Diagnosis: Attention-Deficit/Hyperactivity Disorder (ADHD)
Based on the clinical presentation of difficulty focusing on uninteresting tasks, procrastination with last-minute completion, hyperfocus capability, inability to multitask, and severe working memory deficits (both short-term and long-term), this patient meets diagnostic criteria for ADHD, predominantly inattentive presentation. 1
Clinical Reasoning for Diagnosis
The symptom constellation strongly aligns with ADHD:
Executive function deficits: The inability to focus on tasks without immediate interest, procrastination behavior, and poor task initiation are hallmark features of ADHD's executive dysfunction 1. Research confirms that inattention specifically correlates with general procrastination behaviors 2, and prospective memory deficits (remembering to execute delayed intentions) mediate the link between ADHD symptoms and procrastination 3.
Working memory impairment: The described "very bad short-term memory" and poor working memory represent core ADHD deficits. Studies demonstrate that ADHD is associated with very large magnitude impairments in central executive working memory (effect size d = 1.63-2.03), with 75-81% of pediatric ADHD cases showing impairment 4. Adults with ADHD show significant verbal long-term memory deficits that reflect learning problems at the encoding stage rather than retrieval issues 5.
Hyperfocus with deadline pressure: The ability to hyperfocus when there is an "acute deadline" but pushing tasks to the last moment is characteristic of ADHD's reward regulation dysfunction and time perception difficulties 1.
Multitasking inability: The complete inability to process simultaneous inputs (reading while someone talks) reflects the attentional control deficits and impaired inhibitory control seen in ADHD 1.
Losing items frequently: Losing phones, remotes, and other objects is a classic DSM-5 symptom of inattention 1.
Diagnostic Evaluation Requirements
To confirm the diagnosis, you must establish:
Symptom onset before age 12: DSM-5 criteria require documented or reported manifestations of inattention or hyperactivity/impulsivity before age 12 1. Obtain childhood history from the patient and ideally from parents or school records.
Impairment in multiple settings: Document that symptoms cause significant impairment in at least two major settings (work/academic, social, home) 1.
Rule out comorbidities and mimics: Screen for anxiety, depression, substance use, sleep disorders, and learning disabilities, as these commonly co-occur with ADHD or can mimic its presentation 1. The majority of ADHD patients meet criteria for another mental disorder 1.
Critical pitfall: Depression can present with difficulty concentrating and decision-making per DSM-5 1. However, this patient's lifelong pattern of symptoms, specific executive function profile, and hyperfocus capability distinguish ADHD from primary mood disorder.
Treatment Approach
Pharmacological treatment with FDA-approved stimulant medications (amphetamine or methylphenidate preparations) should be first-line therapy for adults with ADHD, as these directly address the core neurotransmitter deficits underlying executive dysfunction and working memory impairment. 1, 6
Medication Management
Stimulant medications are indicated for ADHD characterized by moderate to severe distractibility, short attention span, and impulsivity 6. These medications directly improve central executive working memory function and attention regulation 1, 4.
Titrate to maximum benefit with tolerable side effects 1. Start with a low dose and increase gradually while monitoring symptom improvement and adverse effects.
Monitor for comorbid conditions: If anxiety or mood symptoms are present, sequence treatments appropriately. Some patients may require treatment of comorbid conditions before or concurrent with ADHD medication 1.
Important caveat: If the patient has any symptoms of orthostatic intolerance (lightheadedness upon standing, tachycardia, exercise intolerance), evaluate for Postural Orthostatic Tachycardia Syndrome (POTS) before initiating stimulants, as stimulant medications can increase sympathetic nervous system tone and complicate POTS management 7.
Behavioral Interventions
Implement organizational strategies targeting working memory deficits: external memory aids (smartphone reminders, written lists), designated locations for frequently lost items, and breaking tasks into smaller components 1.
Address procrastination through structured scheduling with artificial deadlines and accountability systems 3, 2.
Consider cognitive-behavioral therapy focused on ADHD-specific executive function skills 1.
Chronic Disease Management
Manage this patient using the chronic care model and medical home principles, as ADHD is a chronic neurodevelopmental condition requiring ongoing monitoring and treatment adjustment 1. ADHD persists into adulthood in many cases with an estimated adult prevalence of 2.5% 1, 7.