What is the likely diagnosis for a 22-year-old female patient with regular periods, difficulty focusing, unclear mind, and anxiety, but no symptoms of sadness, hopelessness, or suicidal ideation, with a scheduled gynecology appointment and a history of running?

Likely Diagnosis: Inattentive ADHD

This 22-year-old female most likely has inattentive-type ADHD, presenting with classic cognitive symptoms of difficulty focusing and unclear mind ("brain fog"), with secondary anxiety triggered by these functional impairments. 1, 2

Clinical Reasoning

Primary Diagnosis: Inattentive ADHD

The patient's core presentation—inability to focus at work and unclear mind—directly matches the defining symptoms of inattentive ADHD. The American College of Obstetricians and Gynecologists characterizes brain fog in ADHD as difficulty concentrating or sustaining attention on tasks, seeming preoccupied, and reluctance to engage in tasks requiring sustained mental effort. 2

Key diagnostic features present in this case:

• Difficulty focusing and unclear mind are hallmark inattentive symptoms 1, 2
• Absence of mood symptoms (not sad, hopeless, helpless, or withdrawn) argues strongly against primary depression 3, 1
• Anxiety occurs secondarily when she experiences cognitive difficulties, suggesting the anxiety is reactive to ADHD-related functional impairment rather than a primary anxiety disorder 1, 4
• Running previously helped but no longer provides relief, suggesting worsening executive dysfunction that behavioral coping strategies cannot overcome 3, 4

Why Not Primary Anxiety or Depression?

Approximately 10% of adults with recurrent depression or anxiety have underlying ADHD, making differential diagnosis critical. 1 However, this patient explicitly denies the core features of depression (sadness, hopelessness, helplessness, withdrawal, anhedonia) and her anxiety is situational—occurring specifically when she experiences cognitive difficulties. 3, 1

Generalized anxiety disorder requires excessive worry about multiple events occurring more often than not for at least 6 months with difficulty controlling the worry. 3 This patient's anxiety is triggered by specific cognitive impairment episodes, not pervasive uncontrollable worry about multiple life domains. 3

Recommended Diagnostic Approach

Immediate Screening

Administer the Adult ADHD Self-Report Scale (ASRS-V1.1) Part A as the first-line screening tool. 1, 4, 2 A positive screen is defined as checking "often" or "very often" for 4 or more of the 6 questions. 1, 4

If Screen Positive, Complete Full Assessment

1. Have the patient complete Part B of the ASRS to further characterize symptom patterns 3, 1

2. Obtain collateral information from someone who knows her well (parent, partner, close friend), as adults with ADHD often have poor insight and underestimate their symptom severity 3, 1

3. Assess functional impairment using the Weiss Functional Impairment Rating Scale-Self (WFIRS-S), which captures ADHD-specific impairment across life domains including work performance 3, 1, 4

4. Verify diagnostic criteria are met:

   • At least 5 inattentive symptoms present for at least 6 months 3, 1, 2
   • Symptoms cause functional impairment across multiple settings (work, home, social) 1, 2
   • Onset before age 12 (ask about childhood school performance, organizational difficulties) 1, 2
   • Symptoms not better explained by other mental disorders 1, 2

Critical Pitfall to Avoid

Do not dismiss ADHD simply because she is a high-functioning young woman with regular periods and a scheduled gynecology appointment. 3, 4 Many adults with ADHD, particularly women, develop compensatory strategies that mask symptoms until demands exceed their coping capacity. 3, 4 The American College of Obstetricians and Gynecologists notes that ADHD symptoms often become more challenging during periods of increased demands. 4, 2

Special Considerations for This Patient

Hormonal Factors

As a reproductive-age female, her ADHD symptoms may fluctuate with her menstrual cycle. 4 The American Journal of Obstetrics and Gynecology notes that symptoms predictably worsen during early follicular and early luteal phases when estrogen levels drop. 4 Ask if her cognitive difficulties and anxiety vary throughout her cycle. 4

Comorbidity Screening

Screen systematically for comorbid depression and anxiety using validated tools, as these commonly co-occur with ADHD. 4 While her current presentation does not suggest primary mood or anxiety disorders, monitoring is essential. 1, 4

Coordination with Gynecology

Inform her gynecologist about the ADHD evaluation, particularly if she is considering pregnancy in the future. 3, 4 The American College of Obstetricians and Gynecologists notes that ADHD symptoms may worsen during pregnancy when medication is often discontinued, and untreated ADHD carries risks including increased spontaneous abortion and preterm birth. 4