Inattentive ADD, ADHD and the DSM V

Inattentive ADD, ADHD and the DSM V

I have not posted in a long time about the proposed changes to the Psychiatric Diagnostic Manual, the DSM, which is used to diagnose all mental impairments including ADHD.   The reason for this is not neglect but rather there has not been much new to say.

What is new now is the fact that there appears to be so little clarification to the question of what will happen to the ADHD subtypes even though the deadline for the proposed new edition is just 12 months away.

 The manual, that last had a major revision 1994, is called the DSM IV.   It is the fourth edition of the diagnostic manual but now almost 20 years latter, a new manual is necessary.   Much has changed in psychiatry and psychiatrists have been working on the revised version of the manual, the DSM V for over two years.

The new manual was supposed to sort out, among other things, whether there was value in dividing ADHD into three subtypes. The subtypes were developed for the DSM-IV but they have been found to be both helpful and problematic.

The subtypes are helpful because they establish and recognize that there is a subgroup of people with attention deficits that are not inattentive because of hyperactivity and impulsive behavior. The subtypes however are confusing because calling something without hyperactivity, Attention Deficit Hyperactivity Disorder, makes no sense. It is also confusing because the grouping has had the affect, in my opinion, of having psychiatrist treat ADHD, regardless of subtype, much the same.

The two conditions both have Executive Function problems but the problems that they have are not the same. People with Inattentive ADHD do not have the debilitating emotional control and impulse problems of the Combined type though they do have in common much of the organization, time management, motivation and perseverance problems.

There are many conditions in the DSM-IV that also have executive function issues and they are not all lumped into one diagnostic pile. People with Post Traumatic Stress Disorder, Depression and schizophrenia all have executive function problems but they are not all lumped into the same DSM category.

The American Psychiatric Association (APA) was hoping to have some empirical data (research findings, scholarly analysis, etc) to inform them of how to best sort out the entire subtype dilemma by February of 2013 and they still may make their deadline.

Functional MRI studies are shedding light on the ways that the brains of the Inattentive and the Sluggish are different from the brains of the impulsive and the hyperactive and there are some extremely brilliant people working this out. Hopefully they will come to a conclusion that improves recognition, diagnosis and treatment of all the subtypes of ADHD as that, after all, is the goal.

Two other proposed ideas for the new DSM had to do with the age of diagnosis and the number of symptoms that had to be present to determine if there was a 'true' ADHD diagnosis. Currently the DSM-IV states that for you to be diagnosed with ADHD, you have to have had symptoms before the age of seven and that you have to have 'X' number of these symptoms or 'X' number of that symptom.

The symptom number is an issue because as people age, their hyperactivity symptoms can improve or they may control their impulses better than they did when they were six, but they are still impaired despite not having the exact number of symptoms needed for a diagnosis. The age of onset stipulation is also problematic and especially detrimental to those with Inattentive ADHD because Inattentive ADHD kids can sit in a classroom until middle school without anyone noticing that they are not focused on school.

These latter two issues will likely be clarified in the new DSM-V but only time will tell if the APA is able to sort out the subtype issues before the February 2013 deadline for the publication of the new edition.