When They’re Wrong About What’s “Wrong” With You: How to Recognize & Reject Common Misdiagnoses

Hello, my friends. Thank you for joining me for today's episode of Try Easier, Not Harder. Last week, I covered Rejection Sensitive Dysphoria — a concept that evolved from the time when it was first being acknowledged that ADHD is not a "childhood disorder," which was really only in the last 50 years or so. At that time, adults with ADHD were observed to struggle with something that looked like depression, but technically wasn't. More recent experts identified that painful emotional state as arising from the experiences of being corrected and rejected that are common to people with ADHD beginning in childhood and very often carried through adulthood. As research expands, we're learning that differences in brain chemistry, function, and even structure contribute to those experiences — and not just in people with ADHD, but autistic folks, and others with neurodevelopmental differences. I mentioned last week that, despite the advances in understanding, the majority of U.S. clinicians don't understand or acknowledge Rejection Sensitive Dysphoria since it's not a diagnosable condition, which leads to many — if not most — neurodivergent adults receiving additional diagnoses to account for symptoms that are actually extensions of their neurodivergence and result from the experiences neurodivergent people typically have in cultural systems that reward conformity and pathologize differences.

In my work as a psychologist specializing in neurodivergence evaluations and as a neurodivergence coach, misdiagnosis is a critical concern of almost everyone I encounter. Adults come to me for diagnostic clarification after they begin to suspect they're neurodivergent and that the diagnoses they've been given — and treated for over years — don't actually apply. Parents bring their children to me with similar concerns, and people follow me on social media, watch or listen to my podcast, or read this blog as part of their realization that professionals who've been quick to tell them what's "wrong" with them may have been wrong themselves. But on the other side of that, I've worked with and spoken to many neurodivergent adults and parents of neurodivergent kids who truly understand themselves or their children as having neurodevelopmental differences and other distinct diagnoses related to their moods, personalities, and behaviors. It absolutely makes sense that they see things that way, because that's the way diagnosing clinicians are taught to see them, so that's the information they're given, and sometimes it's correct.

Most "mental disorders," as mental health diagnoses are still formally known, can be comorbid with others — meaning multiple diagnoses can be given to the same person. And in the most basic of terms, it comes down to checklists — in that certain symptoms or experiences check off boxes for certain diagnoses, and if the right boxes are checked, any or all of those certain diagnoses are seen to apply. But that fixed, authoritative formula leans toward pathologizing over acknowledging the nuances of human experience, and there are actually many reasons — with growing evidential support — that it's better for people to be given only the diagnoses that are the best explanations for the distress or dysfunction they're experiencing. So today I'm going to give an overview of common diagnoses that are assigned to adults who report experiences that aren't on the checklist of diagnostic criteria for neurodevelopmental disorders, but that we know are often aspects of neurodivergence or the neurodivergent experience. I'm offering this because I get so many questions about specific diagnoses and how they're different than, and the same as, neurodivergence diagnoses, so I know people need and want clarification. However, this is a podcast/blog episode, not a grad school course, so this won't be comprehensive — in fact, it will be quite rapid and rather general — and it isn't intended to, nor could it possibly, suggest or provide diagnostic conclusions about any individual person. Comprehensive psychodiagnostic evaluation requires substantial data about and from a person, and the extensive time of an experienced evaluator, which is why it's a service that's very hard to access. I know that's a huge problem for many of you, and I do this because I want to help as many people as I can have more accurate and more positive understandings of themselves, but this information won't — and can't — be a substitute for comprehensive psychodiagnostic evaluation for those of you who need that.

With that out of the way, let's get to it. We'll begin with Major Depressive Disorder, which is the most diagnosed mental disorder in the U.S. There are general problems with misdiagnosis of Major Depressive Disorder, irrespective of neurodiversity. Whether a person is neurodivergent or neurotypical, if they report depressive symptoms, they're likely to be misdiagnosed with Major Depressive Disorder, especially by primary care physicians, when their symptoms are better explained in other ways. Major Depressive Disorder can technically only be diagnosed when a person has had at least one Major Depressive Episode, which is a period of 2 or more weeks when they experience certain specific depressive symptoms. Major Depressive Episodes must represent a change in a person's functioning, so before and after the episode their state of being is not depressed, and Major Depressive Episodes are not to be confused with "understandable" or "appropriate" responses to significant losses. Major Depressive Disorder is misdiagnosed in people with episodic depressive symptoms that coincide with their menstrual cycles, in which case the correct diagnosis would likely be Premenstrual Dysphoric Disorder, and people who have what can be described as a lower grade depression that is essentially always present, not episodic, over at least 2 years, should likely be diagnosed with Persistent Depressive Disorder rather than Major Depressive Disorder.

Both of these misdiagnoses matter in terms of the treatments that are most likely to alleviate or reduce symptoms and in the ways people understand themselves, but what's even more troubling is how often people are assigned Major Depressive Disorder diagnoses after reporting depressive symptoms that result from life circumstances.

If a person is in a terrible relationship they don't know how to get out of, and can't make financial ends meet, and has problem after problem with their car or house or health, and their kid's school calls several times a week, or whatever collection of overwhelming stressors anyone can be facing, all the things that check the boxes for Major Depressive Disorder might actually be normal, appropriate responses to very difficult circumstances. Prolonged Grief Disorder and Adjustment Disorder are diagnoses that can be assigned when a person's distress and dysfunction result from circumstances, but the diagnostic criteria include responses that are very specific to the loss of a certain person, in the case of Prolonged Grief Disorder, or "out of proportion to the severity or intensity of the stressor," in Adjustment Disorder. And there's no simple, widely used way for a primary care physician or therapist to indicate that a person is being knocked on their ass by a completely understandable amount of grief, distress, or dysfunction relative to their life. Doing poorly in a college class. Being overlooked for promotion or losing a job. The death of a pet. Friends misunderstanding you. Facing steep fines because you let your car insurance lapse. Another breakup. Chronic loneliness. The exhaustion of perfectionism. The utter depletion of being marginalized, targeted, threatened or harmed because of your race, ethnicity, sex, sexual orientation, gender identity or expression, disability, physical appearance, religion, or any other quality observed, known or assumed by others. Many of those examples are experienced more often and/or more intensely as aspects of neurodivergence or the neurodivergent experience, so we know that is part of the reason neurodivergent people are diagnosed with depressive disorders up to 400% more often than the general population.

We know those experiences also contribute to neurodivergent people being diagnosed with anxiety disorders up to 500% more often than the general population. Being neurodivergent in an inflexible, authoritarian world built on neurotypical standards feels harder because it is harder, and that is anxiety-producing for up to half of all people with ADHD and up to 85% of autistic people — and those numbers only account for people who are diagnosed! Many of us have learned from tons of personal experience that things won't go the way we intend them to, regardless of our intentions or effort, and that we'll have to endure circumstances others don't mind, but that we find intolerable, which checks the boxes for Generalized Anxiety Disorder. We've also learned that other people notice and judge our differences, which often leads to painful critique we dread and avoid when possible, which is totally understandable, but still checks the boxes for Social Anxiety Disorder. And many of us have legitimate, significant sensory processing differences that are dismissed as preferences, or even entitlement or obstinance, so our nervous systems adapt by subconsciously developing extreme, automatic responses to certain stimuli, which can check the boxes for diagnoses of Panic Disorder, Agoraphobia, and Specific Phobias.

Something similar can be happening in the case of Obsessive-Compulsive Disorder. Obsessions are defined as "recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted," which is sometimes a close enough match to the mental processes of neurodivergent people whose thoughts may naturally be experienced as racing, repeated, focused on specific topics, or connected in rigid patterns or sequences. Difficult events, especially when recurrent, can result in escalations to thoughts that include warnings or images of disturbing actions or occurrences, which may reasonably be categorized as obsessions, but can also be understood as consistent with a neurodivergent person's inherent cognitive functioning as well as their life experiences. Compulsions, which are defined as "repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly," can be understood as adaptations to being chronically denied agency over our circumstances and our bodies, so our brains find ways to do certain things the ways we want to do them. Behaviors like that should not be classified as compulsions unless they cause us distress or impair our functioning, but in reality, the gauge is often whether or not they cause other people distress, or interrupt or contradict other people's preferences and expectations. For instance, a neurodivergent adult may have a deep affinity for the number 8 and prefer to do things 8 times, like turning a doorknob 8 times before opening a door — much more because they want to and they like to than that they are driven to in a disordered or pathological way. But others will likely call them out for it, pressure them to "be normal," or even physically prevent them from doing it, which can produce a reaction that is observed — and maybe even experienced — as extreme. That's considered additional verification of mental illness, when it may actually be a pretty reasonable response to accumulated experiences of being prevented from functioning in the ways that work best for them.

Essentially all people are likely to repeat or seek out pleasurable and satisfying experiences because they're reinforced by chemical responses in the brain — sometimes to the extent that the logical parts of the brain are overridden, like when a person drives really fast even though they know it's dangerous, stays up most of the night binge-watching a great show instead of getting the sleep they know they'll need, or eats the whole pint of ice cream when they only intended to have half. And in more extreme — though certainly not rare — cases, people overuse drugs and alcohol, gamble or spend money beyond their means, or engage in sexual behaviors that compromise their safety or contradict their values. Everybody's brain tries to overrule reason in favor of pleasure to some extent, but there's increasing evidence that chemical rewards are greater in neurodivergent brains, while our reasoning may be hindered — relative to neurotypical standards — by distractibility, cognitive rigidity, and differences in the ways sensory, social, and other information are processed. That leads to more reward-driven behavior overall, which can absolutely explain behaviors that could be interpreted as compulsions.

It can also underlie body-focused repetitive behaviors, which are also more commonly experienced by neurodivergent people. Body-focused repetitive behaviors is a catchall phrase that is somewhat open to interpretation. It's generally used to describe actions that are not intended to be harmful, but do harm one's body. Examples include pulling or rubbing one's hair out and picking at one's skin — which are diagnosed as Trichotillomania and Excoriation Disorder, respectively, when they cause distress or dysfunction. It can also include biting your lip or cheek, and biting or picking at your nails, though those behaviors don't have specific diagnoses. Self-harming behavior isn't generally deemed a body-focused repetitive behavior because harm is intended, though some neurodivergent people hit themselves or bang their heads without intending to harm themselves, and that is considered self-harming behavior nonetheless. Other types of stimming behavior is neither intended to nor resulting in harm, but arguably meets the broadest definition of body-focused repetitive behavior — depending on whether or not the term is used to describe something someone does or pathologize it.

Neurodivergent people can also be misdiagnosed with — or misunderstand themselves to have — a Bipolar Disorder. A diagnosis of Bipolar I can only be given if a person has experienced a Manic Episode, while a Bipolar II diagnosis requires that a person has had both a Hypomanic Episode and a Major Depressive Episode. Keep in mind that a Major Depressive Episode is a distinct period of time lasting at least 2 weeks, during which a person experiences certain specific depressive symptoms, that represents a change from their normal state but is not due to a loss. The diagnostic criteria for Manic and Hypomanic Episodes are even more specific, because they're actually very rare. A true Manic Episode is a distinct period of at least 1 week, during which the person experiences "abnormally and persistently elevated, expansive, or irritable mood" AND "abnormally and persistently increased activity or energy," AND they experience certain specific symptoms that are "present to a significant degree and represent a noticeable change from usual behavior," AND the change in the person is "sufficiently severe to cause marked impairment in social or occupational functioning, or to necessitate hospitalization to prevent harm to self for others," or include symptoms of psychosis. All of those boxes must be checked for a diagnosis of Bipolar I. For a Bipolar II diagnosis, a person must have had one or more Major Depressive Episodes, as well as a Hypomanic Episode, which is a distinct period of at least 4 days, during which the person experiences "abnormally and persistently elevated, expansive, or irritable mood," AND "abnormally and persistently increased activity or energy," AND certain specific symptoms that represent "a noticeable change from usual behavior and have been present to a significant degree," AND is "associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic," AND is "observable by others."

Without me even listing the specific symptoms, I think we can agree that having the experiences that meet the diagnostic criteria for either type of episode would be an incredible disruption to a person's life. We're talking about a distinct change that lasts at least a week for a Manic Episode, or at least 4 days for a Hypomanic Episode, in addition to at least 2 weeks of a Depressive Episode. That's the diagnostic criteria, and yet I frequently work with neurodivergent people who have been diagnosed with Bipolar I or Bipolar II after reporting fluctuations in their energy levels or sleep patterns, and "mood swings" they typically describe as going from happy to angry, then back to happy, then to sad, et cetera, and usually in response to interactions with people or to circumstances, like a flat tire, a disappointing text from a friend canceling plans last minute, or when their favorite song comes on. A person who is happy, but feels uncontrollable anger or despair when plans get canceled, is not having a Manic, Hypomanic, or Depressive Episode. Being emotionally reactive — meaning your emotions change in reaction to your experiences — is normal to some extent, and when it's extreme, that's generally due to not having had appropriate models of emotion regulation, unresolved trauma, and/or differences in neurocognitive functioning.

Emotional reactivity also sometimes serves a purpose. Think of a toddler throwing an enormous fit in the grocery store. Enraged when they're told they can't open the chocolate chips, they scream and bite their parent's hands until the stressed and mortified parent — who doesn't want to give in to the almost primal urge to hit the child, but also doesn't wanna be bit, and doesn't have time to leave and do the shopping later — opens the chocolate chips or promises the toddler that they can have chocolate chips in the car if they stop acting that way right now. That's an easy example to understand, and to dismiss, because it's a small child, but adults' emotional reactivity can also be effective in getting their needs met. And for some people, it's the only way they know to get care, compassion, attention, or whatever they may need, from other people. That's a very difficult situation to be in, but it's not Bipolar Disorder. Staying up all night playing a video game or completing a project, and not even feeling tired the next day because it was so great to finish that game or get the entire house totally clean? That's not a Manic or Hypomanic Episode unless it's distinctly different than normal for you and lasts at least a week, along with other diagnostic criteria of Bipolar I, or at least 4 days, along with the other diagnostic criteria of Bipolar II, including one or more Major Depressive Episode.

In fact, neurodivergent people often have atypical circadian rhythms, which can lead to differences in when we naturally feel tired, sleep, or feel alert, as well as how much sleep we need to feel rested. That reward-driven behavior I just talked about can also drive us to stay completely engaged in watching that show, playing that game, talking to that person, baking those treats, driving to that place, or what have you, without really feeling fatigue. That is especially true for those of us whose day-to-day lives and obligations are exceptionally limiting in that we don't feel free to be authentic most of the time, so when we're able to do something that just feels fucking great, it contrasts so starkly with most of the rest of our lives that our brains treat us to extra neurochemical rewards, and not much is going to compare to that.

The last common misdiagnosis I'll cover today is Borderline Personality Disorder, which is marked by "a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity." A key feature of Borderline Personality Disorder is "frantic efforts to avoid real or imagined abandonment," which is not the same as Rejection Sensitive Dysphoria, but a person who engages in "frantic efforts to avoid real or imagined abandonment" is, by definition, rejection-sensitive. If you caught the last episode, you may recall that 99% of neurodivergent people experience some degree of Rejection Sensitive Dysphoria, which is a type of emotional dysregulation that often includes mood changes in reaction to experiences, and that is also a diagnostic criterion of Borderline Personality Disorder. As I've mentioned in multiple past episodes, the learned adaptation of concealing our authentic selves to avoid social consequences, commonly known as "masking," can and usually does significantly interrupt the development of healthy relationships with ourselves and others: another trademark quality of Borderline Personality Disorder. Impulsivity is a known attribute of some people with ADHD, but today I also covered high rates of reward-driven behavior in neurodivergent people generally, so many of us could check that box. And if that weren't enough, Borderline Personality Disorder is almost always linked to early experiences of trauma and/or emotional neglect, which means that there are aspects of its clinical presentation that overlap with posttraumatic stress, and for many reasons, neurodivergent children are more likely to experience trauma and/or emotional neglect, and neurodivergent people in general are more likely to struggle with posttraumatic stress. (Incidentally, I'll be covering the overlap between neurodivergence, trauma, and posttraumatic stress in its own episode, because there's just too much to it to include today. I know many of you have a lot of experiences in that area and questions about it, so keep an eye out for that episode.)

Borderline Personality Disorder is diagnosed in neurodivergent adults far more than in the general population. It's also diagnosed significantly more often in women than men, and in transgender, non-binary, or gender-diverse people, and gay, lesbian, or bisexual people versus cisgender, heterosexual people of any biological sex. Research shows there's no true variability in the prevalence of Borderline Personality Disorder between the sexes, and certainly not with regard to sexual orientation or gender identity or expression, so the disproportionate diagnostic rates are assumed to be due, in part, to patterns in help-seeking behavior in that, generally speaking, people in one or more of those groups that are more often diagnosed may be more likely to interact with, or request services from, health systems. But it also suggests substantial diagnostic bias, which is really an undercurrent in so much of what I've covered in this episode. I don't intend to vilify men or cisgender or heterosexual people, but psychology, psychiatry, and medicine more broadly — and philosophy even more broadly — have all historically been hetero-, cis-, and male-normative, meaning that straight men who present themselves masculinely have been considered normal, so anything else must be abnormal. We may be able to accept that as ignorance in the thinking from more than 2,000 years ago, or even what was known and understood hundreds of years ago, but as the voices dictating what “normal” is have become more narrow, ideas about what is “abnormal” have broadened to include everyone who isn't like them — so not white, Christian, middle class, college educated, or non-disabled. As a result, modern psychology, as well as medicine, including psychiatry, are still, in practice, inequitable. Let's hope that Martin Luther King, Jr., was right and the arc of the moral universe bends towards justice. Some progress has been made, but generally speaking, TODAY, a person's access to any kind of healthcare and to quality care specifically, the diagnoses that are likely to be assigned or not assigned, and the treatments that are likely to be recommended, offered, and provided all depend largely on the groups to which one belongs. And that, my friends, is fucking bullshit. But you already knew that.

So getting back to Borderline Personality Disorder, which is a diagnosis you're more likely to be given if you're neurodivergent —  even though much of what checks those boxes are actually extensions of neurodivergence and the neurodivergent experience — and if you're female, not cisgender, or not heterosexual, and exponentially more likely to be given if you're any combination of those. Borderline Personality Disorder is part of a huge category of ten diagnoses that are all complicated, individually and as a construct, because our personalities are who we are, and so much goes into that, essentially all of which is outside of our control and occurs in our very early lives or is coded into our genetic makeup.

As a human being and a licensed psychologist, I think changes are needed in the ways we understand and pathologize what are currently diagnosed as personality disorders and neurodevelopmental disorders to normalize the known differences in human experiences and focus our efforts to help people on preventing the adversity and suffering we know leads to long-term mental health struggles. Instead, we have a lot of names for what's "wrong" with people who are other than “normal,” with tons and tons of data that explains — at least partially — the origins of those differences and of the pain they experience. But accepting those differences and preventing that pain has much less to do with fixing the people who are other than “normal” than it does with fixing the culture dictated by the "normal" ones, and they're not having it.

They'd much rather you think your neurodivergence is a flaw, your personality is defective, and your ways of responding to being misunderstood, corrected, and hurt are what make you sick, and for more diagnoses to be heaped on you — by licensed professionals or through your own conclusions based on information you're flooded with by the truly unconscionable algorithms of TikTok and other social media platforms. That isn't your fault, and if the only or best way you can get some of what you need is through formal or informal diagnoses, I get it. Fixing yourself feels irrelevant when you're in a broken system, and sometimes it truly is, but I hope you'll hold onto what I'm saying that you probably already knew somehow: that wrong diagnoses are wrong, because they're the wrong solution to the wrong problem. And when you're ready and able to reject them — even just in the way you see, understand, and treat yourself — you'll be changing and fixing the culture of what's “normal” and what's not the only way we actually can: by rejecting the narrative that you have to fix yourself and being who you actually are. Remember, the marginalized ARE the majority, and as I always say: You don't have to change yourself to deserve happiness or success. Being who you are isn't the problem; it's the solution. I'm rooting for you — exactly as you are. Power to the people. I'll see you next week.