Driven to Distraction (Revised)

by Edward M. Hallowell

  13. Often loses things necessary for tasks or activities at school or at home.

  14. Often engages in physically dangerous activities without considering possible consequences.

  NOTE: The above items are listed in descending order of discriminating power based on data from a national field trial of the DSM-III-R criteria for disruptive behavior disorders.

  B. Onset before the age of seven.

  C. Does not meet the criteria for a pervasive developmental disorder.

  * * *

  * * *

  TABLE II

  SUGGESTED DIAGNOSTIC CRITERIA FOR ATTENTION DEFICIT DISORDER IN ADULTS

  NOTE: Consider a criterion met only if the behavior is considerably more frequent than that of most people of the same mental age.

  A. A chronic disturbance in which at least twelve of the following are present:

  1. A sense of underachievement, of not meeting one’s goals (regardless of how much one has actually accomplished).

  2. Difficulty getting organized.

  3. Chronic procrastination or trouble getting started.

  4. Many projects going simultaneously; trouble with follow-through.

  5. A tendency to say what comes to mind without necessarily considering the timing or appropriateness of the remark.

  6. A frequent search for high stimulation.

  7. An intolerance of boredom.

  8. Easy distractibility, trouble focusing attention, tendency to tune out or drift away in the middle of a page or a conversation, often coupled with an ability to hyperfocus at times.

  9. Often creative, intuitive, highly intelligent.

  10. Trouble in going through established channels, following “proper” procedure.

  11. Impatient; low tolerance of frustration.

  12. Impulsive, either verbally or in action, as in impulsive spending of money, changing plans, enacting new schemes or career plans, and the like; hot-tempered.

  13. A tendency to worry needlessly, endlessly; a tendency to scan the horizon looking for something to worry about, alternating with inattention to or disregard for actual dangers.

  14. A sense of insecurity.

  15. Mood swings, mood lability, especially when disengaged from a person or a project.

  16. Physical or cognitive restlessness.

  17. A tendency toward addictive behavior.

  18. Chronic problems with self-esteem.

  19. Inaccurate self-observation.

  20. Family history of ADD or manic-depressive illness or depression or substance abuse or other disorders of impulse control or mood.

  B. Childhood history of ADD. (It may not have been formally diagnosed, but in reviewing the history, one sees that the signs and symptoms were there.)

  C. Situation not explained by other medical or psychiatric condition.

  * * *

  * * *

  TABLE III

  UTAH CRITERIA FOR ADULT ADD

  I. A childhood history of ADD with both attentional deficits and motor hyperactivity, together with at least one of the following characteristics: behavior problems in school, impulsivity, overexcitability, and temper outbursts.

  II. An adult history of persistent attentional problems and motor hyperactivity together with two of the following five symptoms: affective lability, hot temper, stress intolerance, disorganization, and impulsivity.

  * * *

  * * *

  TABLE IV

  CONDITIONS THAT MAY ACCOMPANY, RESEMBLE, OR MASK ADD

  Anxiety disorder

  Bipolar disorder or mania

  Caffeinism (excessive coffee or cola drinking)

  Conduct disorder (in children)

  Depression

  Disorders of impulse control (stealing, fire-setting, and the like)

  Fatigue, chronic

  History of fetal alcohol syndrome

  Hyperthyroidism or hypothyroidism

  Lead poisoning

  Learning disabilities

  Medications (e.g., phenobarbital and Dilantin)

  Obsessive-compulsive disorder

  Oppositional disorder (in children)

  Pathological gambling

  Personality disorders, such as narcissistic, antisocial, borderline, and passive-aggressive personality disorders

  Pheochromocytoma

  Posttraumatic stress disorder

  Seizure disorder

  Situational disturbances such as divorce or job loss or other disruption in one’s life

  Substance abuse (e.g., cocaine, alcohol, marijuana)

  Tourette’s syndrome

  * * *

  As was pointed out in chapter 6 on the subtypes of ADD, attention deficit disorder often hides behind other diagnoses, such as depression; alcohol, marijuana, and cocaine abuse; pathological gambling; and the others mentioned before. These diagnoses may mask an underlying case of ADD or they may be hard to distinguish from it. The childhood history is particularly helpful in untangling this knot. Was there evidence of ADD in childhood? If there was, then the presenting symptom of, say, substance abuse, may overlie a case of ADD.

  More difficult to distinguish are those conditions that develop out of ADD, organically, like a limb. These are the personality styles that people with ADD may evolve. They can look like what psychiatry calls personality disorders. For example, consider the passive-aggressive personality. This is the person who cannot express aggression directly. Instead, he expresses it passively, through nonaction or nonresponse. Instead of telling his boss he disagrees with him, he skips his appointment with him. Instead of telling his wife he is angry with her, he buries his head behind the newspaper. Instead of competing for the job he wants, he “forgets” to send in the application on time. Traditionally, we understand the passive-aggressive style in psychodynamic terms and try to help the patient work out, through psychotherapy, whatever fears he may have of directly expressing aggressive feelings. However, forgetting, being late, finding it difficult to tune in to conversations—these are what ADD is all about. What gets labeled “passive-aggressive” may be caused by a case of ADD.

  Similarly, ADD may be the cause of behavior that seems narcissistic. The narcissist, in simple terms, has trouble paying attention to other people. He appears to be wrapped up in himself, preoccupied with his own place in the world, and incapable of genuine empathy or love. If this inability to attend to others can be traced to the individual’s early life experiences of deprivation, narcissism is a probable diagnosis, and the proper treatment would then be psychotherapy or psychoanalysis. However, if the inability to attend is due to ADD, psychotherapy or psychoanalysis will not help. If the person receives treatment for ADD, the “narcissistic” symptoms will fade, and the person will be able to engage with others meaningfully.

  It is critical that these distinctions be made as early as possible in an individual’s life. A great deal of time can be lost treating the wrong condition, or not treating the right one.

  4. Proceed with Psychological Testing

  Once your physician has made the diagnosis through consideration of your history (or your child’s), and he has ruled out other conditions, he then must decide whether to proceed with psychological testing.

  Psychological testing can be very helpful in elucidating any associated learning disabilities or in uncovering other problems that may not have surfaced in the history, such as a hidden depression or problems with self-image or a hidden thought disorder or psychosis. For example, projective testing examines what the subject projects, without knowing it, onto the test stimulus. The classic example of a projective test is the inkblot test (the Rorschach test is the most famous). The person being tested is asked to look at a series of standardized inkblots. What the subject “sees into” the inkblot is of his own creation, and can help reveal what might be on his unconscious mind. Sometimes people see scenes of extraordinary violence or destruction in an inkblot; these people may be dealing with pent-up rage or repressed memories of traumatic abuse. Some people
make up stories of great sadness based upon the inkblot; these people may be dealing with hidden depression. Other people see nothing but chaos and unrecognizable shapes in the blots; these people may have an information-processing problem or even an undetected psychosis.

  Psychological testing can also offer evidence that helps confirm the diagnosis of ADD. Certain subscales on the Wechsler tests of intelligence, called the WISC in children and the WAIS in adults, are typically low in people with ADD.

  There are other tests of attention as well in what is called a neuropsychological battery for ADD. It is up to the tester what test to employ. There is no standard battery, but rather a range of tests from which the tester may select. Testing of this kind is as much an art as a science. The psychologist chooses which test to use depending upon what question is presented. When ADD is the problem, or the question, some psychologists use a test in which the subject is asked to copy an abstract drawing from memory after looking at it for ten seconds. Others use a test called the continuous-performance task in which the subject must attend to patterns of flashing lights. Whenever a prespecified pattern appears, the subject is supposed to press a button; if that pattern does not appear, he is not supposed to press the button. Taking this test is a lot like playing “Simon Says.” Sometimes you press the button when you shouldn’t, and sometimes you should press the button but you don’t. It all depends upon how alert you can be. The test tries to assess both attention span and impulsivity: pressing the button when you should is a measure of paying attention, and pressing the button when you shouldn’t is a measure of impulsivity. The test is far from infallible, however. Extraneous factors such as the subject’s motivation and mood, the conditions of the room where the test is conducted, and the ease of operation of the machine can greatly influence results.

  Other examiners use the TOVA, or Test of Variability of Attention in which the subject responds to different shapes flashed on a screen under similar conditions as the continuous-performance task. Finally there are the Eriksen Flanker Task and the Go/No-Go test. The Flanker task is a response interference task that tests how well subjects correctly respond to an arrow that points in the opposite direction as flanking arrows (in comparison to the case where the arrow points in the same direction as the flanking arrows). The Go/No-Go test is basically the game “Simon Says”—you perform an action in one condition, not in another.

  Whatever the test, they all try to quantify attention, distractibility, and impulsivity. No test pattern, however, can definitively rule in or rule out the diagnosis of ADD. It can only support or detract from the clinical evidence for the diagnosis.

  A strong word of caution should be added here with respect to psychological testing. Often people rely too heavily on psychological testing to make the diagnosis of ADD. This is a grave error, however, because psychological testing is often falsely negative. That is to say, many people who do in fact have ADD appear not to have it when given psychological tests.

  This is because the testing procedure may temporarily treat the ADD, obliterating the symptoms during the time of the testing. Three of the best treatments for ADD are one-to-one tutoring, high motivation, and novelty. People with ADD typically can focus in a one-to-one setting while they become distractible in a group setting such as a classroom, the workplace, or a party. Also in settings where the individual is highly motivated, the symptoms of ADD often disappear. And novel settings—unusual or new places—can stimulate the person with ADD to such a degree that their attention becomes focused. The procedure of psychological testing involves all three of these “treatments” for ADD. It is done one-on-one, with the psychologist guiding the individual orally through the tests, making it difficult for him to tune out. The subject is typically highly motivated, trying to “do well” on the test. And the testing situation is highly stimulating due to its novelty. These three factors combine to make the testing situation an almost ideal treatment for ADD, but a far-from-ideal setting in which to detect ADD. One must be highly skeptical of psychological testing that finds no evidence of ADD if the clinical, real-life data supports the diagnosis.

  Often the history is so complicated that no one thinks of ADD as being part of the diagnosis. A patient whom I shall call Andrea came to see me and recounted a three-year history of misunderstanding and misery in the mental-health system. Brought to an emergency room one morning in June because of light-headedness, Andrea began a long process of being evaluated. All kinds of tests were done, including X-rays and MRIs and various blood tests and metabolic studies and tests of immune function, even a pregnancy test. When no physical cause of her episode of light-headedness could be found, Andrea was referred to a psychiatric unit.

  Because of a series of misunderstandings, Andrea was found to be violent and suicidal. What actually happened was one of those comic-horror stories from the movies where one wrong conclusion leads to another. She met with a psychiatrist and stated she was not crazy. The psychiatrist, who was a rather by-the-book sort of fellow, nodded and wrote down what she said. This angered Andrea. “Why are you writing down what I say?” she asked. “Why don’t you talk to me instead?”

  “Have you been ignored a great deal in your life?” the psychiatrist responded.

  By the end of her psychiatric evaluation Andrea was so frustrated that she picked up an ashtray from the psychiatrist’s desk and threatened to throw it through the window if she were not released immediately.

  “Please do not do that,” the psychiatrist said calmly.

  “How can you be so calm?” Andrea asked. “Can’t you see how upset I am?”

  “I can see that you are upset,” the psychiatrist replied.

  “But you’re just sitting there like a bump on a log,” Andrea went on. “No emotion. No response. Would it help if I said I was suicidal? Then would you react?”

  The psychiatrist did indeed react. Andrea was involuntarily committed to the psychiatric unit on the grounds of being potentially violent and suicidal.

  By the time all the confusion had been resolved, Andrea had developed quite a dislike for the mental-health field. On the other hand, she needed help. While the light-headedness had not recurred, her hospitalization had brought forth a number of complaints Andrea’s husband had been sitting on. He was concerned that she was nervous, forgetful, and unreliable. He was concerned that she was moody and hot-tempered. He was concerned that she was inconsistent with the children, and he was especially concerned that she was drinking too much.

  Andrea and her husband went into couples therapy. Their relationship, if anything, got worse. Andrea’s symptoms did not improve, and her husband was growing tired of the whole situation.

  After a six-month trial separation, Andrea voluntarily checked into an alcohol treatment unit. She had felt terribly guilty about the separation and had indeed started drinking uncontrollably. A counselor at the alcohol unit reviewed Andrea’s history and raised the possibility of ADD. The question had never been raised before. This was no one’s fault; it was at a time when almost nobody knew about ADD. But the counselor at the alcohol unit did. His son was being treated for ADD, and he had read a great deal on the subject.

  “When that man described to me the symptoms of ADD,” Andrea said to me, “I felt as if I was being given a reprieve. Suddenly, there was an explanation other than my being a neurotic. I read everything I could find. It all fit. I got my school records, and sure enough, they were full of comments about how I couldn’t sit still and how I was such a daydreamer.”

  “What happened next?” I asked.

  “My husband had to learn about ADD. It made sense to him, too. Even if the medication hadn’t worked as well as it did, it was great just to come out of the psychiatric nightmare. Finally, I had the right diagnosis.”

  If you think you may have ADD, first consult someone who has experience with the condition. Child psychiatrists, neurologists, psychologists, and pediatricians are the professionals most likely to have developed expertise in recognizin
g ADD. Be sure to ask whomever you consult if they have experience in diagnosing and treating ADD, and whether that experience is with children, adults, or both. The most important factor is not what degree the person has but that he or she have considerable experience in evaluating ADD. At some point in the process an M.D. should be involved to make sure no medical condition is overlooked. If psychological testing is deemed indicated, this should be done by someone with a Ph.D. in clinical psychology. Make sure this person is trained in what is called neuropsychological testing and has experience in testing for ADD and learning disabilities.

  Since ADD in adults is a relatively new “discovery,” it may be difficult to find a clinician in your area with experience in treating this disorder. Later in this chapter, and at the end of this book, you will find listings of ADD resources. In addition, a good starting point in locating a specialist is a medical school in your area. Also the state medical society, psychiatric society, or psychological association can be of assistance.

  The following set of questions reflects those an experienced diagnostician will ask. While this quiz cannot confirm the diagnosis, the questions can increase the reader’s feel for what ADD is, and offer a rough assessment as to whether professional help should be sought to make the actual diagnosis of ADD.

  The more questions that are answered “yes,” the more likely it is that ADD may be present. Since everybody will answer “yes” to some number of questions, and since we have not established norms for this questionnaire, it should only be used as an informal gauge.

  1. Are you left-handed or ambidextrous?

  2. Do you have a family history of drug or alcohol abuse, depression, or manic-depressive illness?

  3. Are you moody?

  4. Were you considered an underachiever in school? Now?

  5. Do you have trouble getting started on things?