My opinion on the DSM rhetoric & an AD(H)D suggestion

DSM-IV’s attempt on using careful, conservative language

Upon examining the rhetoric of the DSM-IV introduction, I noticed the various escape clauses it uses as a way of precautionary measure e.g. here I am paraphrasing the authors:

  • We don’t like using the word ‘mental’ in the title but we could not come up with an alternative.
  • We categorize disorders not people, hence our wordy use of the English language by saying ‘individuals with Alcoholism’ instead of ‘Alcoholics’
  • We are in no way implying that mental disorders and physical disorders are any different but we only use such labels for convenience.

Why I believe the DSM-IV falls short on careful language in relation to ADHD

With the great lengths the DSM authors go through to achieve political correctness and avoid controversy and oversimplifications, I was shocked about the “Diagnostic Features” descriptions written for Attention Deficient/Hyperactivity Disorder. The paragraph devoted to inattentive symptoms uses the word “careless” (or its adverb form) exactly three times to refer to the ADD individual’s work habits. On the other hand, the section devoted to hyperactive symptoms uses the word “excessive” (or its adverb form) exactly five times in one short paragraph and has no mention of the term “careless” (APA p. 78-79). Indeed, their use of word “excessive” is rather…you guessed it, excessive.

ADD and the purported “careless” work ethic

As a person who more identifies with the SCT construct rather than simply ADHD without hyperactivity, I find the DSM authors’ use of the term “careless” inappropriate to refer to my actions and work ethics. In fact, I would consider my mannerisms completely at odds with carelessness. I would say that I am even highly self-conscious of my work and employ a deep sense of conscientiousness. I can however, relate to the information processing deficits often discussed with inattentive ADD that often manifests as missing critical information and jumping from one unfinished activity to another. Even though there are no formal surveys that I know of, I have a hunch that most people with SCT would not characterize themselves as being careless. More research may even reveal that those who have inattentive ADD (but not SCT) are neither careless but the input-output processing error makes it appear that way.

Furthermore, when referring to inattentive symptoms the DSM-IV mentions that activities that require “sustained mental effort” are “aversive” and are avoided when possible (p. 78). I cannot say for certain if my SCT symptoms are representative of most people who have SCT symptoms, but I find myself often engaging in activities that require sustained mental effort and these activities are often self-initiated. For example, I taught myself the technical web standards of HTML and CSS that many people find convoluted and boring and I have played around with programming languages such as Pascal, JavaScript, and C++. (Unfortunately, my actual ability to write working programs is far and in between but that is beyond the point I am making.) I would say that my ability for autodidactic learning is preserved even though I have SCT.

DSM-5 is a step in the right direction from DSM-V

When I originally started writing this page, DSM-5 was not released yet but I have since had a chance to review it.

Originally written in 1994, DSM-IV was showing its age. Almost two decades later, its successor DSM-5 was released May 2013. (As a side note, did the DSM decision makers get bored with roman numerals? I wonder why the change in formatting.) Not only did the world become more digital and information became more accessible, but breakthroughs in all branches of sciences, including psychology, neuroscience, and genetics, called for an entirely new way of thinking.

The DSM-5 immediately pointed out its predecessor’s shortcomings. People are not walking laundry lists of symptoms that readily fit in a perfect checklist. Each individual is unique. One of the reasons why the authors came to that conclusion was the high use of NOS or “not otherwise specified” category which is basically a catch-all for people who fit some, but not all of the requirements for a condition.

The DSM-5 became more flexible in terms of its conceptualizations, and sees disorders as falling on a continuum rather than a box with perfectly solid edges. The new DSM now views itself as a “living document” to reflect its ever changing nature in order to match up to the rate at which information is now published and shared.

Even though the DSM only describes disorders and not treatments for any disorder, I found it interesting that the authors hope for the “eventual cures” for mental ills. It’s curious because “cure” is such a strong word that implies a lot (APA, p. 6). At best, if the authors wanted to follow the careful rhetoric of DSM-IV they would have used a phrase such as “successful management of disorders.” But either way, “cure” is a nice word but without a solid action plan it is only wishful thinking.

Sluggish Cognitive Tempo, which was a proposed disorder for DSM-5, unfortunately didn’t make the cut which leads me to my next discussion.

My DSM suggestion for attention disorders

Now I am not going to pretend that I have the qualifications to be able to propose changes to an official manual such as the DSM, but I view this as more of an academic exercise. The following changes are one of many ways to improve the current DSM. (Another possibility is to break ADD and ADHD up into two separate disorders than then make further subtypes from there.)

Attention Deficient Disorder should be characterized as an attention spectrum disorder in which there are four major stratifications:

I. Primarily Hyperactive
II. Hyperactivity & Inattention
III. Primarily Inattentive
IV. Hypoactivity & Inattention

The H in ADHD currently standing for hyperactivity is counterintuitive when referring to those who have little to no hyperactivity. It further marginalizes a specific group of people and keeps them from getting support and treatment. Therefore, it should be dropped so that Attention Deficient Disorder is the primary label in which all other attention disorders are identified. The subtypes will be the key to further identifying symptoms with a strong degree of specificity. For sake of convenience I have labeled the subtypes from I to IV in order of increasing inattentive, hypoactive symptoms.

Types I through III remain generally unchanged with the DSM-IV three subtypes, but my proposed change is a matter of labeling. Type IV which I have proposed would be the official label for Sluggish Cognitive Tempo. The main difference between the primarily inattentive subtype (type III) and the hypoactivity & inattention disorder (type IV) is that type IV is a much stronger type of hypoactivity which may include daydreaming, sluggishness, fatigue, and a qualitatively different type of information processing. More research needs to be done to elaborate more on the details of information processing, but from anecdotal reports it seems that the extreme hypoactivity and memory deficient found in type IV may lead to compensatory mechanisms not found in those who fit under the primarily inattentive type III category. For this reason, I believe the SCT construct should belong to a new category, but that this category should not stray too far away the attention disorders already officialized. Many people who are diagnosed under the DSM-5 as ADHD-PI do not associate with hypoactive symptoms while the people who associate with the Sluggish Cognitive Tempo construct do by definition.

I believe these changes are a fair and elegant way of addressing the clashes of confusion among attention disorders. I think that these revisions do not drastically refute the research and confirmations already put in place by professionals but rather enhance them.