Driven to Distraction (Revised)

by Edward M. Hallowell

  ADD with Dissociative States

  Probably the most difficult symptom of ADD to evaluate accurately is what we call “distractibility.” While we all know, pretty much, what “distractible” means, it can be very difficult to ascertain exactly what is causing a person to be distractible. A partial list of causes of distractibility would include:

  ADD

  Depression

  Anxiety states

  Drug use or withdrawal

  Stress

  Seizure disorder (petit mal)

  Caffeinism

  Sleep deprivation, fatigue

  Dissociative disorders

  This list is only partial, but it highlights the importance of accurately understanding the cause of a symptom before making a diagnosis. It is the last cause listed above, dissociative disorders, that this section takes up.

  Dissociation refers to the dis-association of a feeling with the cause of that feeling. A dissociative state is a blank, emotionally neutral state of mind wherein one is cut off from one’s external situation and internal feelings. Victims of trauma often dissociate to escape the pain associated with the memory of the trauma or even during the trauma itself they dissociate as their only means of defending themselves against the unendurable. The trauma may be childhood abuse of some kind, experiences in combat, or any event that was of such enormous emotional and/or physical pain as to be psychically unbearable.

  The dissociated state that trauma may produce can closely resemble the distracted state caused by ADD. In recent years, due to the excellent work of investigators like Judith Herman and Bessel Van der Kolk, we have learned a great deal about emotional trauma. As more and more accounts appear of childhood abuse, we are finding more and more people who have suffered trauma but have been unable to speak of it. One of the research questions that has yet to be answered is how much of an overlap exists between the population of people who have suffered trauma and developed dissociative states, and those people with ADD.

  In differentiating the dissociative state from distractibility, the first factor to consider is the individual’s history. Does he or she have a history of trauma? Of course, many victims of trauma cannot recall the trauma they suffered. Frequently, an individual, in the midst of psychotherapy, will gradually remember some awful events that had been forgotten for years. The safe and protective context of psychotherapy allows the person to feel secure enough to recapture the memory and try to work through the pain.

  On the other hand, does the individual have a history that reflects ADD, even if it has not yet been diagnosed? People with a history of ADD do not forget the events, the evidence, of their ADD; they often just do not know what it means.

  Even if one discovers a history of ADD and no history of trauma, this is no guarantee that a history of trauma will not emerge as the therapy moves along. One should always bear in mind that what looks like distractibility may be confused with a dissociative state.

  ADD with Borderline Personality Features

  When the diagnosis of borderline personality disorder was first described in the 1950s, it referred to the “borderline” between psychosis and neurosis.

  Our knowledge of the condition has increased considerably since the fifties, although the original diagnostic label remains. Now we understand the syndrome as follows: Individuals with a borderline personality disorder have a poorly defined inner sense of self. They hunger after relationships on the one hand, with a pressing urge almost to merge with the other person, but on the other hand they abruptly terminate relationships and flee intimacy as soon as it is established. They are given to periods of deep psychic pain, full of rage, fear, and depression. They often feel suicidal, and characteristically make many gestures of suicide during young adulthood, typically by wrist-cutting or overdosing. Usually, their suicide attempts do not end in death but rather serve a kind of self-soothing function. It may seem incongruous to talk of a suicide attempt as self-soothing, but many people with borderline personalities speak of a tremendous difficulty in regulating their feelings. Sometimes a kind of monster of emotion grows inside that feels as if it will overwhelm the individual utterly. The act of cutting into one’s wrist, physically painful as it might be, cuts into the monster inside, and as the blood is let, the bad feelings dissipate in a soothing trickle.

  One of the primary feelings of the borderline syndrome is rage, which can come clawing out unexpectedly and apparently unprovoked. Borderline individuals are exquisitely sensitive to rejection. They tend to draw others into their personal drama magnetically, and they tend to split these people, usually their caregivers, into the good and the bad. They have difficulty seeing other people as combinations of both good and bad, and they resolve this difficulty by idealizing some and totally devaluing others. They often treat their inner pain with drugs and/or alcohol. This constellation of extreme symptoms makes their lives chaotic, painful, unpredictable, and often tragic.

  What does this have to do with ADD? If one reviews the symptoms named above, several points of intersection with ADD can be seen. The poorly defined inner self of the borderline can closely resemble the distracted, fragmented self of the person with ADD. The abrupt breaking off of relationships is not uncommon in ADD when the individual inadvertently simply tunes out. The person with ADD seeks high stimulation in order to focus, while the borderline person seeks high stimulation to deal with painful feelings. Both syndromes are marked by a high degree of impulsivity. The person with ADD carries a great deal of anger, due to frequent frustration over not getting things right, while the person with a borderline syndrome carries much anger due to frequent frustration over not getting his or her emotional needs met. In both syndromes substance abuse is not uncommon as a form of self-medication. These similarities are summarized in the table below.

  We have seen a number of cases in our practice, and have had reports from others, of patients diagnosed as borderline who in fact have ADD. The practical significance of this is that the treatment for ADD is quite different from the treatment for borderline personality disorder.

  As an example, consider the case of Bonnie. As a child, Bonnie was physically aggressive at home and impulsive and unproductive at school. By the third grade she was referred to as “a terror” by her parents and teachers alike and was locked into a power struggle with her mother that would last for years. She felt extremely resentful of her mother’s attempts to “force me into the conventional mold,” and so she rebelled as often as possible. In her teenage years she often used drugs and spent the night away from home. Visits to various family and individual therapists throughout adolescence did not help. Bonnie was attractive, and had a constant entourage of boys throughout high school. She encouraged sexual rumors about herself in order to worry her mother, who responded by trying, unsuccessfully, to set limits on her. Although Bonnie had poor grades, she scored high on the college admission tests, and so went off to a good university. Bonnie settled down in college, falling in love with literature. Although she had great trouble completing papers on time, she did graduate. Soon thereafter she became pregnant and married a man she liked but did not love.

  Her child became the organizing principle in Bonnie’s life, much as literature had been in college. However, once the child left for school, Bonnie became obsessed with suicidal fantasies. When the child was away, Bonnie felt empty. She could not reassure herself that even though her child was not at home, the child was still connected to her. Her old insecurities swirled up and began to choke her. To combat these feelings she started drinking heavily, until finally her husband had her committed to a detoxification center where she was diagnosed as a borderline personality.

  After two years of therapy she felt no better. She was chronically depressed and, as she put it, “distracted from having any goals.” Then, by chance, she happened to read about ADD. After consulting with her therapist, who quite open-mindedly recommended she follow up with an evaluation for ADD, Bonnie came to our clinic.

  After rev
iewing her history and some psychological testing, I could certainly see why the diagnosis of borderline personality had been made. However, by highlighting other aspects of her history, I could also see ample grounds for a diagnosis of ADD. Bonnie and her therapist agreed to a trial of medication for ADD.

  The results were dramatic. What Bonnie had perceived as depression was in retrospect “a state of aimless distractibility.” As the medication helped her focus, she began to develop goals. She enrolled in school, and is now a successful participant in a Ph.D. program in English. Her work with her therapist suddenly became productive, rather than frustratingly off target. She was able to start working through many of the problems from her childhood, rather than avoiding or forgetting them. In addition to the help in focusing the medication provided, the diagnosis of ADD lifted some of the guilt and self-recrimination Bonnie had carried while considering herself borderline.

  Unknowingly, in her past, she had been treating her ADD by finding axes around which to organize herself. First there was the axis of the struggle with her mother. While this damaged her psychologically in many ways, it did serve the constructive purpose of organizing her thoughts and feelings. Then there was the axis of the study of literature in college, followed by the axis of taking care of her baby at home. However, when the child left for school, that relationship no longer filled her day; the organizing axis was gone, and the forces of distractibility took over and she began to self-medicate with alcohol.

  We do not know how common this picture of ADD with borderline features really is. As the diagnosis of ADD gains wider attention, it would not be surprising to see it more frequently. The combination of sudden anger, the search for high stimulation, impulsivity, suicidal thoughts or gestures, self-recrimination, underachievement, and disorganization, which sounds like a borderline personality, could well be hidden ADD.

  ADD with Conduct Disorder or Oppositional Disorder (in Children) or Antisocial Personality Features (in Adults)

  In both children and adults, especially among males, certain kinds of aggressive or defiant behavior can mask ADD or occur concurrently.

  “Conduct disorder” and “oppositional defiant disorder” are two different diagnoses that apply to particular patterns of aggressive behavior in children. Although the terms may conjure up all one’s worst fantasies of some kind of psychiatric enforcement agency, handing down frumpish norms of good versus “disordered” behavior, there are children who have great trouble peacefully coexisting with others in any environment. These children get into frequent fights; they can’t obey rules; they resist limits; they disrupt the work and play of others; they may even break the law. While there is a genetic factor in these disorders we are just learning about, there is also a significant environmental factor. Often these children come from severely troubled families, families where the parents may be absent or uninvolved, where there may be drug use, physical or sexual abuse, extreme neglect, little food, poor housing, little education, few supports of any kind. The “disordered” conduct of these children is often a critical warning sign of the need for intervention and assistance at home.

  The restless, hyperreactive behavior of a child with ADD can resemble that of a child with conduct or oppositional disorder. One must look closely to distinguish between the two. They may indeed coexist. More frequently, however, children with ADD are incorrectly diagnosed as having a conduct disorder and vice versa. In the children with just ADD, one will not find the angry edge, or the premeditation one sees in conduct or oppositional disorders. When an ADD child trips and falls, he may get flustered. When an oppositional-disorder child trips and falls, he immediately looks to blame someone else and plot his revenge at recess. The disruptive outbursts of the child with ADD tend to be impulsive and spontaneous, whereas these outbursts in the conduct-disordered child tend to be planned or in response to some perceived insult or injury. The child with conduct disorder alone, on the other hand, does not show the distractibility or restlessness of the child with ADD. It can be difficult to get an accurate diagnosis for these children because everybody—parents, teachers, school officials—becomes so upset over the “bad” behavior that they don’t attempt to understand what’s causing it before trying to stamp it out.

  A typical example is the child in school who is “bouncing off the walls.” I’m not sure why that is the phrase used, because usually it is not walls but other people the child is bouncing off of, but I know I hear it all the time, and when I do, it is usually in reference to a little boy, age six to twelve, who, wherever he goes, leaves people shaking their heads and muttering to themselves. This is the boy who overturns the table at the birthday party, or upsets the jar of paint in art class, or pushes over a little girl during recess, or bumps into the teacher as she’s bending to pick up a piece of chalk. Or worse. This is the child who uses four-letter words when he’s told to do something, who has a tantrum in the classroom, breaking windows and chairs, who falls on the floor kicking and screaming when asked to go to gym class, who stabs a pencil into his friend’s arm while waiting in line.

  In responding to these children, it is important to figure out the cause of their aggression rather than simply punishing them for the behavior. Among the many possible causes are conduct or oppositional disorder or ADD, or a combination.

  There is a similar group of adults, usually men, whose behavior causes such problems that to many people treatment seems pointless, a liberal-minded luxury. Some of them are in jails, or in mental hospitals with a diagnosis of antisocial personality. Like the borderline population and those with disorders of impulse control, many who are diagnosed as antisocial personalities actually have ADD.

  People with an antisocial personality disorder, those who are sometimes called sociopathic or psychopathic, are the transgressors in our world. They break the law, they test the limits, they deceive, they lie, cheat, and steal. They also can be, often, very likable and charming.

  In the case of adults with antisocial personalities who have a clear childhood history of ADD rather than oppositional disorder, it may be the case that the antisocial diagnosis is incorrect, or that while the antisocial behavior may meet the technical requirements for that diagnosis, yet the individual still responds favorably to treatments specific for ADD.

  Particularly in males with a history of violent behavior—the kinds of people that fill jails and mental hospitals—one finds many who have a classic history of ADD. Their violence is not due to a defect in their conscience or to psychosis or to some morbid familial conflict, but to the frustration intolerance and impulsivity of ADD. When they are properly diagnosed and receive the appropriate treatment, often their course changes for the better.

  ADD with Obsessive-Compulsive Disorder

  Interestingly enough, much of the best research we have on both ADD and obsessive-compulsive disorder (OCD) come from the same person, Dr. Judith Rapoport at the National Institute of Mental Health in Washington, D.C. Her book on OCD, The Boy Who Couldn’t Stop Washing, is an excellent example of psychological thinking made clear.

  As Rapoport points out in her book and elsewhere, OCD can occur with other syndromes, ADD being one of them. The symptoms of OCD include driven, ritualistic thinking; compulsive, repetitive behavior; intrusive, unpleasant thoughts; superstitions that control one’s behavior; and an inability of the “will” to counteract these symptoms, try as it might. Like ADD, it is a biologically based disorder.

  When OCD occurs with ADD, the ADD may go undetected at first because the symptoms of OCD are more troublesome. Or if the disruptive symptoms of ADD predominate, then one may miss the underlying OCD. Since the treatments for the two syndromes are different, it is important to diagnose them both when they occur together.

  Pseudo-ADD

  In concluding this chapter on the subtypes of ADD, we mention one subtype that is not ADD at all. It is not really a subtype, but it is mentioned here because it is directly linked to true ADD. This is the phenomenon of culturally induced ADD
, what we call pseudo-ADD.

  American society tends to create ADD-like symptoms in us all. We live in an ADD-ogenic culture.

  What are some of the hallmarks of American culture that are also typical of ADD? The fast pace. The sound bite. The bottom line. Short takes, quick cuts. The TV remote-control clicker. High stimulation. Restlessness. Violence. Anxiety. Ingenuity. Creativity. Speed. Present-centered, no future, no past. Disorganization. Mavericks. A mistrust of authority. Video. Going for the gusto. Making it on the run. The fast track. Whatever works. Hollywood. The stock exchange. Fads. High stim.

  It is important to keep this in mind or you may start thinking that everybody you know has ADD. The disorder is culturally syntonic—that is to say, it fits right in.

  It is true that the prevalence of ADD—the frequency with which it occurs in the population over a given period of time—is higher in America than it is overseas. We do not know why this is so. The British think that we overdiagnose ADD in America. Until recently, Michael Rutter, one of the leading British child psychiatrists and an expert on epidemiology, doubted that ADD, as we think of it, actually existed as a valid syndrome. He thought we were lumping other syndromes under the heading of ADD. He has since changed his mind, acknowledging that ADD does indeed exist, but he finds it in the British population at lower rates than we diagnose it here.

  One possible explanation for this is that our gene pool is heavily loaded for ADD. The people who founded our country, and continued to populate it over time, were just the types of people who might have had ADD. They did not like to sit still. They had to be willing to take an enormous risk in boarding a ship and crossing the ocean, leaving their homes behind; they were action-oriented, independent, wanting to get away from the old ways and strike out on their own, ready to lose everything in search of a better life. The higher prevalence of ADD in our current society may be due to its higher prevalence among those who settled America.