Decisions, decisions: ADHD and the trap of analysis paralysis

Have you ever stayed up all night replaying a meeting in your head? Or obsessed over an email? Or questioned every instinct you have? If making decisions feels like a full-time job, this one’s for you!

We’re talking with Dr. Mark Schrime, a surgeon with a PhD in the science of decision-making. Hear about the exhausting cycle of analysis paralysis, second-guessing, and decision fatigue that’s a reality for many people with ADHD. 

• Listen: Analysis paralysis

• Read: ADHD and analysis paralysis

Cate Osborn: Hi everybody and welcome back to "Sorry, I Missed This," the show where we talk about all things ADHD, sex, intimacy, relationship, communication, and more. As always, it's me, your host, Cate Osborn.

In this episode, we sit down with Dr. Mark Shrime to talk about how values impact our decision making and how to make big decisions even if you feel like you're chronically bad at choosing the right thing.

Y'all, I am so excited for this episode. I first came across Mark's work a couple of years ago when I read about his work in decision making and how our brains and our bodies and our values all combine to inform the decisions that we make.

I've always struggled with making big decisions and what is fascinating about Mark's work is that he doesn't just focus on whether or not a decision is right or wrong, but his work focuses on why we make those decisions and how we gather the data and the information that we need to make the best possible decision.

Dr. Mark is so knowledgeable, his research is incredible, his book is amazing, and so I'm so excited to welcome you to this decision making episode of "Sorry, I Missed This."

Mark, thank you so much for being on the show. I'm so excited to have you.

Dr. Mark Shrime: Cate, thanks for having me. I've been excited for this one.

Cate: I would love to just know right off the bat, how does one become a decision making scientist?

Mark: Yeah, so there is actually a field called decision science. I did not make this up. Fundamentally every decision, but especially the big ones, are a balance of competing demands. That's what decision science does — it takes all sorts of competing domains that people are trying to balance in their heads and makes it pretty explicit for how to balance that.

Cate: I'm fascinated around the connection between ADHD and decision making. A lot of ADHD decision making difficulty is not about knowledge, is not about motivation, but it often is about cognitive overload. So in high stakes health settings, how do medical professionals like you deliberately reduce your cognitive load so you know that better decisions can happen? And can we steal from that?

Mark: Let me start by saying decisions are hard. So yes, I 100% think it's harder for ADHD folks and the fundamental reason that we struggle with them is that every decision is made under uncertainty.

But if there wasn't uncertainty, you wouldn't have to make a decision. There's some really cool science on this — our bodies react physiologically to uncertainty as stress. Our brains come up with a whole bunch of shortcuts, a whole bunch of heuristics, a whole bunch of ways to make decisions that don't necessarily make us have to face that uncertainty.

So that's just broadly, that's not ADHD related at all. I do think one of the things that happens with the really hard decisions — let's say I'm changing a career. So one of the things that I need to answer is, okay, what am I hoping this new career does for me?

(03:49) The 70% rule

Mark: But then there's a whole bunch of like, okay, so what are the PhD programs that I have available for me? And then how am I going to afford it? And so you go from the why to the what to the how. One of the problems that all of us face — but I do think is harder for folks with ADHD — is bouncing between those levels.

So we'll start with like, I think I want to get a PhD because X. Oh crap, but hold on, how am I going to — what's my budget? How am I going to do this? I can't do it because my budget doesn't work. And so we just bounce between these levels and that prevents making a decision at all, and then it really makes it harder to make a good decision.

Cate: You talk a lot about values and how values shape the decisions that we make. And something that I think is super interesting and that we have seen over and over on this podcast is that at the core of everything is being able to articulate your needs, articulate your wants. And I'm curious about how understanding our values and how unexamined values can shape the decisions that we make.

Mark: When I was talking about the levels of decision making, that's the top level of decision making — what is it that you're trying to actually accomplish? And I use the word values, and I still think it's the best word, but it's got a connotation that those values have to be "good" in quotes.

If you're trying to figure out where you want to direct your midlife, it is okay for your value to be, "I want to make a crap ton of money so I can retire at 53." And we can solve for that. But articulate that, because if you don't articulate that and you port the values that you had as an idealistic 18-year-old who didn't have three children and a mortgage to pay and whatever, you will make a decision based on values that aren't actually yours, and then you'll be dissatisfied. You will have made the wrong decision because you weren't solving for the thing that you truly wanted to solve for.

Cate: A lot of times I hear as a person with ADHD to slow down, think it through. But what I have found is that sometimes making decisions is actually more difficult the longer I give myself because I'm entering into that rumination cycle — shout out to Dr. Jay and the other episode that we just did — but that rumination cycle and the overthinking and now I'm over-researching and I'm using all my cognitive effort to find the perfect piece of information or whatever that is going to inform this very — I don't want to say vibes-based choice — but sometimes decisions aren't — there's not one perfect choice, there's just a choice that you make and then you have to just live with it, right?

Mark: You've said so many good things in here. First of all, absolutely, rumination is a thing. Again, because decisions are made under uncertainty, we as humans have a few different ways to handle the uncertainty. The most common way to handle the uncertainty is to try to reduce it, which is natural.

But if we are constantly trying to reduce the uncertainty until we get to certainty, we will never act. We're trained as health professionals to be like 90%, 95% certain before we tell you, okay, it's time for your surgery. And that's good because that's what I think I would want my doctor to do for me.

(07:54) The paradox of choice

Mark: On the other hand, for our own careers, for our own lives, I really try to encourage people to keep the 70% rule in mind — that you only need to be 70% certain. Like, you can be 30% uncertain. You can be like, yeah, this might actually mess up, and to accept it because there's never a perfect decision. What we're trying to do here is find the good decision that optimizes for all the things that you're trying to solve for. And then making that decision with 70% certainty and also — and this is a really hard thing — trusting yourself that you can handle whatever comes on the other side of that.

Cate: The ADHD experience — like so many people who I talk to, I interact with on a daily basis — talk about the fact that they feel chronically bad at decision making. But we are all making decisions every day, right? What do I have for breakfast is a decision. It's a smaller and perhaps less significant decision than like, should I leave my job and go get a PhD? But we're still making it. And so as someone with ADHD who also works with clients and is in the medical field, why do you think so many people with ADHD just feel inept at decision making generally?

Mark: I think it's because we're looking for the perfect decision and we — I don't have any science to back up what I'm about to say, this is just experiential — we are maybe particularly afraid of regret. Barry Schwartz wrote this very famous book — I want to say it was 2004 — called "The Paradox of Choice."

In it he proposed, and the research has supported this, that the more options you have, the more likely you are to be paralyzed with a choice. I call this the Cheesecake Factory menu — the Cheesecake Factory menu is 45,000 pages long, it's so hard to make a decision, whereas you go to a restaurant and they give you three options, well that's pretty easy to make a decision.

And there's a really interesting corollary — and I forget the names of the researchers that looked at this — they presented two groups of people with choices. One of them had three options and one of them had 15 options. Even if they picked the same thing, the people that had 15 options were less satisfied than the people that had three.

Cate: That makes me so mad and I don't know why, but I'm like, yeah, I would also be mad. I would be like, oh, there was one of those that was way better than what I picked.

Mark: And it's something called expectation disconfirmation, which is that if I have 15 choices, well, there probably is a perfect one. And when the Caesar salad has too many croutons in it, you're like, well dang it, this was not the perfect one, there was probably a better one.

So to back this up to ADHD, it is often a much better exercise to cut out options, to say, all right, Cate, you got two options. You are going to stay in your job or you're going to get your PhD. We're not going to be like, you're going to stay in your job, you're going to get your PhD, you're going to learn to surf, you're going to — no, you're going to do one of these two.

Cate: Wait, I wanted that one.

Mark: Exactly. And part of that is just kind of surgically trimming off some of those options so that the decision actually does start to get to the thing that you're trying to solve for.

(11:34) The difference between permanent and reversible decisions

Cate: I remember thinking about this very specifically when I was choosing where I went to college is that I often feel like Dr. Strange from Marvel, where I see before me like a thousand potential realities in which I could live, in which I could exist.

And it's like, do I choose the reality where I go to the college in Iowa, or the college in New York, or the college in Florida, or the college in England? And all of those are going to then create new things because I'm going to meet new people and have different opportunities and different things happen to me in each of those places that is then going to inform the rest of my life.

And that is how I've always thought about decisions — do I go for the PhD and even if I do get the PhD, maybe I'll get another one down the line because I also think art history is very interesting and very cool and I would like to know more about that.

How do you navigate that Dr. Strange — I'm just going to call it the Dr. Strange-ian quandary — of really feeling like no matter what I do, there is like an entire lived existence that I am letting go of whenever I make the choice? Because I could be an art historian, but I could also keep working in neurodivergence and sexuality, and both of them are fulfilling and fantastic, but there's part of me that just wonders about Cate the art historian. Do you know what I mean?

Mark: I 100% know what you mean by this and yes, I would love for it to be true that we have multiple lives because there are multiple lives that I want to live. It's 100% true that the minute you make a decision, you are killing off a life that could have existed and you are choosing not to go down that path. You are closing an infinite number of doors so you can leave one door open that you're going to walk through.

That is 100% true and there's really no getting around that. I do think where that paralyzes us, though, is that we're like, well dang it, maybe I should have gone to art history or maybe I shouldn't make this decision and then go get my PhD in art history. And then we don't actually close the doors and we don't actually walk through the door and that is a decision.

Choosing not to decide is a decision. So you're still closing off doors — basically, instead of framing it as, oh God, I have to close off all these doors, you're going to close off some of them anyway. It's your choice which ones you close off. It's kind of a reclaiming of the agency of who gets to decide which doors I close, because if I just stay on the path that I'm on, randomness gets to decide which doors I close, whereas I get to decide if I make the decision.

There's another concept in decision theory. It's the idea of Type 1 and Type 2 decisions. One of them is permanent, like you can't put the toothpaste back in the tube. And Type 1 decisions have to be made very slowly. They are permanent, you just have to make them deliberately and think through them. Type 2 decisions should be made quickly. They should be made with 70% information.

We as humans, and I do think even more so in ADHD, tend to view more decisions as permanent than we should. There are actually very, very few truly permanent decisions. So as you just said, you could go for your PhD right now and then you could be like, well, no, maybe — you know what? I do want to get a PhD in art history later. And you haven't fully closed off the art history door until the day you die.

Cate: Because so many ADHDers do tend to struggle with that kind of black and white thinking of there is a right choice, there is a wrong choice, is there a way that — or like a tool or a way of thinking about decisions — that can help someone kind of decide what is a Tier 1, what is a Tier 2 decision and not feel like choosing the chicken Caesar salad is the Type 1 decision where we really have to think about it? If I know we're going out to eat, I look up the restaurant during the day and I spend all day thinking about my options so that way when I go to the restaurant, I know what I want already and I feel like that's my secret third option.

Mark: I don't know of a very simple tool, but what I do encourage folks to do is to practice messing up. And in fact —

Cate: We love messing up here on the show. We love messing up.

(15:05) Impulsivity and the benefit of seeking external mentorship to navigate complex choices.

Mark: Yes. We are so used to this, well, you know, the road to success is paved with a lot of failure, whatever, whatever. I actually try to encourage folks to go a little bit further than that and to actually fall in love with the kind of sucky feeling of making a bad decision. Don't do this with the really big decisions — start with the small ones and see what happens on the other side of that.

Cate: That's like the cocktail menu theory — sometimes you just order the cocktail that you're like, it seems a little weird, it seems a little outside of my comfort zone, and then you get it and you try it and you're like, oh, maybe it's not for me, but like you don't die and nobody explodes, it's just the drink has too much vinegar in it.

Mark: Right.

Cate: So let's talk a little bit about impulsivity. There's like the micro and then there's the macro. And sometimes the impulsive decision making is just you impulsively decide to go out with friends and so you don't go to the store at the time that you normally do and then your dog is out of dog food, right?

And so now you've impacted yourself down the line. But sometimes the impulsive decision making is insidiously macro because sometimes — I don't know why now I'm stuck on this cocktail thing — but sometimes the impulsivity is just you look at the menu and there's a drink with a fun name and you're like, oh, that sounds fun, and you impulsively order it.

But in particular, in the work that I do, those impulsive decisions can be much more life-changing. We see women with ADHD making impulsive sexual decisions, decisions that can impact their sexual health and even the trajectory of their life moving forward. So talk to me a little bit about impulsivity.

Mark: Before I get to talking about impulsivity, I will say, yes, it's annoying that you have to now go to the store at 10 o'clock at night to get dog food for your dog, but you've survived every other one. I'm being oversimplified, but to a large degree you've survived every one of those other — you have survived.

I think what we do often is that we catastrophize, we black and white, we put too much importance on the consequences of the impulsivity and again, sometimes they're incredibly important, especially in the field in which you work, so I don't want to minimize that.

But in the smaller ones, sometimes we put too much importance on that and ignore the fact that we have lived with our impulsive selves for our entire lives and we have built up systems and structures to take that into account. But where I want to go with the impulsivity is I think there are a couple of questions that we have to ask ourselves. If you'll excuse a little bit of vulgarity here, I think the very first question we have to ask ourselves is, "is this a situation in which it's okay to think with my dick?"

Cate: That's a very — that's a fair thing.

Mark: It is. And sometimes the answer to that is yes — this situation is safe enough, the people that I'm around with are safe enough, in which case go for it. The second thing that I would say is, is this a domain in which your gut instinct is actually well developed?

As a physician, there are times that I will walk into a patient's room and just know that that patient is not going to do well. And after 25 years of being a physician, I would not be showing up as my full self if I ignored that intuition. But I cannot port that intuition into, I don't know, day trading stocks because I have the intuition of a ficus tree when it comes to like what a stock is going to do.

So be honest with your own intuition and say, is this a domain in which my intuition has been honed? In which case listen to that, but also be careful because expertise in one area actually sometimes blinds you to your lack of expertise in a different area.

Cate: For our dear listeners who are maybe people who are struggling with decisions or are doing that over-analysis or stuck in that decision paralysis moment, do you have some concrete pieces of advice, just like a little something that you can leave them with to hopefully spur them into this next part of their journey?

Mark: Concrete pieces of advice for all decision making, no pressure. I think a lot of things that we've been talking about this whole episode is there. Give yourself permission to fail, in fact practice failing. Give yourself permission to think with your id sometimes when it's okay. Give yourself permission to bring in your intuition.

All those sorts of things I think are really helpful. At the risk of sounding like a self-promoter, I do think sometimes you need to get a mentor, too. I think you need somebody who is able to see it externally, call you out on your patterns — so get somebody not emotionally invested to help navigate these decisions.

Cate: Awesome. Mark, thank you so much for your time. This was such a great episode.

Mark: Thanks for having me. This was great.

Cate: Thank you for listening! Anything mentioned in the episode will be linked in the show notes, with more resources. Have a question, comment, burning story you'd like to share? Email us at SorryImissedthis@understood.org. 

This show is brought to you by Understood.org. Understood.org is a nonprofit organization dedicated to empowering people with learning and thinking differences, like ADHD and dyslexia. If you want to help us continue this work, donate at understood.org/give.

Cate: "Sorry, I Missed This" is produced and edited by Jessamine Molli.

Video is produced by Calvin Knie and edited by Jessie DiMartino. Our theme music was written by Justin D. Wright, who also mixes the show. Production support provided by Andrew Rector.

Briana Berry is our production director. Neil Drumming is our editorial director. From Understood.org, our executive directors are Laura Key, Scott Cocchiere, and Jordan Davidson.

And I'm your host, Cate Osborn. Thank you SO much for listening!