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Why the DSM Killed Off Subtypes

For many of us who learned about ADHD before the latest revision to the DSM, the diagnostic manual often used to diagnose ADHD, the idea of “subtypes” is ingrained in how we think about the condition.

The idea is that if you have mostly inattentive symptoms of ADHD, you have the “predominantly inattentive subtype” of the condition, and if you have mostly hyperactive or impulsive symptoms you have the “predominantly hyperactive-impulsive subtype.” If you have both, congratulations, you have the “combined subtype”!

DSMOr, at least, you did until 2013, when the DSM got reworked into its fifth edition. At that point, the term subtype got killed off and replaced with presentation. Thus, the “predominantly inattentive subtype” of ADHD became the “predominantly inattentive presentation.”

It’s a relatively minor change, but it reflects an evolution in how researchers and psychologists think about ADHD symptoms.

Basically, as research started to roll in suggesting that ADHDers could move from “subtype” to another relatively fluidly, the word “subtype” started to seem too rigid and categorical.

For example, a 2005 study showed that many children with inattentive ADHD went on to develop combined ADHD, and many who started off with only the “H” went on to become combined ADHDers. In fact, the study found that children in the “predominantly hyperactive” category tend not to stay there at all and that “they sometimes desist from ADHD but mostly shift to [combined subtype] in later years.”

Consistent with that idea, a 2010 study concluded that the hyperactive-impulsive subtype (in other words, hyperactivity without inattentive symptoms) was rare by the time ADHDers reached adulthood – so rare, in fact, that it brought up “questions as to the validity of the [hyperactive-impulsive] subtype in adults.”

With findings like these in mind, the folks in charge of retooling the DSM decided to retire the “subtype” terminology, opting instead for the more flexible term of “presentation.” Now you don’t have one “type” of ADHD. Rather, you have ADHD, which at different points in your life may present itself primarily through inattentive symptoms, hyperactive/impulsive symptoms, or both.

So does that settle the question of how to divide ADHD into different flavors?

Hardly.

There are so many different ways you could potentially categorize ADHDers, and different researchers have suggested different approaches. You could try to find categorizations based on different underlying causes of ADHD, or different cognitive characteristics. In fact, as we learn more about ADHD in the long-term, it’s conceivable that the DSM could evolve to reflect such categorizations.

Even in the DSM’s current form, if you take the idea of “subtypes,” or “presentations,” to an extreme, it turns out you can find 116,200 ways to group symptoms.

It’s probably best not too get too caught up in this line of thinking right now, given how much we have yet to learn about which differences between individual ADHDers matter for purposes of treatment and which don’t. In a way, the DSM 5’s shift in terminology acknowledges how much we still don’t know by moving way from the black-and-white idea of “subtypes” to the more nuanced idea of “presentations.”

Image: Flickr/CCAC North Library

Why the DSM Killed Off Subtypes


Neil Petersen

Neil Petersen writes regularly on education, learning disabilities and technology. He received his B.A. in 2014 and was diagnosed with ADHD at the beginning of his college studies. Neil also works for a music education non-profit and hopes to help create an education system that can better serve students with ADHD.


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APA Reference
Petersen, N. (2020). Why the DSM Killed Off Subtypes. Psych Central. Retrieved on July 4, 2020, from https://blogs.psychcentral.com/adhd-millennial/2020/06/why-the-dsm-killed-off-subtypes/

 

Last updated: 4 Jun 2020
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