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  #1  
Old 01-05-18, 01:30 AM
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Hypoactive (ADHD-I) and Hyperactive (ADHD-H/I)

Quote:
Quote:
Whereas children with ADHD are frenetic and hyperactive, a significant proportion of children with ADD are exactly the opposite. A significant subset of children with ADD are hypoactive, sluggish, and very slow to respond (see Table 1).
http://www.ncbi.nlm.nih.gov/pmc/arti...1/#!po=13.1579
What are the differences and similarities between Attention Deficit Hypoactivity Disorder (ADHD-Inattentive) and Attention Deficit Hyperactivity Disorder (ADHD-Hyperactive/Impulsive)?

Can understanding the differences and similarities between ADHD-I and ADHD-H/I help us better understand ADHD-Combined?







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  #2  
Old 01-05-18, 02:01 AM
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Re: Hypoactive (ADHD-I) and Hyperactive (ADHD-H/I)

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Originally Posted by mildadhd View Post
What are the differences and similarities between Attention Deficit Hypoactivity Disorder (ADHD-Inattentive) and Attention Deficit Hyperactivity Disorder (ADHD-Hyperactive/Impulsive)?
There is no disorder formally called Attention Deficit Hypoactivity Disorder, and it's not a term I've seen used widely in research. Is it something you read somewhere, or a term you invented? It might help the rest of us understand what you want to talk about if you defined that non-standard term.

As we discussed in another recent thread, people diagnosed with ADHD of the predominantly inattentive subtype or presentation typically seem to fall into one of the following groups:

a) People with "subthreshold combined type" (that is, people who have some impulsive/hyperactive symptoms, but not enough to meet the full criteria for combined type/presentation),

b) People with straight-up ADHD, predominantly inattentive type/presentation, who really don't have any symptoms of hyperactivity or impulsivity, yet who don't better fit under the "sluggish cognitive tempo (SCT)" or "concentration deficit disorder (CDD)" label, and

c) People who actually only/primarily have what is now being called "SCT" or "CDD", who have been diagnosed with ADHD simply because "SCT" or "CDD" are not formal diagnoses in the DSM.

I don't know what the distribution/breakdown is across those three categories. ...And I guess we should remember that people can have SCT symptoms even if they have some hyperactive-impulsive symptoms as well.

I would guess that people who fall into the "c" group are more likely to be consistently hypoactive than the "a" group. I don't know about the "b" group.

It seems imprecise to equate ADHD (predominantly inattentive subtype/presentation) with hypoactivity, when a good chunk of the people with that diagnosis are not, in fact, consistently hypoactive.

(If I'm misunderstanding, and you're not saying that ADHD, predominantly inattentive type/presentation = ADHypoactiveD, please correct me.)

Also, out of curiosity, are you omitting people with the combined presentation from the discussion on purpose? [Edit: You edited your post after I started writing this post!]

Combined type/presentation accounts for a huge chunk of people (especially kids) with ADHD overall -- whereas very few people, especially adults, are diagnosed with the predominantly hyperactive-impulsive presentation. The vast majority of ADHDers have significant inattentive symptoms.

Quote:
Originally Posted by mildadhd
Can understanding the differences and similarities between ADHD-I and ADHD-H/I help us better understand ADHD-Combined?
Probably somewhat, though I'm not sure there are very many people with "pure" ADHD-H/I.

I think I might frame it a little differently: Understanding the disorder better from a psychological and biological point of view helps us come up with more useful labels (shorthand). It's an iterative process -- we describe things as best we can, and then study them, and then refine our descriptions, and then study things some more, and keep revising as we learn more and more.


I'd also be curious (though don't have time now to look up) how the ideas that Adele Diamond expressed in her 2006 paper have been refined over the past decade-plus. It seems there are still different models of ADHD (even the combined type) that place different emphasis on response inhibition and/or working memory, and defining executive functions differently.

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  #3  
Old 01-05-18, 04:05 AM
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Re: Hypoactive (ADHD-I) and Hyperactive (ADHD-H/I)

I call ADHD-Hyperactive/Impulsive, “Attention Deficit Hyperactivity Disorder”, because people who have ADHD-H/I, are hyperactive.

I call ADHD-Inattentive, “Attention Deficit Hypoactivity Disorder”, because people who have ADHD-I are hypoactive.

ADHD-I and ADHD-H/I are in the DSM.

The DSM does not specify what the letter “H” represents, when they write “ADHD-Inattentive”.

Hypoactivity makes sense to me.

The medical definition of term “Hypoactivity” represents symptoms of ADHD-Inattentive very well. (And “Hypoactivity” starts with the letter “H”)

I do not think I invented anything new.

See table one, “A comparison of the characteristics of ADHD and ADD”, for a good example of similarities and differences between ADHD-H/I and ADHD-I.

Sorry, I did not emphasize “(see Table 1)”, in the opening post quote, as an example.






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Old 01-05-18, 05:10 AM
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Re: Hypoactive (ADHD-I) and Hyperactive (ADHD-H/I)

Quote:
Originally Posted by mildadhd View Post
I call ADHD-Hyperactive/Impulsive, “Attention Deficit Hyperactivity Disorder”, because people who have ADHD-H/I, are hyperactive.
Yes, this is true, by definition.

Quote:
Originally Posted by mildadhd
I call ADHD-Inattentive, “Attention Deficit Hypoactivity Disorder”, because people who have ADHD-I are hypoactive.
What I'm saying is that this is not universally true.

Not everyone diagnosed with ADHD-PI -- at least, according to the DSM criteria -- is hypoactive. Some people diagnosed with ADHD-PI have normal activity levels, or are even a little hyperactive (but not enough to meet ADHD-C criteria).

If you want to discuss a subset of individuals diagnosed with ADHD-PI who are hypoactive, I won't argue.

But it's incorrect to claim that a diagnosis of ADHD-PI always implies a hypoactive presentation.

Quote:
Originally Posted by mildadhd
The DSM does not specify what the letter “H” represents, when they write “ADHD-Inattentive”.
Yes it does. The "H" in 'ADHD" stands for "hyperactivity", regardless of presentation.

Now, you (and Adele Diamond, and me, and others) may feel that it's silly to have "hyperactivity" in the name of a disorder, when
a) hyperactivity is not the defining characteristic of the disorder and
b) not everyone with the disorder has symptoms of hyperactivity.
But that doesn't mean that substituting another (also inaccurate) word solves the problem.

Quote:
Originally Posted by mildadhd
Hypoactivity makes sense to me.

The medical definition of term “Hypoactivity” represents symptoms of ADHD-Inattentive very well. (And “Hypoactivity” starts with the letter “H”)

I do not think I invented anything new.
No, you didn't invent the word hypoactivity -- and it does indeed start with "h". But you are using non-standard terminology, and it happens to be inaccurate.

It's true that "hyperactivity" does not accurately describe the symptoms of many people who have ADHD-PI.

However, "hypoactivity" does not accurately describe some people diagnosed with ADHD-PI, either.

In making this hyper <---> hypo switcheroo, you're not actually solving the problem, which is that the label does a poor job of describing the underlying neurobiology and the associated range of behavior. The switch from hyper- to hypo- just confuses things even more, at least for me, given the variability in activity levels within the ADHD-PI group.

Quote:
Originally Posted by mildadhd
See table one, “A comparison of the characteristics of ADHD and ADD”, for a good example of similarities and differences between ADHD-H/I and ADHD-I.

Sorry, I did not emphasize “(see Table 1)”, in the opening post quote, as an example.
Table 1 does not refer to "ADHD-H/I" and "ADHD-I", and the table does not compare and contrast the two.

As Diamond is using the term "ADHD with hyperactivity" in Table 1 and throughout the paper, "ADHD" does not mean "ADHD-H/I". It means "Children with combined-type ADHD or hyperactive-type ADHD."

Similarly, "ADD" as used in Table 1 does not mean "all ADHD-PI" as the term is used today. As I understand it, she's referring only to a subset of people with "pure" inattentive symptoms who lack impulsivity or hyperactivity entirely: "Children with inattentive-type ADHD, excluding those with significant hyperactivity, even if they fail to meet the criteria on seven hyperactivity items (they are really combined-type ADHD)." (emphasis mine)

So basically, she's lumping a lot of people with ADHD-PI in with the "ADHD" group because "they are really [subthreshold] combined-type ADHD."

(See footnotes "a" and "b" at the bottom of the table.)

And even then, in the first item in the right-hand column in Table 1, she states that among the people with "ADD", only a subset of them (not all!) are hypoactive.

So Table 1 does not really support the idea that ADHD-PI (as diagnosed under current criteria) implies hypoactivity.

Again, I'd need to do some additional literature review to see how her idea (which was shared by a number of researchers at the time) has changed over the past decade. In particular, I get the sense that working memory problems continue to be implicated in ADHD-C along with response inhibition problems.

All of this is also involved in the discussion about "SCT" or "CDD" and the possible overlap with ADHD.

One of the things that happens with research on complex conditions like ADHD is that the labels and hypotheses and explanations change over time as new knowledge becomes available. What I'm not sure of is how well the model used in the paper has held up over time, vs. whether researchers are drawing different lines or making different models now.

For example, in this paper from 2013, Adele Diamond discusses executive functions as a group, including both working memory (problems associated with "ADD" in the 2006 paper) and inhibitory control (problems assocaited with "ADHD with hperactivity" in the 2006 paper). She explicitly mentions that "disentangling" working memory and inhibitory control is challenging.

It's all still very much an open question!

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  #5  
Old 01-05-18, 11:23 AM
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Re: Hypoactive (ADHD-I) and Hyperactive (ADHD-H/I)

I value the idea of more descriptive (for lack of a better term) labels for diagnoses, and certainly this is the subforum to explore such things, but when presenting an idea or ideas to consider, it may be helpful to use established clinical terminology in the beginning such that mutual understanding of a would-be framework may be more quickly realized.

Once done, articulation of novel or divergent ideas may occur at a much greater pace because of a shared foundation of understanding and perspective based on established clinical knowledge as expressed normatively.


Cheers,
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Old 01-05-18, 04:59 PM
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Re: Hypoactive (ADHD-I) and Hyperactive (ADHD-H/I)

I think aeon said what I meant, but in a much shorter way.

If you want to change the terms we use to describe the condition(s),
a) It's helpful to be precise about how your new terms relate to the old/standard terms, and
b) It's helpful to make sure that your new terms are really more accurate/useful than the old/standard terms.

Since a lot of people diagnosed with ADHD-PI (under DSM-5) are not hypoactive, I'm not sure how your proposal would help clarify things. How would your terminology handle people who are not hypoactive, yet who don't meet the criteria for ADHD-C, either?
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Old 01-05-18, 05:05 PM
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Re: Hypoactive (ADHD-I) and Hyperactive (ADHD-H/I)

I was diagnosed as ADHD-PI...I have all the inattentive criteria, some degree of the impulsive criteria, and none of the hyperactive criteria (though I sometimes have a hyperactive mind in terms of flood of ideas, thoughts, and memories...when unmedicated).

That said, the only time I am hypoactive in terms of presentation is when I am in withdrawal from Dexedrine.

Not counting apathy/lethargy resulting from depression and anhedonia, of course.


Cheers,
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  #8  
Old 01-05-18, 06:41 PM
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Re: Hypoactive (ADHD-I) and Hyperactive (ADHD-H/I)

Quote:
Originally Posted by aeon View Post
I was diagnosed as ADHD-PI...I have all the inattentive criteria, some degree of the impulsive criteria, and none of the hyperactive criteria (though I sometimes have a hyperactive mind in terms of flood of ideas, thoughts, and memories...when unmedicated).

That said, the only time I am hypoactive in terms of presentation is when I am in withdrawal from Dexedrine.

Not counting apathy/lethargy resulting from depression and anhedonia, of course.


Cheers,
Ian
Where does the DSM differentiate between 'hyperactive' and 'impulsive' criteria?

I have only seen them jumbled together in the same list.


added: I just googled "hyperactive vs impulsive" and all the results are for
hyperactive AND impulsive.
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  #9  
Old 01-05-18, 08:18 PM
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Re: Hypoactive (ADHD-I) and Hyperactive (ADHD-H/I)

Quote:
Originally Posted by Lunacie View Post
Where does the DSM differentiate between 'hyperactive' and 'impulsive' criteria?

I have only seen them jumbled together in the same list.

added: I just googled "hyperactive vs impulsive" and all the results are for
hyperactive AND impulsive.
There are 6 symptoms in the DSM-5 ADHD diagnostic criteria that refer to hyperactivity:
  • Often fidgets with or taps hands or feet, or squirms in seat.
  • Often leaves seat in situations when remaining seated is expected.
  • Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
  • Often unable to play or take part in leisure activities quietly.
  • Is often “on the go” acting as if “driven by a motor”.
  • Often talks excessively.
There are 3 symptoms in the list that refer to impulsivity:
  • Often blurts out an answer before a question has been completed.
  • Often has trouble waiting his/her turn.
  • Often interrupts or intrudes on others (e.g., butts into conversations or games)

(One could argue that some hyperactivity is just physical impulsivity. Talkativeness could also probably go either way.)

In the run-up to the publication of DSM-5, there was some discussion about this imbalance (and unfortunately I can't find the relevant paper(s) at the moment):
Why does the list include twice as many "hyperactive" symptoms as "impulsive" ones -- especially when the hyperactive symptoms appear most likely to moderate with time?
But ultimately The Powers That Be were conservative in sticking very closely to the criteria from DSM-IV.

To the extent that a chunk of people diagnosed with ADHD-PI are "subthreshold combined" (which would fall into the group Adele Diamond labeled "ADHD with hyperactivity" in her 2006 paper), and if it's the case that they tend to have more or more noticeable impulsivity symptoms than hyperactivity symptoms, it is possible that this imbalance makes some difference. If the criteria were weighted more towards impulsivity, or if impulsivity were separated from hyperactivity and both sets of symptoms were given equal weight, perhaps more "subthreshold combineds" who have significant impulsivity but less physical hyperactivity would wind up as honest-to-goodness "combineds" in presentation.

I didn't follow the deliberations in great detail, but it is possible that there wasn't strong enough evidence to support distinguishing hyperactivity from impulsivity as separate categories in the diagnostic criteria. Maybe it doesn't really improve diagnosis to separate them -- and if it doesn't, why bother?

In any case, the enduring emphasis (in both the name of the disorder and in the diagnostic criteria) on physical hyperactivity -- which is one of the more easily observed symptoms in a subset of (mostly young) ADHDers -- seems to be a perennial source of confusion about the disorder (regardless of actual presentation). The hyperactivity that some people experience is (occasionally but) only rarely the most salient or impairing feature of ADHD. For the subset of people who are indeed HYPOactive, I don't know whether that is the most noticeable or impairing thing, either.
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  #10  
Old 01-05-18, 09:03 PM
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Re: Hypoactive (ADHD-I) and Hyperactive (ADHD-H/I)

1)ADHD-Primarily (Hypoactive)/Inattentive

2)ADHD-Primarily Hyperactive/Impulsive

3)ADHD-Combined = ADHD-Primarily (Hypoactive)/Inattentive + ADHD-Primarily Hyperactive/Impulsive


1 + 2 = 3


So..

Quote:
Originally Posted by mildadhd View Post
(question from opening post]

..Can understanding the differences and similarities between ADHD-I and ADHD-H/I help us better understand ADHD-Combined?







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Old 01-05-18, 09:06 PM
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Re: Hypoactive (ADHD-I) and Hyperactive (ADHD-H/I)

Thanks Namazu. . Does it actually differentiate between them that way in the
DSM? I haven't seen anything explaining that in any internet information.

I definitely relate to all 3 of the impulsive symptoms much more than than the
6 hyperactive symptoms.
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Old 01-05-18, 09:12 PM
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Re: Hypoactive (ADHD-I) and Hyperactive (ADHD-H/I)

Quote:
Originally Posted by namazu View Post
I think aeon said what I meant, but in a much shorter way.

If you want to change the terms we use to describe the condition(s),
a) It's helpful to be precise about how your new terms relate to the old/standard terms, and
b) It's helpful to make sure that your new terms are really more accurate/useful than the old/standard terms.

Since a lot of people diagnosed with ADHD-PI (under DSM-5) are not hypoactive, I'm not sure how your proposal would help clarify things. How would your terminology handle people who are not hypoactive, yet who don't meet the criteria for ADHD-C, either?
I also would like to see this explained.
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Old 01-05-18, 10:36 PM
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Re: Hypoactive (ADHD-I) and Hyperactive (ADHD-H/I)

Quote:
Originally Posted by Lunacie View Post
I also would like to see this explained.

Guessing...( this is the type of question, we may inspire researchers to understand)?

If a person has hypoactive symptoms and hyperactive symptoms, maybe the hypoactive symptoms appear to cancel out the hyperactive symptoms somehow (or vice versa) depending partly on the individuals ratio of hypoactive:hyperactive symptoms?

This question is way to complex to decide, in this thread discussion, but we could try to compare physiological similarities and differences between hypoactive/inattentive symptoms and hyperactive/impulsive symptoms here at ADDForums for fun.





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Old 01-06-18, 01:25 AM
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Re: Hypoactive (ADHD-I) and Hyperactive (ADHD-H/I)

Quote:
Originally Posted by Lunacie View Post
Thanks Namazu. . Does it actually differentiate between them that way in the DSM? I haven't seen anything explaining that in any internet information.
No, in the DSM they are lumped together as "symptoms of hyperactivity-impulsivity".

There definitely have been discussions of this in the scientific literature, but I'm not sure how much of that has made its way into sources that would be easier to find and access online. A lot of the papers in journals are behind paywalls.


Quote:
Originally Posted by mildadhd
If a person has hypoactive symptoms and hyperactive symptoms, maybe the hypoactive symptoms appear to cancel out the hyperactive symptoms somehow (or vice versa) depending partly on the individuals ratio of hypoactive:hyperactive symptoms?
This is an interesting question.

For some people, the symptoms may be fairly consistent in one direction (like, a person who is generally hyperactive, or generally hypoactive).

If some people sort of swing back and forth, depending on...which side of the bed they woke up on*...then there might not be a consistent pattern.

I don't know if this is a phenomenon that goes beyond typical fluctuations in energy levels, or if we could actually demonstrate something more pronounced in a subpopulation of ADHDers.

Over what time period would these changes from hyperactivity to hypoactivity and back again happen, do you think?

Also, at the moment, there are no symptoms of ADHD that are really "hypoactive", though things related to that are sometimes included in lists of symptoms of "SCT" or "CDD". But some ADHDers may experience hypoactivity anyway, even if it's not a symptom that leads to diagnosis of (DSM-5) ADHD.

* I don't know what mechanisms we could posit that wouldn't point more towards another condition, like blood sugar regulation problems, depression or bipolar disorder (and I'm not sure we understand how cycling there works, either, if it's not seasonal or drug-induced), or other conditions...but there could plausibly be things. Hmm...
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Old 01-13-18, 01:15 AM
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Re: Hypoactive (ADHD-I) and Hyperactive (ADHD-H/I)

Quote:
Originally Posted by namazu View Post
No, in the DSM they are lumped together as "symptoms of hyperactivity-impulsivity".

There definitely have been discussions of this in the scientific literature, but I'm not sure how much of that has made its way into sources that would be easier to find and access online. A lot of the papers in journals are behind paywalls.



This is an interesting question.

For some people, the symptoms may be fairly consistent in one direction (like, a person who is generally hyperactive, or generally hypoactive).

If some people sort of swing back and forth, depending on...which side of the bed they woke up on*...then there might not be a consistent pattern.

I don't know if this is a phenomenon that goes beyond typical fluctuations in energy levels, or if we could actually demonstrate something more pronounced in a subpopulation of ADHDers.

Over what time period would these changes from hyperactivity to hypoactivity and back again happen, do you think?

Also, at the moment, there are no symptoms of ADHD that are really "hypoactive", though things related to that are sometimes included in lists of symptoms of "SCT" or "CDD". But some ADHDers may experience hypoactivity anyway, even if it's not a symptom that leads to diagnosis of (DSM-5) ADHD.

* I don't know what mechanisms we could posit that wouldn't point more towards another condition, like blood sugar regulation problems, depression or bipolar disorder (and I'm not sure we understand how cycling there works, either, if it's not seasonal or drug-induced), or other conditions...but there could plausibly be things. Hmm...
The labels can be deceptive simply because they tend to focus one's awareness.
If inattentive symptoms are causing you more trouble- you may focus on those and miss the others.
Equally, the danger with the label ADHD is that you may overgeneralise your awareness of the focus problem and MISS the times when your attention is fine.
It is important to notice them and to ask yourself "what was happening that allowed me to focus well this time?"

I do not think that anybody has shown any significant biological differences between combined type and predominantly inattentive type.

The classification may not have any real validity- but it is helpful- because it helps clinicians to see that not all that is ADHD is hyperactive.

SCT failed to get into the DSM, and some are arguing that it might be a transdiagnostic concept.
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