Although people who live with bipolar, depression, or other psychiatric illnesses often are relieved to receive an explanation for why they are feeling the way they feel, they rarely, if ever, appreciate being “labeled.” In fact, we go out of our way not to label people as “depressed,” “bipolar,” or “schizophrenic,” because these labels can be stigmatizing. Instead, we use “people first language” to describe people as “having” or “living with” these conditions, in an effort to reduce stigma. The question then becomes why are such labels even necessary?
In medicine, the terms used to reference diagnoses serve a valuable purpose. The intent is not to label patients but to label illnesses, so we can discuss specific conditions, diagnose them more accurately, and formulate targeted treatment plans. Having an accurate diagnosis expedites the process of getting the patient the most effective treatments available.
ADHD without Hyperactivity?
Unfortunately, sometimes diagnostic terminology creates more confusion than clarity. For example, in my practice, when a child or teen presents to me with symptoms of inattention, but not hyperactivity or behavioral impulsivity, patients and families are often surprised when they receive a diagnosis of attention deficit hyperactivity disorder (ADHD). Parents and/or children/teens rightfully wonder why we would include “hyperactivity” in their diagnosis if that doesn’t describe them at all. The reasons for this awkwardly worded label are based on scientific research about ADHD that has shown the two patterns to be much more similar than they are different.
In 1994, the Diagnostic and Statistical Manual 4th Edition (DSM IV) dropped the ADD diagnosis. Rather, the diagnostic term became ADHD, divided into three different types: predominantly inattentive, predominantly hyperactive/impulsive, and combination. In the most recent DSM, (DSM 5), these distinctions have become even less clear-cut, and we refer to ADHD as having a current presentation of inattentive, hyperactive/impulsive, or combination.
A major reason for this evolution grew out of research showing that impulsivity — problems with the “stop” or “off” systems in the brain — is part of the big picture of ADHD, even when someone is not physically impulsive. For example, we often think about kids who are inattentive but not hyperactive as daydreamers, and we frame this as “difficulty maintaining focus.” However, “off” switch disruptions are part of inattention. Kids with ADHD are unable to turn off their attention to one thing (the ever present squirrel in the window) and shift their attention to the teacher’s words and actions. Other ADHD symptoms include not paying attention to details and making careless mistakes by misreading or mishearing instructions. These are also impulsivity challenges — trying to squash the impulse to attend to something shiny or more interesting rather than to maintain focus on what the teacher is saying or on the reading in front of them.
Another part of shifting our language away from strict categories of inattentive or impulsive is that treatments do not seem to have different effects based on the subtype of ADHD. That suggests the existence of common underlying brain signaling problems in all types of ADHD that respond to similar types of interventions.
A further component of the change in thinking about “types” of ADHD to “presentations” of ADHD at any given time is because people often present differently at different points in time. One of the most common shifts is very hyperactive, physically impulsive young children who seem to mature out of those symptoms into a primarily “busy brain” presentation, which looks more inattentive than hyperactive/impulsive.
Additional Complexity with Bipolar Disorder
The bipolar disorder diagnosis has undergone its own evolution that can be traced back to Hippocrates in the fourth century BCE. Much later, in the nineteenth century, it was first referred to as “manic depressive insanity” — a term that was incorporated into the first DSM and lasted until DSM III, when episodic mood dysfunction started to be described as “bipolar disorder.” (Brittany L. Mason, E. Sherwood Brown, and Paul E. Croarkin. (2016). “Historical Underpinnings of Bipolar Disorder Diagnostic Criteria.” Behavioral Sciences, 6(3): 14.)
For people with bipolar disorder, more layers must be addressed when considering an ADHD diagnosis. Hyperactivity and impulsivity — both physical and mental — are core symptoms of a manic episode. Someone who has ADHD with an impulsive/hyperactive presentation struggles with these problems most of the time, even when not experiencing mania. For mania to be diagnosed, the level of activity and impaired impulse control must be clearly more than at baseline. For people with bipolar disorder and ADHD presenting primarily as inattentive, their baseline typically includes getting distracted from tasks, or starting things but having trouble finishing them, for example. These are also symptoms that can be part of a manic episode. Like impulsivity, in a manic period these symptoms would look more severe than the person’s day-to-day ADHD.
For more about the differences between bipolar mania and ADHD hyperactivity, see my previous post, Manic or Hyperactive: What’s the Difference?”
Diagnostic terms are important only because they help us to identify and understand a problem we are trying to solve and to develop an effective treatment plan for that problem. The evolving semantics of the DSM are not really important except in helping us communicate and making sure that we (physicians and other providers) are using language that makes sense to our patients and their families. Unfortunately, when a term’s meaning evolves, it may lead to more confusion than clarity, as in the case of ADD and ADHD. Just remember that if a doctor is speaking in language that doesn’t make sense (or seems not to apply to you) don’t hesitate to speak up and ask about it.