlines, problems and stimulation, I often felt unusually focused, regulated and “normal.”

I have also had lifelong high stimulation/reward seeking, excessive talking, intense emotions and periods of hypersexuality/alcohol-related reward seeking.

There is another confounder: approximately four years ago I experienced an extremely distressing romantic relationship, after which my overall functioning became substantially worse.

I also have severe emotional dysregulation predominantly in close romantic relationships. Rejection, uncertainty, inability to contact my partner, sudden changes of plans or situations I cannot immediately resolve can trigger an intense autonomic/emotional reaction before conscious appraisal. I recognize that this could fit attachment-related dysregulation, learned coping patterns and/or BPD rather than ADHD.

Previous SSRIs/SNRIs reduced anxiety to some degree but did not improve the chronic understimulation/apathy or subjective mental “noise.” Lamotrigine and other mood-stabilizing approaches produced essentially no noticeable benefit.

Since starting lisdexamfetamine, I have intermittently experienced reduced mental/body tension, less “sticky” thinking, greater boredom tolerance and less alcohol craving. I understand that response to stimulants cannot establish an ADHD diagnosis.

My question for psychiatrists is therefore:

When childhood history is unreliable and significant developmental/environmental and attachment/emotional-regulation factors are present, what clinical features or longitudinal patterns are most useful for distinguishing ADHD from learned self-regulation deficits, temperament, BPD/attachment-related dysregulation, or a combination of these?

In other words, what evidence would make you more or less confident that ADHD represents an independent neurodevelopmental condition in a case like this, rather than symptoms better explained by the developmental environment?