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Diagnostic ADHD symptoms according to DSM, ICD, Wender-Utah et al.

Diagnostic ADHD symptoms according to DSM, ICD, Wender-Utah et al.

The symptom catalogs listed below are alternative classifications of ADHD. They must not be applied schematically, which already results from the fact that several alternative symptom lists exist.
These are not treatment guides.

The DSM (Diagnostic and Statistical Manual of Mental Disorders) is a catalog published since 1952 by the American Psychiatric Association (APA), the American psychiatric society. The 5th edition, DSM 5, was published in May 2013.1

ICD is the catalog of the World Health Organization (WHO), the international health organization. The current ICD is ICD 10, ICD 11 is in preparation.
The DSM IV incorporated the catalog numbers of the ICD 9 on psychiatric diseases and is in this respect a separate part of the ICD. DSM and ICD arose from the need to record statistically which diseases occur how frequently.

DSM and ICD are therefore not really instruments for diagnosing diseases, but serve more for statistical recording and classification of diagnoses. Such statistical classifications are of great importance, especially with regard to health insurance companies. In terms of medical diagnosis from the perspective of optimal treatment, on the other hand, they must not be accorded the same importance.

ATTENTION: DSM and ICD only name the diagnosis-relevant symptoms. In addition to the diagnosis-relevant symptoms, there are other symptoms that often result originally from a disorder (here: from ADHD), but which can also arise from other disorders, which is why they are not diagnosis-relevant.

The totality of all symptoms is relevant for treatment. It would therefore be a medical or therapeutic error to base treatment solely on the symptoms of the DSM or ICD.
Symptom total list according to manifestations

1. DSM

While DSM-IV still classified ADHD in the group of behavioral disorders, DSM-V has assigned ADHD to the group of Neurodevelopmental Disorders.

1.1. DSM 5

Inattention

  • Often fails to pay close attention to details or makes careless mistakes in schoolwork, work, or other activities
  • Often has difficulty maintaining attention for extended periods of time during tasks or play
  • Often does not seem to listen when directly addressed
  • Often does not follow instructions completely and often fails to complete schoolwork, chores, or duties at work (loss of concentration; distraction)
  • Often has difficulty organizing tasks and activities (e.g., works in a messy, haphazardly disorganized manner; does not meet deadlines and deadlines)
  • Often avoids, dislikes, or is reluctant to engage in tasks that require prolonged mental effort (e.g., assisting in class; filling out forms)
  • Often loses items needed for tasks or activities (e.g., school supplies, pens, books, tools, wallet, keys, paperwork, glasses, cell phone)
  • Is often easily distracted by external stimuli or irrelevant thoughts
  • Is often forgetful about daily activities (e.g., running errands, paying bills, keeping appointments)

Hyperactivity/impulsivity

  • Often fidgets with hands or feet, beats beat with them or squirms on the seat
  • Often leaves his place in situations where this disturbs
  • Often runs around or climbs in inappropriate situations (in adolescents or adults, a subjective feeling of restlessness is enough)
  • Is often unable to play quietly or participate quietly in recreational activities
  • Is often “on the go” or acts “as if driven” (e.g.: cannot stay quietly in one place for long, or feels very uncomfortable doing so, e.g. in restaurants)
  • Often talks excessively
  • Often blurts out an answer before the question is completed or finishes others’ sentences
  • Has difficulty waiting his/her turn (e.g., waiting in line)
  • Frequently interrupts or disturbs others (e.g., bursts into conversations, games, or other activities; uses other people’s things without asking first; in adults: interrupts or takes over activities of others)

ADHD diagnosis is possible only when all general and specific observations are available:

Necessary general observations

  • It is a consistent pattern of inattention and/or hyperactivity/impulsivity that impairs level of functioning or development
  • Several symptoms of this pattern appeared before the age of 12 years
  • Multiple symptoms of this pattern persist in two or more different areas of life (e.g., at home, school, or work; with friends or relatives; in other activities)
  • There is strong evidence that symptoms interfere with or reduce the quality of social, educational, or occupational functioning
  • Symptoms are not better explained by another mental disorder (e.g., schizophrenia or psychotic disorder, affective disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal)

Necessary special observations

  • For inattention and for hyperactivity/impulsivity, each must be present at a minimum
    • For children and adolescents (up to 16 years): six out of nine symptoms
    • For adolescents (17 years and older) and adults: five out of nine symptoms
      (see notes on this)
  • Symptoms have occurred consistently over the past 6 months at a level inconsistent with developmental status
  • Symptoms have a direct negative impact on social and school or work activities
  • The symptoms are not exclusively an expression of defiance, hostility, or difficulty understanding.

Mood stability and emotional dysregulation are considered by DSM 5 to be associated features that support the diagnosis.2

Notes:
The updated 2018 European Consensus on the Treatment and Diagnosis of ADHD indicates that compelling evidence now exists that a cut-off of 4 symptoms in adults would be more correct for a correct ADHD diagnosis.234

1.2. DSM IV (obsolete, applied only to children)

  • At least 6 symptoms
    • From the area of inattention
      or
    • The area of hyperactivity/impulsivity
      or
    • From both areas together.
  • Some of the symptoms before the age of 7.
  • Due to the symptomatology, impairments in at least two areas of life.
  • Symptoms not better explained by another mental disorder or medical condition.

Inattention

  • Often fails to pay attention to details or makes careless mistakes
  • Often has difficulty maintaining attention during tasks or play
  • Often seems not to listen when others address him/her
  • Often does not follow through on instructions from others and cannot finish work
  • Often has difficulty organizing tasks
  • Has an aversion to tasks that require prolonged mental effort
  • Frequently loses items that she/he needs for activities
  • Gets distracted more often by external stimuli
  • Is often forgetful during everyday activities

Hyperactivity

  • Fidgets frequently with hands or feet and slides around on chair
  • Frequently stands up in class or other situations where remaining seated is expected
  • Frequently runs around or climbs excessively in situations where this is inappropriate (in adolescents or adults, this may be limited to a subjective feeling of restlessness)
  • Often has difficulty playing quietly or engaging in leisure activities quietly
  • Is often “on the move” or often acts as if he/she were driven
  • Often talks excessively

Impulsivity

  • Frequently blurts out answers before the question is finished.
  • Can only wait with difficulty for his/her turn.
  • Frequently interrupts and disturbs others (e.g., bursts into others’ conversations or games).

1.3. ADHD and subtypes in the DSM

  • DSM III-R did not distinguish by subtype.
  • DSM IV distinguished ADHD by subtype.
  • DSM V (May 2013) has again abandoned the division into subtypes.
  • ICD also does not distinguish between subtypes.

According to this view, a distinction according to subtypes is essential for the diagnosis and understanding of ADHD; for the treatment, however, the differences are, at least for the time being, not yet pervasive. We consider the subtypes with hyperactivity/impulsivity (ADHD-HI, ADHD-C) and dreaming, predominantly inattentive (ADHD-I) as different symptomatology of one and the same underlying disorder, depending on the individual stress phenotype (the way stress manifests) of the affected person.
SCT, Sluggish Cognitive Tempo is now understood as a disorder in its own right, even though it has a very high overlap with ADHD.
Since attention symptoms in humans can be detected developmentally at the earliest at the age of 6 to 7 years and at the latest at the age of 14 to 15 years, ADHD-C (hyperactivity/impulsivity + attention problems) is often only the age- and development-related subsequent stage of the ADHD-HI subtype (pure hyperactivity).
The subtypes of ADHD: ADHD-HI, ADHD-I, SCT, and others

2. ICD 10

ICD 11 is expected for Jan. 1, 2022.

Attention Deficit Disorder

  • Is inattentive to task details, makes errors of care in tasks
  • Is often unable to maintain attention during play or tasks
  • Often does not seem to hear what he/she is being told
  • Is often unable to perform tasks and duties (not due to oppositional behavior)
  • Is impaired to organize tasks and duties
  • Avoids unloved tasks that require perseverance
  • Frequently loses things that are important for completing tasks (e.g., pens)
  • Is often distracted by external stimuli
  • Is often forgetful in the course of daily activities

Over at least 6 months, at least 6 of the above 9 symptoms occur.

Overactivity

  • Frequently flails hands and feet or squirms on seats
  • Leaves classroom or other situations where sitting is expected
  • Frequently runs around or climbs excessively in situations where this is inappropriate
  • Is often unnecessarily loud when playing or has difficulty with quiet recreational activities
  • Persistent pattern of excessive motor activity that cannot be thoroughly influenced by social contact or prohibitions

Over at least 6 months, at least 3 of the above 5 symptoms occur

3. ICD 11

ICD 11 has not yet been adopted. The Draft version of ICD 11 in relation to ADHD now adopts the subtypes of predominantly hyperactive/impulsive type, predominantly inattentive type, and mixed type

4. Wender Utah criteria for adults

Wender-Utah is a special symptom catalog on ADHD in adulthood

For a diagnosis in adulthood, the symptoms attention deficit disorder and motor hyperactivity must be present, as well as two other of the total 7 symptom groups.5

Attention Deficit Disorder

  • Inability to follow conversations attentively
  • Increased distractibility
  • Forgetfulness

Motor hyperactivity

  • Inner restlessness
  • Inability to relax
  • Inability to perform sedentary activities
  • Dysphoria with inactivity

Affect lability

  • Switch between neutral and depressed
    Mood
  • Duration from a few hours to a maximum of a few days

Disorganized behavior

  • Inadequate planning and organization of activities
  • Tasks are not completed

Affect Control

  • Persistent irritability, even for a minor reason
  • Reduced frustration tolerance and short outbursts of anger

Impulsivity

  • Interrupting others in conversation
  • Impatience
  • Impulsive purchases
  • Inability to delay actions in the course

Emotional overreactivity

  • Inability to adequately deal with everyday stressors, sensory overload, black-outs

5. Adult criteria according to Hallowell / Ratey

The authors of the book “Compulsively Absentminded”, Edward M. Hallowell and John Ratey, have suggested the following characteristics for recognizing ADHD in adults. The characteristics are vividly explained there with examples.6

The basic requirement is that the symptoms have been present since childhood and that other organic or psychological disorders are not better suited to explain the symptoms.

  • Feeling of underachievement or of not having achieved the set goals
  • Difficulties with the organization of everyday life
  • Chronic procrastination,
    Trouble to start a thing
  • Pursue many projects at the same time,
    Difficulty in following through
  • Tendency to say whatever comes to mind without due consideration of the timing or circumstances
  • Frequent hunt for high level stimulation
  • Lack of tolerance for boredom
  • Easy distractibility,
    Problems focusing attention,
    Tendency to switch off or drift off in thought in the middle of a page or conversation
    not infrequently associated with ability to hyperfocus as well
  • Problems adhering to procedural rules or procedures
  • Impatience, low frustration tolerance
  • Impulsiveness in speech as in action
  • Tendency to worry incessantly, searching for topics of concern while at the same time disregarding or overlooking real dangers
  • Sense of insecurity
  • Mood swings / mood instability
  • Motor or inner restlessness
  • Decreased self-esteem
  • Inaccurate self-assessment
  • Familial occurrence of ADHD

Often creative, intuitive, intelligent (not a symptom, but often typical).

6. Limitations of DSM and ICD

6.1. DSM and ICD only name diagnostic symptoms, not all symptoms

Often there is talk of a diagnosis according to DSM IV, DSM 5 or IDC 10 / ICD 11.
This designation is somewhat misleading. DSM and ICD are at least as much statistical catalogs as diagnostic manuals. They are by no means binding or the only valid diagnostic standards, even if they are often misunderstood as such.

DSM and ICD list only those symptoms of ADHD that are particularly well suited to distinguish ADHD from other disorders and from non-affected individuals.
For the treatment and therapy of ADHD it is essential to know all the symptoms that ADHD can cause.
A list of more than 40 ADHD symptoms can be found at Symptom total list according to manifestations.

Unfortunately, we experience again and again that doctors or therapists do not even recognize procrastination, the most common symptom caused by ADHD, as a symptom that can be caused by ADHD. Procrastination can also be caused by other disorders. However, this does not excuse negating that ADHD can cause procrastination.
If doctors or therapists do not know all symptoms that can be caused by a disorder (here: ADHD), this can lead to the fact that affected persons come out of an (ADHD) therapy even more destroyed than they went in, because symptoms of their disorder are blamed on them as faults for which they are personally responsible, instead of working with them to fight the symptom of the disorder. The same is true for many other symptoms, such as rejection sensitivity, which in many patients is immediately released when stimulants take effect, emotional dysregulation, and anxiety, which can also be original (meaning: can be directly triggered by ADHD) symptoms of ADHD.
Very often, the original ADHD symptom of dysphoria with inactivity, which together with the also common ADHD symptoms of anhedonia and listlessness frequently occurs in ADHD, is also misdiagnosed as depression.

6.2. Statistics does not change diseases

The changes from DSM I to DSM 5 have changed the statistical recording of diseases, but not their existence. According to our understanding, illness is a subjective impairment of the well-being of people that is so severe that either the affected person would like to change something about it for himself, which justifies treatment, or that it affects third parties to such an extent that treatment seems objectively necessary.
Whether the impairment of well-being is listed in the DSM or ICD or has a billing number with a health insurance company is cordially irrelevant for the affected person’s perception of illness or the impairment of the environment. Conversely, in our view, it is not decisive whether symptoms that a person has are listed in DSM or ICD if neither the person nor third parties have a problem with them.

Krause quote the chairman of the DSM IV editorial board, psychiatrist Frances Allen, as making the exceedingly correct and important critical observation: The DSM must remain simple, but psychiatry need not. DSM diagnostics should be only a small part of the overall assessment.“. And further Allen criticizes: A nuanced psychiatry has become a checklist psychiatry that levels individual differences…“.7

6.3. DSM / ICD are aids, not bibles

The diagnostic criteria of DSM and ICD are valuable aids in determining to which group the impairment of the affected person belongs. However, anyone who only asks about the DSM or ICD symptoms and makes them the sole yardstick for treatment shows that they are not really familiar with the actual problem or do not take the patient seriously.

The fact that DSM and ICD are only statistical tools and diagnostic manuals and cannot be used as the sole decisive diagnostic criteria results, as already mentioned, from the fact that the two systems have already gone through many iterations with quite different criteria and also differ among themselves. It is not ADHD itself that has changed, but only the respective concepts of understanding of DSM and ICD. In addition, important symptoms are still missing in DSM and ICD, such as dysphoria with inactivity, which is still only mentioned in Wender/Utah.
In any case, DSM IV and ICD 10 were always tailored to ADHD in children and adolescents only.8
However, adult symptoms differ considerably. ADHD in adults

For those affected, the only thing that counts is the discomfort they suffer as a result of their illness, regardless of whether this is covered by a list of criteria or not.


  1. https://www.psychiatry.org/psychiatrists/practice/dsm/history-of-the-dsm

  2. Kooij, Bijlenga, Salerno, Jaeschke, Bitter, Balázs, Thome, Dom, Kasper, Filipe, Stes, Mohr, Leppämäki, Brugué, Bobes, Mccarthy, Richarte, Philipsen, Pehlivanidis, Niemela, Styr, Semerci, Bolea-Alamanac, Edvinsson, Baeyens, Wynchank, Sobanski, Philipsen, McNicholas, Caci, Mihailescu, Manor, Dobrescu, Krause, Fayyad, Ramos-Quiroga, Foeken, Rad, Adamou, Ohlmeier, Fitzgerald, Gill, Lensing, Mukaddes, Brudkiewicz, Gustafsson, Tania, Oswald, Carpentier, De Rossi, Delorme, Simoska, Pallanti, Young, Bejerot, Lehtonen, Kustow, Müller-Sedgwick, Hirvikoski, Pironti, Ginsberg, Félegeházy, Garcia-Portilla, Asherson (2018): Updated European Consensus Statement on diagnosis and treatment of adult ADHD, European Psychiatrie, European Psychiatry 56 (2019) 14–34, http://dx.doi.org/10.1016/j.eurpsy.2018.11.001, Seite 17

  3. Solanto, Wasserstein, Marks, Mitchell (2012): Diagnosis of ADHD in adults: what is the appropriate DSM-5 symptom threshold for hyperactivity-impulsivity? J Atten Disord. 2012 Nov;16(8):631-4. doi: 10.1177/1087054711416910.

  4. Kooij, Buitelaar, van den Oord, Furer, Rijnders, Hodiamont (2005): Internal and external validity of attention-deficit hyperactivity disorder in a population-based sample of adults. Psychol Med. 2005 Jun;35(6):817-27.

  5. Würdemann (2010): ADHS (Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung) bei jungen Erwachsenen, Dissertation, Seite 26

  6. Hallowell, Ratey (1999): Zwanghaft zerstreut oder Die Unfähigkeit, aufmerksam zu sein, Seite 119 ff

  7. Krause, Krause (2014): ADHS im Erwachsenenalter, Seite 65

  8. Eigene Aussage von Barkley, der an DSM IV mitgewirkt hat