Do you have questions about Dissociative Identity Disorder (DID) / Multiple Personality Disorder (MPD)?

We have some answers, along with information on treatment plans, how to select a therapist, and more.

Please keep in mind the information below is for educational purposes only and should not be treated as medical, psychiatric or psychological advice. Nothing here is intended to be for medical diagnosis or treatment or a substitute for consultation with a qualified therapist or medical professional.

As views on various topics may differ greatly, even amongst professionals, we encourage you to take your questions and concerns to your personal therapist or medical doctor.

For easier viewing while off-line, you can click FILE, then SAVE AS in the menu bar at the top of your browser, enabling you to read and/or print the article later.

• Terminology: Common terms used when discussing Dissociative Identity Disorder (DID)/ Multiple Personality Disorder (MPD).
• FAQ Sheet: Including things to look for in deciding whether you may need to seek further evaluation.
• MPD/DID Key Findings Quick Facts: From the National Foundation for the Prevention and Treatment of Multiple Personality.
• Questionnaire: Is it possible you have an ego state disorder? Do you dissociate? This questionnaire may help you decide if you should get help now.
• Understanding Dissociative Disorders Through Dissociative Signs and Symptoms
• An Overview of Diagnosis and Treatment: by Joan A. Turkus, M.D.
• Aspects of the Treatment of Multiple Personality Disorder: From the book by Richard P. Kluft, M.D.
• The Treatment Of Multiple Personality Disorder (MPD): Current Concepts: Volume 5 -lesson 24 Richard P. Kluft, M.D., PH.D, F.A.P.A.
• Uses Of Hypnosis with Multiple Personality by Bennett G. Braun, M.D.
• Projective Techniques in the Counseling Process: by Arthur J. Clark
• Rating Your Psychotherapist: A list of things to look for in a Psychotherapist and/or a way to rate your current Psychotherapist.
• Potential Triggers: Things that may bring on switching, panic, memories and such.
• Tips for Managing Triggers: When YOU choose to process.
• Switching Characteristics: Common and not so common.
• Discerning Alter Personalities from Demons James G. Friesen, Ph.D.
• Inner Faces Of Multiplicity: Contemporary Look at a Classic Mystery by Jacklyn M. Pia.
• Child Abuse And Multiple Personality Disorder: Philip M. Coons, M.D. Department of Psychiatry. Indiana University School of Medicine.
• Multiple Personality, Mirrors of a New Model Mind: From Investigations; Institute of Noetic Sciences.
• The People Inside by Edward Dolnick.
• What You Can Change and What You Can't Excerpted From The Book: What You Can Change and What You Can't by Martin E. P. Seligman.
• Considering Suicide? Questions and Links.

next:   Common Terms Used When Discussing Dissociative Identity Disorder (DID)/Multiple Personality Disorder (DID)

Examples by Adam Khan, author of Self-Help Stuff That Works

by Adam Khan

How do you explain it?

The most important two categories of optimism is how permanent and pervasive your explanations are of setbacks. See if you can guess which is the more optimistic explanation of the event. There's a link to the answers at the bottom.

You forgot you and your spouse's anniversary.
A. There's a lot going on in my life right now.
B. I'm forgetful.

You had an important meeting scheduled for yesterday, and you completely forgot about it until today.
A. I forgot to check my appointment book.
B. My memory isn't what it used to be.

You're late on a credit card payment.
A. I've been distracted by an important project.
B. When I get involved in something, I tend to get distracted.

You fail a test.
A. I didn't prepare well.
B. Preparation isn't my strong point.

Close friends are probably the most important contributor to your lifetime's happiness and your health.
How to Be Close to Your Friends

If you have hard feelings between you and another person, you ought to read this.
How to Melt Hard Feelings

Is it necessary to criticize people? Is there a way to avoid the pain involved?
Take the Sting Out

Would you like to improve your ability to connect with people? Would you like to be a more complete listener? Check this out.
To Zip or Not to Zip

If you are a manager or a parent, here's how to prevent people from misunderstanding you. Here's how to make sure things get done the way you want.
Is That Clear?

Most the people in the world are strangers to you. Here's how to increase your feeling of connectedness to those strangers.
We're Family

next: People

Chapter 63 of the book Self-Help Stuff That Works

by Adam Khan

WHEN SOMEONE AT WORK talks badly about you behind your back, puts you down, interferes with your work, makes you mad, or otherwise makes trouble for you, the natural tendency is to focus on them. You want to get back at them. You want to talk badly about them behind their back, put them down, make trouble for them in some way.

But I want you to consider the possibility that returning like for like is a mistake. Look at the three practical steps below - all of them effective ways to deal with troublemakers - and notice: None involve talking about, thinking about, or speaking with the troublemakers themselves, because that doesn't work. Here's what does work:

1. Do your work extremely well. Think of your level of excellence as a sliding scale, from doing-as-little-as-you-can-do-without-
getting-fired all the way up to doing-your-very-
best-every-second-you-are-at-work. At any given moment, you are somewhere between those two extremes. Move yourself further up the scale and you will feel more confident of your position. Doing your work well counteracts the feelings of insecurity a troublemaker can cause.

2. Keep your integrity level high. Doing anything unethical will increase the insecurity you feel. Conversely, the more you act with honesty and fairness, the better you will feel about yourself and about your position at work.

3. Stay in good communication with everyone else. A common response to feeling that someone is out to get you is to withdraw. But that's a big mistake. The universe of human opinion abhors a vacuum, and if a troublemaker says something bad about you and the listener hears nothing from you, guess what? The slanderous information will tend to hold the floor from lack of any other viewpoint. Your bosses and coworkers may be mature, rational people, but human emotions still influence their decisions, opinions, and conclusions. Stay in communication with people - not trying to prove anything, but just being yourself - and the reality of who you are will help negate any rumors about you.

DO THESE THREE and the threat from the troublemaker will be minimized. You can't really get rid of such an element for good. That's the trouble with troublemakers. They are bound to crop up now and then, as inevitably as a bad storm. If you try to argue with them or fight with them or use their tactics on them, you will lose. They've been at it longer than you.

Do your work to the best of your ability, conduct yourself honorably, and stay in good communication. Your position will be solid and the storm will pass over you without so much as a shudder.

Do your work exceptionally well, keep your integrity level high, and stay in good communication with everyone else.

Dale Carnegie, who wrote the famous book How to Win Friends and Influence People, left a chapter out of his book. Find out what he meant to say but didn't about people you cannot win over:
The Bad Apples

An extremely important thing to keep in mind is that judging people will harm you. Learn here how to prevent yourself from making this all-too-human mistake:
Here Comes the Judge

The art of controlling the meanings you're making is an important skill to master. It will literally determine the quality of your life. Read more about it in:
Master the Art of Making Meaning

Here's a profound and life-changing way to gain the respect and the trust of others:
As Good As Gold

What if you already knew you ought to change and in what way? And what if that insight has made no difference so far? Here's how to make your insights make a difference:
From Hope to Change

next: The Spirit of the Games

Study shows hyperkinetic children were three times more likely to have suffered removal from home than children with other psychiatric diagnoses.

The Association Between Hyperkinesis and Breakdown of Parenting in Clinic Populations

D M Foreman, D Foreman, E B Minty

Arch Dis Child 2005;90:245-248. doi: 10.1136/adc.2003.039826

Background: There is increasing recognition that child based, as well as parent based factors may be associated with children being excluded from their families. Despite the distress routinely observed among the parents of hyperactive children, there is little research on this in clinic populations.

Aims: To examine removals from home in a typical secondary care population, where hyperkinesis was accurately diagnosed.

Methods: A total of 201 cases were coded using mulitaxial ICD-10 criteria and Jarman indices derived from census data.

Results: Hyperkinetic children were more than three times more likely to have suffered removal from home than children with other psychiatric diagnoses, independent of any psychosocial measure.

Conclusion: Hyperkinesis is a specific risk factor for removal from home, which can operate in the absence of other psychosocial stressors. Screening children for hyperactivity is now simple, and the routine paediatric examination for children accommodated by the local authority gives an opportunity for early detection and treatment of hyperactivity in children at risk of family breakdown.

D M Foreman, Child and Adolescent Mental Health Service, Skimped Hill Health Centre, Bracknell, UK - D Foreman, Department of Psychology, University of Southampton, UK - E B Minty, Department of Psychiatric Social Work, School of Psychiatry and Behavioural Sciences, University of Manchester, UK.

Loss is a part of life

We all undergo many losses, real and imagined. My father died 32 years ago. I was 20 then. I am almost the same age he was when he had his fatal car accident. His death was the greatest "real" loss of my life. My eating disorder began a year later.

But I am not alone. In fact, I have never met a person who has bulimia who did not suffer a life-changing loss. Some people lose their parents through death or divorce. Others feel a loss when a sister or brother goes off to college or marries. Or when we move to a new town and lose our friends.

Some of us mourn the loss of childhood, or of a childhood dream. Sometimes bodies betray us. Young ballerinas become too big-chested to perform professionally. High school valedictorians discover that they are only average students once they attend a good college.

We also lose face after wetting the bed at camp, receiving a a scolding from the teacher in front of the class, or being demoted from the first reading group.

Friendships and love relationships leave us especially vulnerable to loss. Your best friend may betray you, or move away. Your boyfriend may leave you for another girl.

Sadly, some of us are physically or sexually abused, which causes us to lose not only our innocence but our capacity to trust. We also lose our body as a part of us that we love and enjoy. Once we become alienated from our bodies, we are prone to hate and hurt them.

Even those of us who grew up in close, seemingly healthy families can also suffer loss, though in more subtle ways. Some parents need us to remain dependent on them so that they never have to deal with their own issues. They stifle our efforts at independence by withdrawing their love and support. They may reject our friends and suitors, and make comments like, "Oh, I guess we can't talk to you anymore, now that you're a college girl..." or, "It's obvious that you like your boyfriend more than us, so why should we invite you to dinner?" To hear comments like these is to suffer a thousand deaths.

Some of these losses roll off the backs of other people -- but not ours! We tend to dwell on what we have lost, and often we blame ourselves. "If only I weren't so bad, or so fat," we say, "If only I were better, then this wouldn't have happened."

We Blame Ourselves

In our minds, the loss is all our fault. Shame and guilt fill us. Looking for a way to punish ourselves, we use our bodies, concluding wrongly, "If I were thin enough, everything would be better." So we eat to fill the empty feeling left by the loss, and we throw up to hurt ourselves, and to keep ourselves from getting fat.

If we can't control our losses, at least we can control our bodies. Eating becomes the one area in our lives where we feel in charge. We alone can determine what's kept and what's lost.

Ironically, the act that once made us feel in control ultimately takes control of us. The trap is set and we are caught.

Breaking Free

What can we do to free ourselves?

First, examine your basic assumption. You didn't suffer a loss because you were bad or fat. You suffered a loss because LOSS HAPPENS.

Sometimes other people are at fault; sometimes, it's no one's fault. It's just life.

And if you base your life on the faulty assumption that you are bad and need to be punished, you can lose your health and your life-- over nothing.

Count Your Losses -- Not Your Calories

You can work through your losses in treatment, but first you have to realize what they are.

Make a time-line of your life for as far back as you can remember. List the events that knocked you down, no matter how small or silly they seem. Today you may laugh at the recollection that someone called you "chubby" when you were twelve -- but you didn't laugh then.

Think about those losses -- real and imagined. What did they do to you? How did you cope with the pain and grief? Did you stuff it down and throw it up, as a metaphor for your hurt feelings?

One thing is for sure. Bingeing and purging won't bring back what is gone, and won't make the pain go away. And being thin is not a guarantee against future loss.

Reflection, understanding, an attitude shift, and the support of a professional -- these can help you understand your internal life. These are the seeds of change.

Linking loss and bulimia is the first step toward recovery.

Did you know?

"Et lux in tenebris lucet" means, "The light shineth before the darkness."

Judith Recommends

To understand how a young girl deals with loss and grief, I recommend THE MEMBER OF THE WEDDING, by Carson McCullers.

In this poignant novel, Frankie, a 12-year-old Georgia tomboy, grapples with devastating losses -- the death of her parents, the marriage of her beloved brother, and a traumatizing sexual experience -- all of which would make her a prime candidate for developing an eating disorder. Yet she doesn't. Find out why. Her story will inspire you.

I also recommend "Party of Five" on Fox TV (Tuesday nights). Neve Campbell plays Julia, one of five siblings who lost their parents in a car accident when they were young. Julia goes through a divorce, leaves for college, and then is physically abused by her boyfriend. She is also a good candidate for an eating disorder -- so many early losses and blows to her self-esteem. Will she?...

next: Reworking the Myth of Personal Incompetence: Group Psychotherapy for Bulimia Nervosa
~ all Beat Bulimia articles
~ eating disorders library
~ all articles on eating disorders

How can someone with an eating disorder healthfully navigate through the busy holiday season? Here are twelve suggestions that may help.

1. Eat regularly and in some kind of reasonable pattern. Avoid "preparing for the last supper." Don't skip meals and starve in attempt to make up for what you recently ate or are about to eat. Keep a regular and moderate pattern.

2. Worry more about the size of your heart than the size of your hips! It is the holiday season, a great time to reflect, enjoy relationships with loved ones, and most importantly a time to feel gratitude for blessings received and a time to give back through loving service to others.

3. Discuss your anticipations of the holidays with your therapist, physician, dietitian, or other members of your eating disorder treatment team so that they can help you predict, prepare for, and get through any uncomfortable family interactions without self destructive coping attempts.

4. Have a well thought out game plan before you go home or invite others into your home. Know "where the exits are," where your support persons are, and how you'll know when it's time to make a brief exit and get connected with needed support.

5. Talk with loved ones about important issues: decisions, victories, challenges, fears, concerns, dreams, goals, special moments, spirituality, relationships and your feelings about them. Allow important themes to be present and allow yourself to have fun rather than rigidly focusing on food or body concerns.

6. Choose, ahead of time, someone to call if you are struggling with addictive behaviors, or with negative thoughts, or difficult emotions. Call them ahead of time and let them know of your concerns, needs, and the possibility of them receiving a call from you.

7. If it would be a support or help to you, consider choosing one loved one to be your "reality check" with food, to either help plate up food for you, or to give you a reality check on the food portions which you dish up for yourself.

8. Write down your vision of where you would like your mind and heart to be during this holiday time with loved ones. Take time, several times per day, to find a quiet place to become in tune again with your vision, to remember, to nurture, and to center yourself into those thoughts, feelings, and actions which are congruent with your vision for yourself.

9. If you have personal goals for your time with loved ones during the holidays, focus the goals around what you would like to do. Make your goals about "doing something" rather than about trying to prevent something. If you have food goals, then make sure you also add personal emotional, spiritual, and relationship goals as well.

10. Work on being flexible in your thoughts. Learn to be flexible in guidelines for yourself, and in expectations of yourself and others. Strive to be flexible in what you can eat during the holidays. Take a holiday from self imposed criticism, rigidity, and perfectionism.

11. Stay active in your support group, or begin activity if you are currently not involved. Many support groups can be helpful. 12-step group, co-dependency group, eating disorder therapy group, neighborhood "Bunco" game group, and religious or spiritually oriented groups are examples of groups which may give real support. Isolation and withdrawal from positive support is not the right answer for getting through trying times.

12. Avoid "overstressing" and "overbooking" yourself and avoid the temptation and pattern of becoming "too busy." A lower sense of stress can decrease a felt need to go to eating disorder behaviors or other unhelpful coping strategies. Cut down on unnecessary events and obligations and leave time for relaxation, contemplation, reflection, spiritual renewal, simple service, and enjoying the small yet most important things in life. This will help you experience and enjoy a sense of gratitude and peace.

next: Eating Disorders: Culture and Eating Disorders
~ eating disorders library
~ all articles on eating disorders

The ICD-10 Classification of Mental and Behavioural Disorders World Health Organization, Geneva, 1992

Contents

F91 Conduct Disorders

F91.0 Conduct Disorder Confined To The Family Context

F91.1 Unsocialized Conduct Disorder

F91.2 Socialized Conduct Disorder

F91 Conduct Disorders:
Conduct disorders are characterized by a repetitive and persistent pattern of dissocial, aggressive, or defiant conduct. Such behaviour, when at its most extreme for the individual, should amount to major violations of age-appropriate social expectations, and is therefore more severe than ordinary childish mischief or adolescent rebelliousness. Isolated dissocial or criminal acts are not in themselves grounds for the diagnosis, which implies an enduring pattern of behaviour.

Features of conduct disorder can also be symptomatic of other psychiatric conditions, in which case the underlying diagnosis should be coded.

Disorders of conduct may in some cases proceed to dissocial personality disorder (F60.2). Conduct disorder is frequently associated with adverse psychosocial environments, including unsatisfactory family relationships and failure at school, and is more commonly noted in boys. Its distinction from emotional disorder is well validated; its separation from hyperactivity is less clear and there is often overlap.

Diagnostic Guidelines
Judgements concerning the presence of conduct disorder should take into account the child's developmental level. Temper tantrums, for example, are a normal part of a 3-year-old's development and their mere presence would not be grounds for diagnosis. Equally, the violation of other people's civic rights (as by violent crime) is not within the capacity of most 7-year-olds and so is not a necessary diagnostic criterion for that age group.

Examples of the behaviours on which the diagnosis is based include the following: excessive levels of fighting or bullying; cruelty to animals or other people; severe destructiveness to property; firesetting; stealing; repeated lying; truancy from school and running away from home; unusually frequent and severe temper tantrums; defiant provocative behaviour; and persistent severe disobedience. Any one of these categories, if marked, is sufficient for the diagnosis, but isolated dissocial acts are not.

Exclusion criteria include uncommon but serious underlying conditions such as schizophrenia, mania, pervasive developmental disorder, hyperkinetic disorder, and depression.

This diagnosis is not recommended unless the duration of the behaviour described above has been 6 months or longer.

Differential diagnosis. Conduct disorder overlaps with other conditions. The coexistence of emotional disorders of childhood (F93.-) should lead to a diagnosis of mixed disorder of conduct and emotions (F92.-). If a case also meets the criteria for hyperkinetic disorder (F90.-), that condition should be diagnosed instead. However, milder or more situation-specific levels of overactivity and inattentiveness are common in children with conduct disorder, as are low self-esteem and minor emotional upsets; neither excludes the diagnosis.

Excludes:

• conduct disorders associated with emotional disorders (F92.-) or hyperkinetic disorders (F90.-)
• mood [affective] disorders (F30-F39)
• pervasive developmental disorders (F84.-)
• schizophrenia (F20.-)

F91.0 Conduct Disorder Confined To The Family Context:
This category comprises conduct disorders involving dissocial or aggressive behaviour (and not merely oppositional, defiant, disruptive behaviour) in which the abnormal behaviour is entirely, or almost entirely, confined to the home and/or to interactions with members of the nuclear family or immediate household. The disorder requires that the overall criteria for F91 be met; even severely disturbed parent - child relationships are not of themselves sufficient for diagnosis. There may be stealing from the home, often specifically focused on the money or possessions of one or two particular individuals. This may be accompanied by deliberately destructive behaviour, again often focused on specific family members—such as breaking of toys or ornaments, tearing of clothes, carving on furniture, or destruction of prized possessions. Violence against family members (but not others) and deliberate fire-setting confined to the home are also grounds for the diagnosis.

Diagnostic Guidelines
Diagnosis requires that there be no significant conduct disturbance outside the family setting and that the child's social relationships outside the family be within the normal range.

In most cases these family-specific conduct disorders will have arisen in the context of some form of marked disturbance in the child's relationship with one or more members of the nuclear family. In some cases, for example, the disorder may have arisen in relation to conflict with a newly arrived step-parent. The nosological validity of this category remains uncertain, but it is possible that these highly situation-specific conduct disorders do not carry the generally poor prognosis associated with pervasive conduct disturbances.

F91.1 Unsocialized Conduct Disorder:
This type of conduct disorder is characterized by the combination of persistent dissocial or aggressive behaviour (meeting the overall criteria for F91 and not merely comprising oppositional, defiant, disruptive behaviour), with a significant pervasive abnormality in the individual's relationships with other children.

Diagnostic Guidelines
The lack of effective integration into a peer group constitutes the key distinction from "socialized" conduct disorders and this has precedence over all other differentiations. Disturbed peer relationships are evidenced chiefly by isolation from and/or rejection by or unpopularity with other children, and by a lack of close friends or of lasting empathic, reciprocal relationships with others in the same age group. Relationships with adults tend to be marked by discord, hostility, and resentment. Good relationships with adults can occur (although usually they lack a close, confiding quality) and, if present, do not rule out the diagnosis. Frequently, but not always, there is some associated emotional disturbance (but, if this is of a degree sufficient to meet the criteria of a mixed disorder, the code F92.- should be used).

Offending is characteristically (but not necessarily) solitary. Typical behaviours comprise: bullying, excessive fighting, and (in older children) extortion or violent assault; excessive levels of disobedience, rudeness, uncooperativeness, and resistance to authority; severe temper tantrums and uncontrolled rages; destructiveness to property, fire-setting, and cruelty to animals and other children. Some isolated children, however, become involved in group offending. The nature of the offence is therefore less important in making the diagnosis than the quality of personal relationships.

The disorder is usually pervasive across situations but it may be most evident at school; specificity to situations other than the home is compatible with the diagnosis.

Includes:

• conduct disorder, solitary aggressive type
• unsocialized aggressive disorder

F91.2 Socialized Conduct Disorder:
This category applies to conduct disorders involving persistent dissocial or aggressive behaviour (meeting the overall criteria for F91 and not merely comprising oppositional, defiant, disruptive behaviour) occurring in individuals who are generally well integrated into their peer group.

Diagnostic Guidelines
The key differentiating feature is the presence of adequate, lasting friendships with others of roughly the same age. Often, but not always, the peer group will consist of other youngsters involved in delinquent or dissocial activities (in which case the child's socially unacceptable conduct may well be approved by the peer group and regulated by the subculture to which it belongs). However, this is not a necessary requirement for the diagnosis: the child may form part of a nondelinquent peer group with his or her dissocial behaviour taking place outside this context. If the dissocial behaviour involves bullying in particular, there may be disturbed relationships with victims or some other children. Again, this does not invalidate the diagnosis provided that the child has some peer group to which he or she is loyal and which involves lasting friendships.

Relationships with adults in authority tend to be poor but there may be good relationships with others. Emotional disturbances are usually minimal. The conduct disturbance may or may not include the family setting but if it is confined to the home the diagnosis is excluded. Often the disorder is most evident outside the family context and specificity to the school (or other extrafamilial setting) is compatible with the diagnosis.

Includes:

• conduct disorder, group type
• group delinquency
• offences in the context of gang membership
• stealing in company with others
• truancy from school

Excludes:

• gang activity without manifest psychiatric disorder (Z03.2)

ICD-10 copyright © 1992 by World Health Organization. Internet Mental Health copyright © 1995-1997 by Phillip W. Long, M.D.

Suggested Diagnostic Criteria For Attention Deficit Disorder In Children

The two most common documents used for the diagnosis of ADD/ADHD are the DSM IV and ICD 10. The DSM IV is used mostly in the United States though it has been used elsewhere, including the U.K., whereas the ICD 10 is more commonly used in Europe. We have included the descriptions of both, as below.

Note: Consider a criterion met only if the behaviour is considerably more frequent than that of most people of the same mental age.

DSM IV (Diagnostic & Statistical Manual) ATTENTION DEFICIT HYPERACTIVITY DISORDER Diagnostic Criteria:

A. Either (1) OR (2)

(1). Six (or more) of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level.

INATTENTION

• (a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities.

• (b) Often has difficulty sustaining attention in tasks or play activities.

• (c) Often does not seem to listen when spoken to directly.

• (d) Often does not seem to follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behaviour or failure to understand instructions).

• (e) Often has difficulty organising tasks and activities.

• (f) Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework).

• (g) Often loses things necessary to tasks or activities (e.g. toys, school assignments, pencils, books, or tools).

• (h) Is often distracted by extraneous stimuli.

• (i) Is often forgetful in daily activities.

(2). Six, or more, of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level.

HYPERACTIVITY

• (a) Often fidgets with hands or feet, or squirms in seat.

• (b) Often leaves seat in classroom or other situation where it is inappropriate (In adolescents or adults, this may be limited to subjective feelings of restlessness).

• (c) Often has difficulty playing or engaging in leisure activities quietly.

• (d) Is often 'on the go' or often acts as if 'driven by a motor'

• (e) Often talks excessively.

IMPULSIVITY

• (f) Often blurts out answers before questions have been completed.

• (g) Often has difficulty awaiting turn.

• (h) Often interrupts or intrudes on others (e.g. butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before the age of 7 years.

C. Some impairment from the symptoms is present in two or more settings (e.g. at school (or work) and at home).

D. There must be clear evidence of clinically significant impairment in social, academic or occupational functioning.

E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder, and are not better accounted for by another mental disorder (e.g. Mood disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Attention Deficit Hyperactivity Disorder - European Description

The ICD-10 Classification of Mental and Behavioural Disorders World Health Organization, Geneva, 1992

Contents

• F90 Hyperkinetic Disorders
• F90.0 Disturbance Of Activity And Attention
• F90.1 Hyperkinetic Conduct Disorder

F90 Hyperkinetic Disorders:
This group of disorders is characterized by: early onset; a combination of overactive, poorly modulated behaviour with marked inattention and lack of persistent task involvement; and pervasiveness over situations and persistence over time of these behavioural characteristics.

It is widely thought that constitutional abnormalities play a crucial role in the genesis of these disorders, but knowledge on specific etiology is lacking at present. In recent years the use of the diagnostic term "attention deficit disorder" for these syndromes has been promoted. It has not been used here because it implies a knowledge of psychological processes that is not yet available, and it suggests the inclusion of anxious, preoccupied, or "dreamy" apathetic children whose problems are probably different. However, it is clear that, from the point of view of behaviour, problems of inattention constitute a central feature of these hyperkinetic syndromes.

Hyperkinetic disorders always arise early in development (usually in the first 5 years of life). Their chief characteristics are lack of persistence in activities that require cognitive involvement, and a tendency to move from one activity to another without completing any one, together with disorganized, ill-regulated, and excessive activity. These problems usually persist through school years and even into adult life, but many affected individuals show a gradual improvement in activity and attention.

Several other abnormalities may be associated with these disorders. Hyperkinetic children are often reckless and impulsive, prone to accidents, and find themselves in disciplinary trouble because of unthinking (rather than deliberately defiant) breaches of rules. Their relationships with adults are often socially disinhibited, with a lack of normal caution and reserve; they are unpopular with other children and may become isolated. Cognitive impairment is common, and specific delays in motor and language development are disproportionately frequent.

Secondary complications include dissocial behaviour and low self-esteem. There is accordingly considerable overlap between hyperkinesis and other patterns of disruptive behaviour such as "unsocialized conduct disorder". Nevertheless, current evidence favours the separation of a group in which hyperkinesis is the main problem.

Hyperkinetic disorders are several times more frequent in boys than in girls. Associated reading difficulties (and/or other scholastic problems) are common.

Diagnostic Guidelines
The cardinal features are impaired attention and overactivity: both are necessary for the diagnosis and should be evident in more than one situation (e.g. home, classroom, clinic).

Impaired attention is manifested by prematurely breaking off from tasks and leaving activities unfinished. The children change frequently from one activity to another, seemingly losing interest in one task because they become diverted to another (although laboratory studies do not generally show an unusual degree of sensory or perceptual distractibility). These deficits in persistence and attention should be diagnosed only if they are excessive for the child's age and IQ.

Overactivity implies excessive restlessness, especially in situations requiring relative calm. It may, depending upon the situation, involve the child running and jumping around, getting up from a seat when he or she was supposed to remain seated, excessive talkativeness and noisiness, or fidgeting and wriggling. The standard for judgement should be that the activity is excessive in the context of what is expected in the situation and by comparison with other children of the same age and IQ. This behavioural feature is most evident in structured, organized situations that require a high degree of behavioural self-control.

The associated features are not sufficient for the diagnosis or even necessary, but help to sustain it. Disinhibition in social relationships, recklessness in situations involving some danger, and impulsive flouting of social rules (as shown by intruding on or interrupting others' activities, prematurely answering questions before they have been completed, or difficulty in waiting turns) are all characteristic of children with this disorder.

Learning disorders and motor clumsiness occur with undue frequency, and should be noted separately when present; they should not, however, be part of the actual diagnosis of hyperkinetic disorder.

Symptoms of conduct disorder are neither exclusion nor inclusion criteria for the main diagnosis, but their presence or absence constitutes the basis for the main subdivision of the disorder (see below).

The characteristic behaviour problems should be of early onset (before age 6 years) and long duration. However, before the age of school entry, hyperactivity is difficult to recognize because of the wide normal variation: only extreme levels should lead to a diagnosis in preschool children.

Diagnosis of hyperkinetic disorder can still be made in adult life. The grounds are the same, but attention and activity must be judged with reference to developmentally appropriate norms. When hyperkinesis was present in childhood, but has disappeared and been succeeded by another condition, such as dissocial personality disorder or substance abuse, the current condition rather than the earlier one is coded.

Differential diagnosis. Mixed disorders are common, and pervasive developmental disorders take precedence when they are present. The major problems in diagnosis lie in differentiation from conduct disorder: when its criteria are met, hyperkinetic disorder is diagnosed with priority over conduct disorder. However, milder degrees of overactivity and inattention are common in conduct disorder. When features of both hyperactivity and conduct disorder are present, and the hyperactivity is pervasive and severe, "hyperkinetic conduct disorder" (F90.1) should be the diagnosis.

A further problem stems from the fact that overactivity and inattention, of a rather different kind from that which is characteristic of a hyperkinetic disorder, may arise as a symptom of anxiety or depressive disorders. Thus, the restlessness that is typically part of an agitated depressive disorder should not lead to a diagnosis of a hyperkinetic disorder. Equally, the restlessness that is often part of severe anxiety should not lead to the diagnosis of a hyperkinetic disorder. If the criteria for one of the anxiety disorders are met, this should take precedence over hyperkinetic disorder unless there is evidence, apart from the restlessness associated with anxiety, for the additional presence of a hyperkinetic disorder. Similarly, if the criteria for a mood disorder are met, hyperkinetic disorder should not be diagnosed in addition simply because concentration is impaired and there is psychomotor agitation. The double diagnosis should be made only when symptoms that are not simply part of the mood disturbance clearly indicate the separate presence of a hyperkinetic disorder.

Acute onset of hyperactive behaviour in a child of school age is more probably due to some type of reactive disorder (psychogenic or organic), manic state, schizophrenia, or neurological disease (e.g. rheumatic fever).

Excludes:

• anxiety disorders
• mood (affective) disorders
• pervasive developmental disorders
• schizophrenia

F90.0 Disturbance Of Activity And Attention:
There is continuing uncertainty over the most satisfactory subdivision of hyperkinetic disorders. However, follow-up studies show that the outcome in adolescence and adult life is much influenced by whether or not there is associated aggression, delinquency, or dissocial behaviour. Accordingly, the main subdivision is made according to the presence or absence of these associated features. The code used should be F90.0 when the overall criteria for hyperkinetic disorder (F90.-) are met but those for F91.- (conduct disorders) are not.

Includes:

• attention deficit disorder or syndrome with hyperactivity
• attention deficit hyperactivity disorder

Excludes:

• hyperkinetic disorder associate with conduct disorder (F90.1)

F90.1 Hyperkinetic Conduct Disorder:
This coding should be used when both the overall criteria for hyperkinetic disorders (F90.-) and the overall criteria for conduct disorders (F91.-) are met.

ICD-10 copyright © 1992 by World Health Organization. Internet Mental Health (www.mentalhealth.com) copyright © 1995-1997 by Phillip W. Long, M.D.

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Evidence is mounting that sleep - even a nap - appears to enhance information processing and learning. New experiments by NIMH grantee Alan Hobson, M.D., Robert Stickgold, Ph.D., and colleagues at Harvard University show that a midday snooze reverses information overload and that a 20 percent overnight improvement in learning a motor skill is largely traceable to a late stage of sleep that some early risers might be missing. Overall, their studies suggest that the brain uses a night's sleep to consolidate the memories of habits, actions and skills learned during the day.

The bottom line: we should stop feeling guilty about taking that "power nap" at work or catching those extra winks the night before our piano recital.

Reporting in the July, 2002 Nature Neuroscience, Sara Mednick, Ph.D., Stickgold and colleagues demonstrate that "burnout" - irritation, frustration and poorer performance on a mental task -- sets in as a day of training wears on. Subjects performed a visual task, reporting the horizontal or vertical orientation of three diagonal bars against a background of horizontal bars in the lower left corner of a computer screen. Their scores on the task worsened over the course of four daily practice sessions. Allowing subjects a 30-minute nap after the second session prevented any further deterioration, while a 1-hour nap actually boosted performance in the third and fourth sessions back to morning levels.

Rather than generalized fatigue, the researchers suspected that the burnout was limited to just the brain visual system circuits involved in the task. To find out, they engaged a fresh set of neural circuitry by switching the location of the task to the lower right corner of the computer screen for just the fourth practice session. As predicted, subjects experienced no burnout and performed about as well as they did in the first session -- or after a short nap.

This led the researchers to propose that neural networks in the visual cortex "gradually become saturated with information through repeated testing, preventing further perceptual processing." They think burnout may be the brain's "mechanism for preserving information that has been processed but has not yet been consolidated into memory by sleep."

So how might a nap help? Recordings of brain and ocular electrical activity monitored while napping revealed that the longer 1-hour naps contained more than four times as much deep, or slow wave sleep and rapid eye movement (REM) sleep than the half-hour naps. Subjects who took the longer naps also spent significantly more time in a slow wave sleep state on the test day than on a "baseline" day, when they were not practicing. Previous studies by the Harvard group have traced overnight memory consolidation and improvement on the same perceptual task to amounts of slow wave sleep in the first quarter of the night and to REM sleep in the last quarter. Since a nap hardly allows enough time for the latter early morning REM sleep effect to develop, a slow wave sleep effect appears to be the antidote to burnout.

Neural networks involved in the task are refreshed by "mechanisms of cortical plasticity" operating during slow wave sleep, suggest the researchers. "Slow wave sleep serves as the initial processing stage of experience-dependent, long-term learning and as the critical stage for restoring perceptual performance."

The Harvard team has now extended to a motor-skill task their earlier discovery of sleep's role in enhancing learning of the perceptual task. Matthew Walker, Ph.D., Hobson, Stickgold and colleagues report in the July 3, 2002 Neuron that a 20 percent overnight boost in speed on a finger tapping task is accounted for mostly by stage 2 non-rapid eye movement (NREM) sleep in the two hours just before waking.

Prior to the study, it was known that people learning motor skills continue to improve for at least a day following a training session. For example, musicians, dancers and athletes often report that their performance has improved even though they haven't practiced for a day or two. But until now it was unclear whether this could be ascribed to specific sleep states instead of simply to the passage of time.

In the study, 62 right-handers were asked to type a sequence of numbers (4-1-3-2-4) with their left hand as rapidly and accurately as possible for 30 seconds. Each finger tap registered as a white dot on a computer screen rather than the number typed, so subjects didn't know how accurately they were performing. Twelve such trials separated by 30-second rest periods constituted a training session, which was scored for speed and accuracy.

Regardless of whether they trained in the morning or the evening, subjects improved by an average of nearly 60 percent by simply repeating the task, with most of the boost coming within the first few trials. A group tested after training in the morning and staying awake for 12 hours showed no significant improvement. But when tested following a night's sleep, their performance increased by nearly 19 percent. Another group that trained in the evening scored 20.5 percent faster after a night's sleep, but gained only a negligible 2 percent after another 12 hours of waking. To rule out the possibility that motor skill activity during waking hours might interfere with consolidation of the task in memory, another group even wore mittens for a day to prevent skilled finger movements. Their improvement was negligible -- until after a full night's sleep, when their scores soared by nearly 20 percent.

Sleep lab monitoring of 12 subjects who trained at 10 PM revealed that their improved performance was directly proportional to the amount of stage 2 NREM sleep they got in the fourth quarter of the night. Although this stage represents about half of a night's sleep overall, Walker said he and his colleagues were surprised at the pivotal role stage 2 NREM plays in enhancing learning of the motor task, given that REM and slow wave sleep had accounted for the similar overnight learning improvement in the perceptual task.

They speculate that sleep may enhance motor skill learning via powerful bursts of synchronous neuronal firing, called "spindles," characteristic of stage 2 NREM sleep during the early morning hours. These spindles predominate around the center of the brain, conspicuously near motor regions, and are thought to promote new neural connections by triggering an influx of calcium into cells of the cortex. Studies have observed an increase in spindles following training on a motor task.

The new findings have implications for learning sports, a musical instrument, or developing artistic movement control. "All such learning of new actions may require sleep before the maximum benefit of practice is expressed," note the researchers. Since a full night's sleep is a prerequisite to experiencing the critical final two hours of stage 2 NREM sleep, "life's modern erosion of sleep time could shortchange your brain of some learning potential," added Walker.

The findings also underscore why sleep may be important to the learning involved in recovering function following insults to the brain's motor system, as in stoke. They also may help to explain why infants sleep so much. "Their intensity of learning may drive the brain's hunger for large amounts of sleep," suggested Walker.

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This is taken from Attention Research Update written by David Rabiner, Ph.D. This really is a fantastic resource which is well worth signing up to receive, it is also free to subscribe so you can't go wrong can you and you can gain regular updates of information and news of new research

The Multimodal Treatment Study of ADHD (MTA Study) is the largest ADHD treatment study ever conducted. A total of 597 children with ADHD-Combined Type (i.e., they had both inattentive and hyperactive-impulsive symptoms) were randomly assigned to 1 of 4 treatments: medication management, behavior modification, medication management + behavior modification (i.e., combined treatment), or community care (CC). Medication treatment and behavior therapy were selected because they had the most extensive evidence-base to support their efficacy, and alternative and/or less well-established ADHD treatments were not investigated.

The medication and behavioral treatment provided in the MTA study were far more rigorous than what children typically receive in community settings. Medication treatment began with an extensive double-blind trial to determine the optimum dose and medication for each child, and the ongoing effectiveness of children's treatment was carefully monitored so that adjustments could be made when necessary. The behavioral intervention included over 25 parent training sessions, an intensive summer camp treatment program, and extensive support provided by paraprofessionals in children's classrooms. In contrast, children in the community care condition (CC) received whatever treatments parents opted to pursue for their child in the community. Although this included medication treatment for the majority of children, it appeared that this treatment was not conducted with the same rigor as with children who received medication treatment from the MTA researchers.

The initial results from this landmark study examined children's outcomes 14 months after treatment began. Although results from this complex study do not lend themselves to a brief summary, the overall pattern suggested that children who received intensive medication management - either alone or in combination with behavior treatment - had more positive outcomes than children who receive behavior therapy alone or community care. Although this was not true for all the different outcome measures considered (e.g., ADHD symptoms, parent-child relations, oppositional behavior, reading, social skills, etc.) it was the case for primary ADHD symptoms as well as for a composite outcome measure that included measures from a broad array of different domains. There was also modest evidence that children who received combined treatment were doing better overall than children who received medication treatment alone.

In terms of the percentage of children within each group who were no longer showing clinically elevated levels of ADHD symptoms and symptoms of oppositional defiant disorder, results indicated that 68% of the combined group, 56% of the medication only group, 33% of the behavior therapy group, and only 25% of the community care group had levels of these symptoms that fell in the normal range. These figures highlight that intensive medication treatment was more likely to result in a normalized level of core ADHD and ODD symptoms than either behavior therapy or community care, and that combined treatment was associated with the highest rate of "normalization".
(For a more complete description of MTA treatments and the initially reported outcome results, please visit http://parentsubscribers.c.topica.com/maaclGpaa7D1Ub3aW2hb).

As noted above, the results previously reported for the MTA Study cover the period out to 14 months after children's treatment began. An important, but as yet unanswered question, is the extent to which treatment benefits persisted after children were no longer receiving the intensive treatments provided in the study. For example, did the benefits associated with carefully conducted medication treatment persist once children's treatment was no longer being monitored through the study? And, was there persistent evidence that the combination of careful medication treatment and intensive behavior therapy was superior overall to medication treatment alone?

The persistent effects of MTA treatments were examined in a study published recently in Pediatrics (MTA Cooperative Group, 2004. National Institute of Mental Health Multimodal Treatment Study of ADHD: 24-Month Outcomes of Treatment Strategies for ADHD, 113, 754-760.). In this report, the MTA researchers examined how children were faring 10 months after all study-related treatments had ended. During these 10 months, children were no longer receiving any treatment services from the researchers; instead, they received whatever interventions their parents selected for them from providers in their community.

Thus, children who had received medication treatment through the study may or may not have continued on medication. And, if their parents chose to continue medication treatment, they were no longer carefully monitored by MTA researchers so that treatment adjustments could be made when indicated. Similarly, children who received intensive behavior therapy were no longer be receiving such treatment through the study. Parents of these children could thus continue with behavioral intervention in whatever way they were able to. Or, they may have opted to begin treating their child with medication.

To examine whether treatment benefits persisted, the MTA researchers examined 24-month follow-up data on children in 4 different domains: core ADHD symptoms, symptoms of Oppositional Defiant Disorder (ODD; for a discussion of ODD please visit http://parentsubscribers.c.topica.com/maaclGpaa7D1Vb3aW2hb/), social skills, and reading. They also examined whether parents' use of negative ineffective discipline strategies differed according to children's initial treatment assignment.

RESULTS

In general, results from the 24-month outcome analyses were similar to those found at 14 months. For core symptoms of ADHD and ODD, children who had received intensive medication treatment - either alone or in combination with behavior therapy - had superior outcomes to those who received intensive behavior therapy only or community care. Some, but not all of the persistent benefit of having received intensive medication treatment depended on whether children received medication for some portion of the 10-month interval since study treatment services had ended.

Compared to the magnitude of the differences that were evident at 14 months the superior outcomes for children who had received medication treatment from the researchers was reduced by about 50%. Children who had received combined treatment were not doing significantly better than those who received intensive medication treatment alone. And, those who received intensive behavioral treatment were not doing better than children who had received routine community care.

In order to better understand the clinical significance of these findings, the researchers examined the percentage of children in each group who had levels of ADHD and ODD symptoms at 24 months that fell within the normal range. These percentages were 48%, 37%, 32%, and 28% for the combined, medication only, behavior therapy, and community care groups respectively. Thus, as was found at the 14-month outcome assessment, normalization rates of ADHD and ODD symptoms was highest among children whose treatment included the intensive MTA medication component. It is noteworthy, however, that while the percentages of children with normalized symptom levels were essentially unchanged for the behavior therapy and community care groups, they had declined substantially for the combined (i.e., from 68% to 47%) and medication only (i.e., from 56% to 37%) groups.

For the other domains examined - social skills, reading achievement, and parents use of negative/ineffective discipline strategies there was no evidence of significant treatment group differences in 24-month outcomes. In the social skills domain, however, children who received combined treatment tended to be doing better than children who received intensive medication treatment alone. Similar results were found for parents' use of negative/ineffective discipline. Thus, there continued to be some indication that combined treatment may have been more effective in some domains that medication management only.

As a final analysis, the researchers examined the use of medication treatment for children in each group at the 24-month outcome period. Seventy percent of children in the combined group and 72% of children in the medication only group were still taking medication. In contrast, 38% of children in the behavior therapy group had been started on medication and 62% of children who received community care were on medication. The doses being received by children who had received medication treatment from MTA researchers were higher than for other children.

SUMMARY AND IMPLICATIONS

Results from this study indicate the persistent superiority of the intensive MTA medication treatment for ADHD and ODD symptoms, even after families were left to pursue whatever treatments they preferred and the intensive study-related treatments were replaced with care provided by community physicians. Although these persistent benefits are encouraging, it must be noted that they were less robust than they had been at the 14-month outcome assessment. In addition, there was no evidence that intensive medication treatment was associated with better 24-month outcomes in the other domains examined. Overall, therefore, it appears that the persistent benefits associated with carefully conducted medication treatment were relatively modest.

One likely reason for the dimunition in benefits associated with MTA medication treatment is that a number of children ended medication treatment completely after study-delivered services ended. In addition, it is unlikely that children who continued on medication received the same level of treatment monitoring as had been provided by MTA physicians. Had this careful monitoring of ongoing medication treatment effectiveness continued, it is possible that these children would have continued to do ever better than was found to be the case.

Although children who had received intensive behavior therapy alone were not faring quite as well, a substantial percentage, i.e., 32%, continued to show normalized levels of ADHD and ODD symptoms. Thus, this is additional evidence for the utility of behavior therapy for ADHD. It should be noted, however, that many parents whose child had received behavior therapy chose to begin medication treatment for their child.

In conclusion, results from this study indicate that the benefits of high quality medication treatment persist to some extent even when this treatment is no longer being provided. Although the persistent benefits were modest at best, the MTA authors note that even these modest effects may have important public health benefits. The results also suggest that even intensive multimodal treatment conducted over an extended period does not eliminate the adverse impact of ADHD for most children, and that high quality treatment services provided over many years is likely to be required to help most children reach their full potential.

Finally, these results highlight the pressing need to develop new interventions for ADHD whose efficacy is established through carefully conducted research. Even when provided in the most rigorous way possible, medication and behavior therapy were not successful in normalizing levels of ADHD and ODD symptoms for a large percentage of children. Thus, it seems very important for researchers to focus attention on developing alternative ADHD interventions, and perhaps to strategies for preventing the development of ADHD in the first place.

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