<i>> Some physicians and researchers have argued for years that emotional dysregulation is not peripheral to ADHD but a central, overlooked part of the condition. Yet this symptom does not appear in the formal diagnostic criteria for ADHD in the manual that doctors use to classify mental disorders. That gap has left clinicians without a clear way to categorize what they’re seeing: Are these children best understood as having severe anxiety, as being on the autism spectrum, or as something else entirely? Or does ADHD itself need to be more broadly defined?</i><p>Again and again and again. Psychiatry is an epistemic mess.<p>Psychiatrists are touristic guides of the Paris catacombs that orient themselves with a map of the subway.
"With DSM-V, psychiatry firmly regressed to early 19th-century medical practice. Despite the fact that we know the origins of many of the problems it identifies, its diagnoses describe surface phenomena but completely ignore the underlying causes. Even before DSM-V was released, the American Journal of Psychiatry published the results of validity tests of various new diagnoses which indicated that the DSM largely lacks what, in the world of science is known as, 'reliability', that is, the ability to produce consistent, replicable results. In other words, it lacks scientific validity." ― Bessel Van Der Kolk, M.D.
It reminds me that ADHD is really not that useful of a name, executive function disorder would be a more accurate name from when I was looking into ADHD in the past. It's not about attention deficit per se, as that's downstream of struggling with executive functioning. At least it's the definition that lines up with my experience best (I have ADHD). I'll make lists in order to keep track of important tasks (which in theory would help with attention deficit) but then I'll sit down to do the things on the list and... can't. It's such a hard thing to explain, but no amount of attention hacks can get me over the hump of doing the tasks I'm dreading. That seems much more related to executive functioning.
It was even called "minimal brain damage" at one point early on!<p>I'm also reminded that "Obsessive-Compulsive Disorder" and "Obsessive-Compulsive Personality Disorder" are different in kind but necessarily in magnitude.<p>The former comcerns more localized obsessions and the latter is more of a global "default state of perfectionism".
> It's not about attention deficit per se<p>I've always considered it <i>Too Much Attention Disorder</i>.<p>The way I like to think about it is that neurotypical people have a beam of light shining out in front of them, wherever they turn their head the light shines and that's where their attention is. Nothing else distracts them from where the light is shining.<p>With ADHD (for me at least) it's like 50 beams of light scanning the entire room constantly for 'something'. This is <i>too much attention</i> to things that I'm not really interested in, but can distract me from anything I'm trying to do or wan't to do.<p>For things that I am really interested in (like writing code) the 50 beams of light all manage to synchronise and focus in the same place and that's hyperfocus.
I experience the same thing very frequently. I likened it to activation energy in a reaction, that no matter what I did I couldn't create the required electrochemical bias in my brain needed to put ideas into action. It's like being stranded in your own mind, you know what you need to do, but the 'go' just never arrives.<p>I eventually discovered that the adrenaline response from extreme stress ('if I don't get this fucking thing done by 7:30am I'm fired' kind of thing) allows me to lock in and do the thing.
I find similar behaviour in myself, particularly that dreading a task makes it significantly more difficult to start. I find that if I can manage to do just a little bit, even just open the application and maybe look around a bit at what I need to do, it really gets the momentum going for me.<p>Do you think there's anything that differentiates what we might call "general task dread" that perhaps anyone experiences to a certain degree from a more broad executive function disorder? Or is it that dreading leading to task paralysis is one of many symptoms of an executive function disorder?
How are you for task completion? For me, transferring a load of laundry from the washer to dryer is not an atomic operation. There is ample room to get derailed and wander off during the twenty seconds it should take. It can be interrupted by almost anything. Oh, I forgot to send that message. Oh, I forgot to check for the parcel. Oh, I need to go to the store today still. And I will walk away and forget to come back and finish.
I think the frequency and level of impairment is what differentiates normal executive dysfunction from an executive functioning disorder.<p>Perhaps a bit rhetorical, but how often does this task dread occur? Does it also ever occur for things you want to do, not just obligated to do?<p>For me, I experience this issue for many tasks everyday. Then again, I have never had a normal executive functioning, so I cannot claim to know what it is like for normies.<p>I’ll also add that ADHD is more than just executive dysfunction too.
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For me it’s that as soon as I intend to begin a task, I start thinking about every step, and everything that might go wrong at every step, and planning contingencies for every hypothetical problem, and on and on.<p>So suddenly the task seems totally overwhelming, when I could just… not do it. So I find a time later I can attempt it and after a few times it is no longer novel and I forget about it.<p>If anything is hyper-active, it’s the executive function part of my brain that is driven to plan out every tiny, hypothetical detail before I can start.<p>What’s missing is the reward and internal incentives for doing things when there are other things that do feel good to do (that aren’t what I need to do).
Executive function problems are <i>symptoms</i> of ADHD, therefore renaming it as executive function disorder would omit the root cause. Dr. Edward Hallowell proposes Variable Attention Stimulus Trait (VAST) as a better name.
In my mental model of ADHD, executive functioning is at the center of an hourglass-shaped graph. The bottom half consists of multiple "internal" layers/systems (neurological, psychological), in which some deficiency or deficiencies cause a lack of executive functioning (arrows point up from layers down below upwards to the central element of "executive functioning" to visualize the direction of causation). The upper half shows the outward facing layers/system behavior, social relationships, skills; the arrows point only upwards. I don't have any scientific source for this graph, but I never experienced any "ADHD"-related problem that I couldn't understand through this lens. Happy to share my sketch if anyone is interested.
As they often say, ADHD is about having _too much_ attention and not being able to control it.
Yeah, it’s a common topic of discussion in the various adhd discussion groups across the internet. Unfortunately changing the name would have some unintended effects because a bunch of regulations and other things are using the current denomination
Ah man I feel you. What helped a bit for me is relentlessly trying to get your career focused on only fun things. It's a long term strategy, but I am now a not-so-successful-yet entrepreneur but I do love about 95% of what I do and that makes me do things fast and without it feeling like effort.
A lot of "ADHD" in children is more like "children don't want to sit quietly and not move while being talked to and made to do things for 8 hours a day" which is less "a disease" and more "this is what it's like when schools are prisons and childhood consists of a fully scheduled attempt to optimize career potential".<p>In other words, kids want to be kids and they're being put in cages and drugged so they follow their training schedule better.
That's not what ADHD is, that's what someone who knows very little about ADHD and has never experienced it themselves thinks it is.
Your comment's parent might know very little about ADHD, but your critique shows an antiquated view as well. It's not only the ADHD person that needs to change by any means available so that they fit the expectation of the system. The system, too, is in need of change, so that we accommodate more diverse people. Improving the environment that you operate in goes a very long way and might enable exactly the kind of change that makes children and adults with ADHD thrive. Medication is just one option. CBT and more flexible environments are as important, probably even more so.
There are many people who have the diagnosis and don’t agree with the mainstream perspective on medication etc. Don’t claim to speak everyone.
Ok, but what about when those children grow into adults that can’t sit still for 8 hours either? I am in my mid-thirties and I am still waiting for the hyperactivity to die down.
Do you think most people are made to sit still for 8 hours? Do you think someone who can't do that is defective?
Getting the best out of yourself and your environment isn't a matter of waiting to fit in to the sit-down-and-focus shaped life. You have to learn about yourself and learn about how to shape your environment to live your best life, and a major step is not thinking about having that temperament as a disease to be overcome.
It’s amazing to see a disproven and frankly ancient viewpoint espoused with a straight face here. When I was a kid in the eighties your way of thinking was already defunct.
This isn't defunct in any way. To the contrary. I've been diagnosed with ADHD myself and creating an environment that is accommodating to my individual needs has absolutely been in line with what experts recommended to be, and it's been a corner stone of my success.<p>CBT teaches you to evaluate how to shape the environments your living in so that you can benefit the most from your resources and weaknesses and suffer the least from your weaknesses. For some people, this can include taking stimulants, and this is where I do not condone your parent comment's undertone. Nevertheless, it's been proven over and over again that the rigid system that we call schools does not welcome neuro-atypical students and that we could do a lot more to help those who do not react well to stimulants, who do not want to use them (for whatever individual reason), or simply haven't been diagnosed yet! Allowing for movement instead of forcing to suppress it is a very good example for what could be done. One shouldn't make the mistake to think that this alone would be enough for every single child with ADHD, though. But for some, it could be enough.
And that viewpoint doesnt even account for adult ADHD/executive dysfunction.
I've described the field of Psychiatry as trying to describe a building, using only its shadow (projection from high dimensional space to 2d space), with only a handful of choices for the building type. Ultimately only the building (the patient) really knows the full scope of complexity, but a doctor has to be careful in how they get info out.<p>I don't have a solution, as its an inherently hard problem with a lot of risks (like giving medicine to the wrong person). But I also think this desire to have nice categories for things can be counterproductive in a lot of cases.<p>I personally think rebranding aspergers + Autism to the autism spectrum was a mistake, as there's a huge difference between someone who's really good at their job but weird and despises certain workplace nonsense - and someone who can't take care of themselves.<p>ADHD is another great example of a bucket that makes non sense. We were evolved to be hunter gatherers that get many hours of walking or running, and other physical activity every day. Then we act surprised when 11 year olds don't want to sit still 6 hours a day, or getting people like me to write a JIRA ticket is like pulling teeth.<p>I think separating out these large categories into smaller ones is a good step, but ultimately I think the categories are a counterproductive solution to our human urge to find a logical explanation to things.
<i>Melissa DelBello, a professor of psychiatry and pediatrics at the University of Cincinnati, said that while brain imaging holds promise, it is still impractical to conduct such scans broadly in clinical settings because they are too expensive and not yet precise enough at the level of the individual.</i><p>As if questionnaires and slot-machine prescription medicine treatments are accurate. I don't want to generalize for lack of statistical data, but reports of psychiatrists 'just phoning it in' while providing little actual patient engagement are widespread.
I think this is me. I was diagnosed with “regular” ADHD a few years ago, but I’ve had issues with rejection sensitive dysphoria my whole life. As a kid I would have a lot of meltdowns when I couldn’t get something right on the first try or made any kind of mistake.<p>The meltdowns stopped, but I still have issues spiralling into thoughts of failure and being a horrible person when I feel like I’ve disappointed family or friends.<p>Guanfacine has helped though. Tried a bunch of medications and this is the only one that seems to have made an impact.
Hey, you've basically described me to a tee as a boy. I had the exact same temperament: meltdowns when I thought I disappointed people, putting myself down all the time for failures and mistakes. My parents weren't even particularly strict.<p>Glad I wasn't just a weird, overly sensitive kid.
Might be worth giving Qelbree a shot as well. I switched to it last year and...yeah, it' was a complete game changer. Hard to get insurance to cover, but it's been well worth it.
Anyone know to what paper this article refers? I don't have WaPo
> “They are simmering volcanoes basically,” Rosen said. “When things go wrong, they explode. These are kids who will have hour-long meltdowns, throw things and hit and break things.”<p>...<p>> For children with this extreme form of ADHD, standard behavioral strategies may fall short. DelBello said that widely used approaches such as positive reinforcement — like giving prizes or other trinkets, or extra recess for good behavior — do not always have the intended effect.<p>I'm a former foster parent who adopted kids from foster care. Two of them were diagnosed with RAD[1]. This "extreme form" of ADHD aligns with both my personal experience of RAD and a subset of the symptoms described by clinicians. Attachment issues in general are either commonly comorbid with, or misdiagnosed as ADHD and ODD[2] (the latter of which also somewhat matches the symptoms from TFA).<p>I don't really have a point here, just an observation I wanted to make.<p>1: <a href="https://en.wikipedia.org/wiki/Reactive_attachment_disorder" rel="nofollow">https://en.wikipedia.org/wiki/Reactive_attachment_disorder</a><p>2: <a href="https://en.wikipedia.org/wiki/Oppositional_defiant_disorder" rel="nofollow">https://en.wikipedia.org/wiki/Oppositional_defiant_disorder</a>
I recall someone posting that the human brain is essentially "overclocked". I don't recall if that was the phrasing but the gist was that our level of intelligence can only exist by skirting the fringes of sanity. Like some set of dynamic differential equations where, if you bump a coefficient, it spins off into chaos.<p>Perhaps this Brave New World, as opposed to the more agrarian one our species had been accustomed to, pushes many of us over that threshold.
ADHD is interesting. I think ADHD is mainly an executive dysfunction and reward centre dysfunction, from my own experience.<p>And a bit of nature, a bit of nurture.<p>It’s a real double edged sword for me.<p>On one hand relationships and “boring” tasks feel insurmountable. When I say boring I don’t even mean boring in the traditional sense, I just mean “not novel” - so even something like playing my favourite ever video game gets extremely difficult once the novelty is gone.<p>On the other hand, as a software developer, working on novel concepts or exploring novel concepts or ideas is basically like crack-cocaine, I literally can’t stop or put them down.<p>Double edged sword is struggling with most basic tasks, but excelling at the peripheries.
When you put it that way this might be one of the greatest disabilities ever. Humans that don’t complete things they begin and chase novelty are hard to respect because it’s common and trite. Persevering through failure and the hard bits is essentially the crux of achievement, productivity and success.
I don’t agree as greatest disability ever as in “most-disabling” I’d say it’s the greatest potential modifier disability there is.<p>Some scenarios I loathe having it, but when I’m in the flow state I love it.<p>It’s made my life-path very non-standard (huge swings up and down), but it’s also created insane opportunities (when paired with high-drive and completing things/discipline)<p>I personally don’t consider it a disability in my case, but I’m definitely at a disadvantage in a typical work environment compared to my peers. So I understand completely why it’s generally classed as a disability in today’s society and societal expectations.<p>Like autism, it can produce insane outcomes (think savants etc), and if you can find the right environment for you, you can outperform more neurotypical peers.<p>I for instance finish all my software projects, because I force myself through discipline. My work output is probably the same or slightly less-good than my peers. But my personal projects where I have full creative control of the outcomes I’d say far exceeds my peers.<p>I mean in my own case, I’ve achieved far more than my friends and peers - whether that be in business success or other creative areas, but at massive cost - they have much more stability than me, whereas my path is a very non-linear path. I either do exceptionally well or exceptionally shit, no in-between, very black and white
One thing that I can’t seem to parse from the article is <i>why</i> the researchers assume that this is an unresearched part of ADHD and not a different disorder entirely. I’m sure they have their reasons, but I don’t think it’s written in the article.<p>To me it seems that if it’s not „treatable“ the same way ADHD is, I’m not sure if it’s useful to categorize it as such. On the other hand, I’m happy if kids with this disorder can get a diagnosis and treatment that actually helps them sometime in the future due to this research.
You have a set of diagnosis criteria, and matching those criteria gets you the ADHD diagnosis. This study takes people who fit the diagnosis, and says there's a test you can do to split those people into three groups.<p>But yes, once they have a better understanding of what that difference means, the next step might well be to split the ADHD diagnosis into two separate disorders, or even that, like cancer, ADHD is actually a whole range of separate but related conditions.
Diabetes has a similar issue, with type 1 and type 2 having very different causes and pathologies.
It is a good point and I also struggled with that bit somewhat. It is different in so many ways, have different symptoms, does not respond (as well) to the same medication, and affect different parts of the brain. The jump from there to "subtype" was not too logical for me ...
<a href="https://archive.ph/iAqUj" rel="nofollow">https://archive.ph/iAqUj</a>
They've basically "reinvented" DSM-IV ADHD-PH, -PI, and -C more or less, but at least someone's examined the organ responsible rather than treat it like a magical black box.
Paywalled/emailwalled
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