Does ADHD Cause Fatigue?

The day ends. Three items on the list are crossed off. But you are exhausted and you cannot explain it to anyone, because there seems to be nothing to be tired from.

For a long time I counted this state as my own defect. When I could not find the answer to "I did three things, why am I this wrecked?", I went to the easiest explanation: so I have no stamina. After the diagnosis I changed the question. Instead of "what did I do," I began to ask "what did I set up in order to be able to do these," and the answer suddenly became understandable.

Fatigue is not on the diagnostic list of ADHD. But it is one of the things people living with ADHD describe the most.

Where the fatigue comes from

Three sources pile on top of one another.

1. The same work costing more.

You are doing a job everyone does, but you are running by hand the parts that should have been put on autopilot: deciding where to start, holding the steps in mind, bringing attention back every time it escapes.

Think of this with a concrete example. Writing a reply to an email looks like a single task. What actually happens is this: finding the email, reading what was asked a second time, remembering the parts of the answer, setting aside another thought that cuts in, adjusting the tone while writing, reading it once more before sending. Most of this happens where no one sees.

The person looking from outside sees the same result. They do not see the energy spent. I took up this invisibility separately in the article on the invisibility of thinking labor.

2. Constant compensation.

Alarms, lists, rechecking, reading twice. All of these work and all of them cost something.

On top of this comes the effort not to show symptoms. Masking is a system that runs at every hour of the day: adjusting facial expression, not letting on that your attention has slipped, recovering when you have missed the question, appearing to sit still. The bill comes in the evening, and when it comes you no longer remember the reason.

3. Sleep.

The review by Kooij and Bijlenga (2013) shows that delayed sleep phase is common in adult ADHD. In the glossary, under delayed sleep phase. Someone who goes to bed late and has to get up early lives with a chronic sleep deficit.

A sleep deficit also enlarges all the other symptoms: attention drifts faster, emotion arrives harder, work takes longer. When work gets longer the night ends even later. The cycle feeds itself.

Fatigue is the bill not for the work done, but for the scaffolding set up to be able to do that work.

Why it is mistaken for laziness

Because the effort spent is not visible.

What is visible is the outcome: either the work has been finished (then "so it was easy") or it has not (then "so they did not try"). The third possibility in between, "they tried very hard and still could not keep up," is not visible from outside at all.

Over time this settles inside the person as well. This was the thing that lasted longest in me: thinking that I did not deserve the fatigue. There were periods when I was even ashamed to say I was tired, because I had no reason to show. Yet there was a reason; only its bill was not visible.

Its fluctuation is a separate matter

Fatigue in ADHD does not stay at a fixed level. When you sink into a task that interests you, you can work for hours as if you never tire. Then, as soon as that task ends, or conversely in front of a task that does not interest you at all, you can be done within fifteen minutes.

This fluctuation creates two problems. The first is in other people's eyes: the sentence "yesterday you worked six hours, today you can't do one." The second is in your own eyes: taking the good day as the measure and blaming yourself on the bad day.

When I stopped taking the good day as the measure, the bad days decreased too. Because on the good day I stopped spending myself to the very end.

When something else should be looked for

This is an important heading, because not every fatigue is something to attribute to ADHD.

You need to see a doctor in the following situations:

• If the fatigue has clearly increased recently
• If it does not pass even when you sleep
• If it is accompanied by bodily symptoms such as weakness, shortness of breath, palpitations, hair loss, feeling cold
• If it is accompanied by not being able to take pleasure and hopelessness
• If daytime sleepiness is marked, or there is snoring or waking at night

The common causes that need to be investigated: thyroid dysfunction, iron and B12 deficiency, sleep apnea, depression.

The review by Instanes and colleagues (2018) reports an association between adult ADHD and some physical health problems. So saying "I have ADHD, that's why I'm tired" can sometimes overlook a real picture.

The long-term follow-up study by Hinshaw and colleagues (2012), on the other hand, shows that the risk of depression is higher in women with ADHD. A long-lasting exhaustion may not be something to manage alone; I described the depression side in the article ADHD and depression.

I know that while reading these items, even making an appointment can be hard. What worked for me was to stop waiting to feel ready to make the appointment; I made it without feeling ready, and the feeling-ready part never came anyway.

What helps

Think of energy as a budget. Tracking how much is left during the day is better than collapsing at the end of the day. In the glossary, energy budget.

Leave the day after an expensive day empty. New people, long meetings, crowded settings; these are more expensive than other days. Not putting heavy work on the next day is not counted as a luxury; it becomes part of maintenance. Noticing that your social battery has run out after a crowded day is enough information to plan the next day.

Treat sleep like a treatment. This is the highest-yield intervention on this list. The details are in the article ADHD and sleep.

Do not carry the mask everywhere. Not having to explain yourself in at least one setting markedly lowers the energy spent through the day.

Write the recovery time in the calendar. It appears in the glossary as recovery time, and when it is visible, guilt does not pile on top of it.

Count the invisible work. A small movement that works for me: at the end of the day, next to the three items on the list, I also write how much "preparation" I did that day. Messages that cut in, restarts, files that could not be found. The list suddenly looks full and the exhaustion is accounted for.

Tell the kinds of fatigue apart. When you feel exhausted in the evening, ask yourself a single question: does this fatigue seem like something that would pass with sleep, or does it seem like it would stay the same even if I slept? The first usually points to a sleep deficit. If the second keeps recurring, there is nothing to wait for before telling a doctor about it.

A common mistake

The most common mistake is trying to solve fatigue with more caffeine or a tighter plan.

Both work in the short term and both widen the deficit. Caffeine makes the next day more expensive because it delays sleep; a tight plan collapses at the first hitch because it leaves no room for a bad day, and adds guilt on top.

What changed in me was not tightening the plan; it was leaving gaps in it. When gaps are left, the plan does not die at the first obstacle.

What remains

ADHD causes fatigue, but not as a symptom; as a cost. The extra effort spent to get the same result, compensation systems that run constantly and poor sleep come together.

If the fatigue is severe and lasting, other causes need to be ruled out before attributing it to ADHD.

I covered the long-term form of this in the article on burnout in ADHD.

I described one day of this fatigue in the diary: Fatigue.