Families in general have tremendous power both to heal and to inflict pain. If the family is willing to cast a new eye upon a chronically wounded member, if the family is willing to help heal him, it can be more effective than all the medications, therapies, and incantations ever devised. However, if the family is unwilling to look differently upon its George, if the family instead sneers and snorts, “Just another one of your lame excuses! Why don’t you just shape up?” then the family can undermine whatever good treatment he may receive. Few of us ever outgrow the power of our families both to deflate us and to fill us up. Few of us ever get past the wish for love and approval from mother or father, sibling or kin. That wish can be used in our favor, to support us as the wish is granted, or it can be used in our destruction as the wish is perpetually denied.
For the family to use its considerable power to heal, it must be willing to accept the challenge of change. All groups, most especially families, feel threatened by a change in the status quo, no matter how bad the status quo may be. As the person with ADD seeks to change, he is also asking his family to change with him. This is never easy. It is not the troubled family that has a hard time with change; it is all families. But with education and information as guides, with encouragement and support as reinforcers, most families can successfully adapt. As there is less suffering in the family system, life at home can even be fun.
* Quotation marks set off direct quotations from Getting to Yes: Negotiating Agreement Without Giving In, rev. ed., by Roger Fisher, William Ury, and Bruce Patton (Penguin Books, 1991), pp. 10–11.
6
Parts of the Elephant
SUBTYPES OF ADD
We do not yet have one concise definition for ADD. Instead, we have to rely on descriptions of symptoms to define ADD. Often the descriptions focus on one part of the syndrome or another, highlighting this aspect or that, in a way that is reminiscent of the story of the blind men describing an elephant. One blind man feels the trunk and describes something long and tubular emitting warm air. Another feels the tail and describes something narrow and pliable. Another feels a leg and describes something like a tree trunk. Still another feels the belly and describes something massive yet spongy. None of the blind men is able to step back and see the elephant as a whole.
So it can be with ADD. When we focus in on one part of the syndrome, we are at risk of overlooking another, quite different part. For example, if we focus in on inattentiveness, we can overlook the fact that most people with ADD can hyperfocus at times. Or if we focus in on hyperactivity, we can overlook the many people with ADD who are quiet and daydreamy. It is difficult to step back and see that all of these aspects are part of a greater whole. By examining the various parts, or subtypes, of ADD, however, one can gain a better understanding of this complex syndrome. The formal diagnostic nomenclature recognizes only two subtypes of ADD: ADD with hyperactivity and ADD without hyperactivity. ADD in children and ADD in adults constitutes another broad classification.
We would like to introduce some other subtypes, not all formally recognized, but, based upon our clinical experience, useful in identifying the most common and distinct ways in which ADD is manifested. Because many of the secondary symptoms associated with ADD develop over time, these subtypes apply mainly to ADD as it is seen in adults. We list them, roughly speaking, in descending order of frequency.
The subtypes include:
1. ADD without hyperactivity
2. ADD with anxiety
3. ADD with depression
4. ADD with other learning disorders
5. ADD with agitation or mania
6. ADD with substance abuse
7. ADD in the creative person
8. ADD with high-risk behavior, or “high-stim” ADD
9. ADD with dissociative states
10. ADD with borderline personality features
11. ADD with conduct disorder or oppositional disorder (in children) or antisocial personality features (in adults)
12. ADD with obsessive-compulsive disorder
13. Pseudo-ADD
ADD without Hyperactivity
One of the most common misconceptions about attention deficit disorder is that it only occurs with hyperactivity. Many people believe that if the child is not “bouncing off the walls,” then he or she does not have ADD. If the child is not a behavior problem, or a discipline problem, or at least a fidgety nudge, then the child does not have ADD. Or, if the adult is not a restless whirling dervish, then he or she cannot have ADD. The diagnosis seems to rest, in many people’s minds, upon the symptom of motoric hyperactivity.
While untrue, this is understandable. ADD was first described in the population of hyperactive children. Our comprehension of the disorder is rooted in studies of hyperactive kids. It is only fairly recently that we have come to understand that ADD can occur without hyperactivity, or, for that matter, that it can occur in adults. Just as reputations die hard, so does dated knowledge fade slowly.
But the evidence now shows that there are hosts of children and adults who have all the other symptoms of ADD but who are not hyperactive, or even overactive. If anything, they are motorically slow, even languid.
These are the daydreamers. These are the kids—often girls—who sit in the back of the class and twirl their hair through their fingers while staring out the window and thinking long, long thoughts. These are the adults who drift off during conversations or in the midst of reading a page. These are the people, often highly imaginative, who are building stairways to heaven in the midst of conversations, or writing plays in their minds while not finishing their day’s work, or nodding agreeably and politely while not hearing what is being said at all. They steal away silently, without the noisemaking of their hyperactive brethren, but they steal away just the same.
Perhaps due to the manner in which the ADD gene is expressed, or due to the absence of the Y chromosome, girls seem to have ADD without hyperactivity more often than boys do. It can occur in both sexes, but it is more common in girls or women.
Usually in these people the core symptom is distractibility. It is a quiet phenomenon, their shifting of attention. It happens as silently, but as definitely, as a cut in a film sequence. Imagine, one moment you are in one place, and in the next moment you are somewhere else. You don’t really notice it. Rather you go along with it, as you go along with a cut in a movie. The narrative carries you, as you view your own internal story, your own internal screening of the day’s events.
In some ways it is a charming symptom. The mind meanders like a brook, winding through the contours of the land, bending here, falling there, quietly making its way, in its own time, to some larger river of thought.
But in other ways it is anything but charming. It can be downright disabling not to be able to rely on your own mind to remember things, to prompt you to get to places on time, to keep you involved in a conversation when you want to be, or focused on a page you really do want to read, or concentrated on a project you need to complete. The meandering brook, in its desultory way, seems to be forever carrying you away from where you want to be.
“I can be working on a project at my desk,” reports one patient, “when, without really knowing it, I begin to think about some other idea my work suggests. Then I follow that thought, or I may even leave my desk to go get something, and by the time I’ve gone to get the thing, I’ve forgotten what it was I was going to get. I’m almost sleepwalking. Hours can pass in this unfocused state. Lots of interesting thoughts pass by, I can be engaged in lots of creative enterprises, but relatively little gets done. I can combat it consciously for a few minutes, but the moment I get into anything, the moment I stop monitoring what I’m doing and get into the flow of the work, then I’m at the mercy of my whims. If I could just stay focused for even one hour, I could probably get my whole day’s work done.”
After this woman was treated for ADD, her life changed. “It was amazing,” she says. “I didn’t really feel any different, but I started gettin
g all my work done. Projects I’d had on the back burner for years began to get finished, and at the end of a day I couldn’t believe how much I’d actually accomplished. But it was more than just my productivity that changed. My whole way of looking at myself changed, too. I stopped thinking of myself as some kind of spaceshot and started realizing I was just as smart as anybody else. I started realizing I was not defective. In fact, I was pretty good. It was quite a change, I can tell you. My only regret is that I didn’t find out about my condition sooner in my life.”
Many factors other than ADD can contribute to an inability to focus consistently. The most common of these include the hectic pace of everyday life, traumatic events in the present or the past, depression, substance abuse or overuse of prescribed medication, anxiety disorders, grief reactions, major life changes, and various medical conditions, such as certain seizure disorders, that require a visit with a physician to evaluate. However, the cause may also be untreated ADD.
Particularly when hyperactivity is not present, the diagnosis of ADD is easy to miss. The individual simply appears to be one of the many people who “can’t get their act together.” You want to take them and shake them and say, “Shape up! Get with it! Don’t you realize you’re frittering your life away?!” But if someone in the person’s life could stop to consider that the problem might be rooted in something more complex than laziness or general fecklessness, then a new light could shine on the situation, and, perhaps, a better life could begin.
ADD with Anxiety
For some people, the experience of ADD is one of chronic anxiety. What bothers them most is not the inattentiveness or impulsivity of ADD, but the attendant anxiety they so frequently feel.
This anxiety can be separated into two parts, one logical and obvious, the other irrational and hidden. The “logical” anxiety is the anxiety that one would expect to feel if one were chronically forgetting obligations, daydreaming, speaking or acting impulsively, being late, not meeting deadlines—all the typical symptoms of ADD. Living in such a state naturally leaves one feeling anxious: What have I forgotten? What will go wrong next? How can I keep track of all the balls I have in the air?
The hidden anxiety is hard to believe, but we see it frequently in clinical practice. This is the anxiety or worry that the individual actively seeks out. The person with “anxious ADD” often starts the day, or any moment of repose, by rapidly scanning his or her mental horizon in search of something to worry about. Once a subject of worry has been located, the individual locks in on it like a heat-sensing rocket and doesn’t let go. No matter how trivial the subject or how painful the worry, the individual keeps the worry alive, returning to it magnetically, obsessively. Some of these people do in fact have obsessive-compulsive disorder, but the majority do not. They are actually using worry as a means of organizing their thinking. Better to have the pain of worry, they seem to feel, than to have the disquietude of chaos.
Listen to one patient’s description: “The minute I have my mind cleared of one problem, I go out and look for another. They are usually really stupid things like an unpaid bill or something someone said to me two days before or whether or not I’m too fat. But I brood over them until they ruin my whole mood.”
This tendency to organize around worry defines the subtype of ADD with anxiety. It is common. Why is it so persistent? In part because the individual doesn’t know why he’s doing it. Like most habits of mind, it persists until insight can begin to try to change it.
Another explanation for this ruminative, often extremely painful style of thinking has to do with what we call the startle response in ADD. It is a sequence of events that goes as follows:
1. Something “startles” the brain. It may be a transition, like waking up, or going from one appointment to the next, or it may be the completion of a task, or the receiving of some piece of news. It may be, and usually is, trivial, but the “startle” requires some reorganization on the part of the brain.
2. A minipanic ensues. The mind doesn’t know where to look or what to do. It has been focused on one thing and is now being asked to change sets. This is very disorganizing. So the mind reaches out for something red-hot, something to focus on. Since worry is so “hot,” and therefore so organizing, the mind finds something to worry about.
3. Anxious rumination replaces panic. While anxious rumination is painful, it is at least organized. One can say over and over in one’s mind, thousands of times a day, “Will I get my taxes paid on time?” or “Does that look she gave me mean she is angry with me?” or “Did I pass the exam?” The panic induced by the “startle” is replaced by the focused ache of anxious rumination.
The whole point of the sequence is to avoid chaos. No one likes chaos, but most people can endure milliseconds, or even seconds, of it as they go from one task to another, one state to another, one stimulus to another. The ADD mind often cannot. Instead, it fixates on worry and gets organized—or stuck—around it.
ADD with Depression
Sometimes the first symptom that brings a person with ADD to a psychiatrist is some form of mood disorder, particularly depression. While ADD is usually defined in terms of other symptoms—distractibility, impulsivity, and restlessness—and consequently is not considered when someone says he or she is depressed, the fact is that ADD and depression frequently coexist.
This is not hard to understand when one considers the typical life experience of someone with ADD. Since childhood, the person with ADD has felt a sense of chronic frustration and failure. Underachieving all along, accused of being stupid or lazy or stubborn, finding the demands of everyday life extraordinarily difficult to keep up with, tuning out instead of tuning in, missing the mark time and again, living with an overflow of energy but an undersupply of self-esteem, the individual with ADD can feel that it is just not worth it to try anymore, that life is too hard, too much of a struggle, that perhaps it would be better if life were to end than go on.
It is heartening how valiantly people with undiagnosed ADD try in the face of their despair. They don’t give up. They keep pushing. Even when they’ve been knocked down many times before, they stand up to get knocked down again. It is hard to keep them down for good. They tend not to feel sorry for themselves. Rather, they tend to get mad, to get up, to have at it again. In this sense one might say they are stubborn: they just don’t give up. But they may remain depressed.
While life experience can lead to some of the depression one often sees among people with ADD, there may be a biological factor at work as well. It may be that ADD partakes of a common pathophysiology with biological depression (i.e., depression not caused by life events but by biology). That is to say ADD and biological depression may be physiologically, and genetically, related. Whatever goes wrong in depression, whatever the “patho” part of the physiology is, that part may also go wrong in ADD.
James Hudson and Harrison Pope at the Harvard Medical School, in their innovative research, have speculated that eight separate disorders, among them depression and ADD, may share a common physiologic abnormality. They call the group affective spectrum disorder. (It also includes bulimia, obsessive-compulsive disorder, cataplexy, migraine, panic disorder, and irritable-bowel syndrome.) The grouping is supported by response to similar medications, as well as by clinical evidence. If, as is the case, a medication that successfully treats major depression also successfully treats ADD, might we not suppose that there is a link between the two disorders? Although it is not necessarily so—indeed, there are unrelated disorders in medicine that the same medication treats—it is worth wondering about. Hudson and Pope did just that. Their research shows strong evidence for a physiologic linkage among the eight disorders they include within the “affective spectrum.”
On the basis of both biology and life experience, then, it is not surprising to find depression associated with ADD.
Often, however, the mood problem in ADD is subtle. It is not severe enough to be called depression, but it is more severe than the ord
inary dips in mood of everyday life. Listen to this description from a patient:
I don’t think I’ve ever really been happy. For as long as I can remember, there’s always been a sadness tugging at me. Sometimes I forget about it. I guess that’s when you could say I was happy. But the minute I start to think, then the bad feeling comes back. It isn’t despair. I’ve never attempted suicide or anything like that. It’s just that I’ve never felt good, about myself or about life or about the future. It’s all been an uphill battle. I guess I always thought that’s just what life was—one long series of disappointments interrupted by moments of hope.
This patient’s description brings to mind a remark made by Samuel Johnson, a man for whom there is ample evidence of having ADD and depression. Johnson observed that “life is a process not from pleasure to pleasure, but from hope to hope.” Elsewhere he wrote, “Life is a state everywhere in which there is much to be endured and little to be enjoyed.” He also said that “we live in a world that is bursting with sin and sorrow.”
Such persistent sadness, or lack of pleasure, often accompanies ADD. Sometimes, when the ADD is treated, the sadness lifts. As if a mote had been removed from the eye, the person can see pleasure where there had only been confusion or a blur. In people with this subtype of ADD the distractibility that is part of the syndrome interferes with the process of apprehending pleasure, of perceiving order, and of sensing that life can be all right.
It had never occurred to the patient quoted above that matters could work out in her life because she never recognized it when they did. She was always distracted by some relatively benign worry. But she was so distractible, so subject to the disruptions the worries caused her, that she could never see the forest for the trees. Her sense of chronic disappointment was as much a function of her inability to perceive order or stability in her world as it was of actual failures.
Driven to Distraction (Revised) Page 20