As a part of the medical diagnosis, both the DSM and ICD list 3 Sub ADHD Types, Hyperactive, Inattentive and Combined. This is more of a description on how you look to others, and not much help to the individual who has been diagnosed. Here we will cover both what the medical descriptor categories mean and some categories that I find helpful.
For more about ADHD, check out our selection: ADHD Page [Link]
DSM and ICD, Hyperactive, Inattentive and Combined
When ADHD was added to the DSM in 1968, the goal was primarily to help mental health diagnosticians to recognise the neurologicaly condition of ADHD. Consider that people did not yet know why some people had these attention problems, and why the recent discovery of some medications that helped actually helped those people. The goal in adding ADHD was to help the diagnostician recognise and diagnose ADHD, and as such, the description of the two major presentations was useful. ADHD presentation, that is what we see from the outside, exists on a spectrum of kinesthetically hyperactive to mostly still and phazed out.
The Hyperactive ADHD subtype can initially seem a bit redundant, after all, ADHD literally stands for Attention Deficit Hyperactivity Disorder. Brain scans have shown that the ADHDer has a hyperactive brain, which we now know is an attempt to compensate for insufficient Dopamine availability, and that this will sometimes present kinesthetically, that is in physical movement.
People who struggle with physical hyperactivity will also often have action impulse control problems. Action impulse control is about filtering your thoughts before taking action. We consider many things that we can do about a situation, some of them can be absurd, some can be wise, some can be helpful and some not so much. When we can filter these ideas, we try to select what seems wise and helpful. When we cannot filter the thoughts, the idea that hits first or seems loudest is the action we take. Often, afterwards, the person struggling with action impulse control won’t be able to fully explain why they selected this action to take.
There are other kinds of impulse control problems that are not often considered to be a part of the kinesthetic hyperactive subtype, such as over spending, gambling, gaming and addiction problems that are not considered to be the “kinesthetic hyperactive impulse control” problems.
The Inattentive ADHD subtype describes how a person may be relatively still in body movement and slow to act/react to situations, thus also not seeming to have the action impulse control issues discussed above. Frequently this person will seem to be inattentive to the local situation, perhaps gazing a million miles away or out a window, perhaps listening to a conversation several tables away instead of to you, or just disassociated.
A more careful look at the person will often show that they are frequently quietly stimming or fidgetting. The gross mechanical movements a person may use to compensate for low Dopamine have been optimised into a form that is easier to hide. Some people have muted the movements entirely (or never really had them), which often correlates with greater phasing out/dissassociation.
Phasing out is where you lose focus of the situation/conversation/task and then phase back in.
The Combined ADHD subtype is the most common. This is where the ADHDer will have times where they are kinesthetically hyperactive (lots of gross body movements) and will phase out and lose focus on the tasks, especially when being still.
Often a person will be given this subtype when their answers on the ADHD questionaires (Conners or ASRS1.1 etc) indicate both action impulse control problems, gross motor movements and loss of attention when attention was warranted.
This subtype is more about what the diagnostician perceives than what is going on internally for the ADHDer. It can feel validating to know that the reason you struggle to sit still is that you are kinesthetically hyperactive, or that the reason you keep phazing out is because you are inattentive. However, these subcategories don’t really help you know what to do about it, help in any particular treatment plan or describe what it is like to be you.
- Disassociation in ADHDers is most commoly a result of low dopamine availability to the Executive Function, a combination of brain centres that form your ability to focus, understand, plan and retain temporary information. There are some other reasons why you might be disassociating, so if this persists past dopamine medication, talk to your psychiatrist about it.
- Diassociation is feeling distant like you are remote controlling your body often with bad lag; loss of conscious time while your body is running on autopilot; emoitional numbness; very strong brain fog (brain fog is where it feels like your thinking is heavy, hard or a struggle)
- Kinesthetic Hyperactivity, and fidgetting are indicators of trying to increase adrenaline, either because the neurological norepinephrine neutrotransmitter is low, or because you are subconsciously trying to use adrenaline to substitute for low dopamine. Stimulant medication often helps to reduce this need, by either increasing the dopamine availability, and increasing the background available norepinephrine neurotransmitter levels.
- Action Impulse Control issues are often also an indicator of low dopamine as you find it difficult to process the pros and cons of the decision list your brain has given you, so the choice is either random, or adrenaline seeking (the choice with the highest adrenaline kick). It is an instinctive choice rather than a reasoned one.
- “Inattention” has three common causes when it is mistaken disassociation.
- Mild to moderate brain fog – it is hard to follow what is happening, so you tune out a bit and just “go with the flow” [Dopamine]
- Difficulty holding on to temporary information, chronic “why am I in this room?” except it may be “why am I in this conversation?”, “what was I doing?”, “where did I put that thing?” [Dopamine]
- Cognitive fatigue, where you have run out of ability to understand the situation. Another way to look at this is that ADHDers are like Greyhounds – the fastest couch potatoe on Earth. If there is something to chase/do, 100% effort is put into it; but if the thing isn’t interesting/important enough to do, you become 1 with the couch, simply because there isn’t enough Dopamine and Norepinephrine to waste on unimportant things.
- This can be exacerbated by Auditory Processing diffiuclties – where other sounds can interfer with turning a persons sounds into words, which can lead to many words being missed, or cognitive fatigue in trying to compensate.
- Unimportant is frequently measured in anciety human survivability rather than modern civilisation measures, where everything is considered important even if it doesn’t immediately harm you. Things that seem like “fun” or “dangerous” are often seen as “important”.
Three Useful Classification Systems
While there are many ways that we could do this, I present to you 3 useful classifications. The first two are from a Medical perspective, the last is more helpful from a thereapeutic pathway perspective.
Humans like to compiled classifications as an efficient way to make decisions. While helpful, the problem with this is that we then want everyone to neatly fit into these categories, rather than using the categories as decision aids and noting when someone doesn’t fit neatly into the categories. Categories are only useful if they help – they can hinder self-assessment when they don’t fit well. Don’t get too caught up on these having to be exactly right for you or the person you are thinking about.
ADHD Type 1, 2 and 3
This classification looks at the two major ADHD neurotransmitters, Dopamine and Norepinephrine. In brief, all ADHDers struggle to get enough functional Dopamine in the brain centres collectively referred to as the Executive Function. If you are not struggling with Dopamine availability (not enough), then you don’t have ADHD. Dopamine is a natural hormone that your body creates from both your adrenal gland in your torso, and separately in your brain to use as a neurotransmitter. Neuronal Dopamine is the first in a castcade of neurotransmitters in the dopaminergic system, where each link in the chain cascade is the source ingredient for the next link.
Norepinephrine is the next link in this chain. It is a key neurotransmitter used to filter your perception of the current or expected situation and make a survival assessment that is recognised as a “feeling” (fear, anger, joy, sadness, disgust and surprise) [Link – More on a breakdown of these here], and connecting your wants/choices to actions.
Neurology is hideously complex, so please be aware that this description is a simplification for general usefulness.
ADHD Type 1
Insufficient Dopamine is being released in the brain, which means that there isn’t enough to make sufficient levels of Norepinephrine.
Type 1 ADHDers often requires amphetamine medication to agitate the release of more Dopamine. It Will also act as a Dopamine Reuptake Inhibitor, which both increases the amount of Dopamine release and the amount ofDopamine availability in the brain. Secondarily, amphetamine medication acts as a mild Norepinephrine Reuptake Inhibitor. Now that enough of the first link in the chain is being released, given a bit of time, there is now enough Dopamine to make enough Norepinephrine. Due to the Reuptake Inhibition, the relevant brain centres can user the Neurotransmitter more easily. Sometimes this ADHDer can benefit from a stronger Norepinephrine Reputake Inhibitor.
Type 1 ADHDers often struggle with brain fog, kinesthetic hyperactivity, action impulse control and mood regulation. There is commonly a chaotic disorganised feel to the ADHDer.
ADHD Type 2
Sufficient Dopamine is being released in the brain, however it is being co-opted by Nor-epinephrine and Epinephrine/adrenaline production.
Type 2 ADHDers will find that amphetamine medication does work initially, but often leads to feeling mood flat, having odd thoughts, bruxism (jaw grinding, tighening of the jaw muscles or tight face), an increase in anxiety, an increase in aggression, too much hyperfocus (unable to stop doing a task) and so on.
Type 2 ADHDers will find that methylphenidate (Ritalin) medication works much better, as it doesn’t agitate the brain to release more Dopamine, it only acts as a Dopamine Reuptake Inhibitor, giving the brain access to the Dopamine that was released better and slowing down its transfer to Norepinephrine. Ritalin also acts as a weak Norepinephrine Reuptake Inhibitor, which helps the availability of Norepinephrine for mood management and slows down the neurological drive to quickly transform released Dopamine into Norepinephrine.
Frequently this ADHDer can benefit from a stronger Norepinephrine Reputake Inhibitor.
Type 2 ADHDers often struggle with general anxiety, more often social anxiety, anger filters, and aggression responses. This ADHDer is often drawn to drama, or has drama drawn to them, as the adrenaline of this drama is being used to compensate for the low Dopamine availability. Other adrenaline seeking behaviours can often be seen, such as too much fitness, thrill seeking, and working in industries that are more dangerous.
Type 2 ADHDers are the most often sub-type mistaken for Borderline Personality Disorder or Bipolar Affective Disorder, but not exclusively so (can be any of these). This is often due to the drama side and the black and white thinking that adrenaline brain brings (fight/flight).
ADHD Type 3
Type 3 ADHDers don’t fit the major two categories. Three subcategories for here: A, B and C.
T3A don’t respond well to amphetamine or methylphenidate medications, even though they show all of the expected ADHD traits and family history. Often this leads to the use of indirect Dopamine modification medications such as guanfacine, agomelatine and/or only using NRI medication.
T3B get the primary benefits from the two major categories of Dopamine modifying medications (amphetamine and methylphenidate) but have too much Norepinephrine and or Epinephrine/Adrenaline production. This is characterised by clearer thinking with the Dopamine medications, but too much anxiety, aggression, bruxism side effect. This is often managed by a adrenergic suppressant such as Clonidine (brain anxiety), Metoprolol (body anxiety) or Alpha/Beta Blockers. This gets far too complex and person specific to adequately cover here.
T3C are very complex and need very specific work with a talented ADHD psychiatrist to work through the various complexities of neurochemistry. That is, the person shows all of the right signs to be considered an ADHDer, but there are complexities around how their brains work and react to medications.
Category 1, 2 and 3
This categorisation system helps to look at the “severity” of ADHD experienced by the person. I use scare quotes around the “severity” because this is just not a good way to define ADHD, but it is a concept people are familiar with. What we are looking at here is how much a person may need medications based on their non-medicated experience.
This ADHDer clearly has the traits for ADHD. Through careful diet (avoiding foods that destabilise mood or exacerbate brain fog), good exercise, good social environment, rewarding work place and careful use of legal substances (alcohol, caffeine etc) this ADHDer is experiencing a Good Quality of Life with frequent enjoyment.
Some ADHDers do manage to get to this when their brains Dopamine insufficiency is mild enough to be managed via good lifestyle and good personal skills. We aren’t born with these skills, they need to be developed over time and optimised to a point where they do not pose an overall cost that leaves the person in deficit. Many ADHDers cannot get to this category.
Medication wise, if you are doing fine without medication, don’t take any. That being said, beware of self-delusion. Two major self-delusions I come across with people who insist that this describes them, when it doesn’t:
Delusion 1: Substances / Addiction. If you are using cannabis, excess alcohol, nicotine, excess caffeine (more than 200 mg daily or equivalent [energy drinks use caffeine analogues they often don’t have to declare, so daily energy drink counts as caffiene misuse]), gambling, daily pornography, substance addictions etc, then you are self medicating, and likely doing so in an unhealthy manner.
Delusion 2: Denial / Lack of Insight. If you are constantly in therapy, or the people around you are suffering from your behaviours, then likely you are not Category 1.
You are doing all of the things in Category 1 and you are struggling to have or maintain Quality of Life. We are not here to exist, we are here to live. Living means having many times a month that you are happy, general contentment and only a few times of strong stress / distress.
Struggling with task completion, anxiety (general anxiety and more often social anxiety), negative self talk, suicidal ideation and self harm practices, questionable substance use, behaviour problem lapses, frequent therapy, a diagnosis of BPD, PTSD or BPAD that resist treatment and feeling like you are always behind everyone else/where you should be are strong indicators that you are here.
At this level, formal medication is warranted. This might be achieved by GP level medications such as Sertraline (helps cognition if this is your primary struggle), Desvenlafaxine (helps mood if this is your primary struggle) but often you will benefit much better for the direct Dopamine medications (amphetamine and methylphenidate).
No medication, no function. Being a bit less trite, your daily quality of life is poor, chaotic, distressful and often described as disasterous. While not everyone in this category has an addiction problem, most do.
Some psychiatrists recommend that ADHDers take occasional “medication break days” (which should be no more than 2 days a month for most). If you are in this category medication free, my general advice is don’t. You might be safe to take a slightly reduced dose (perhaps 10-50% depending), but not a ceasation.
This Cateogory system is used to help you self-evaluate where you are at. Have you achieved the Quality of Life without Medication (including self-medication)? Or do you need Medication to turn a Poor Quality of Life (Category 2) or Dysfunctional Quality of Life (Category 3) into a meaningful Quality of Life (Category 1)?
ADHD is congenital (you are born with it) and is life long. You don’t grow out of it, you don’t get over it, but you can adapt your life to working better with ADHD and be quite happy. This most often needs medication to manage that Nature side of ADHD, while the Nurture side of ADHD is based on skills, positive social environment, good nutrition, good exercise and knowing yourself well. It can be impossible to learn the Nurture side without the Nature side being managed properly, and it is important to recognise that medication alone isn’t the whole solution.
I want to be careful here, as Personality Types is the psychologists equivalent of Astrology – it sounds meaningful, it seems to apply to everybody, but it is essentially meaningless and useless.
What I am describing here is the 6 most common “people feels” / management characteristic categories / persona traits that are noted when looking at an ADHDer that is undiagnosed, unmedicated and generally not managing themself. These are likely to be mistaken as a persons personality, even though this is NOT actually there personality, this is them surviving.
Please note, the central personality qualities of the person do not change with medication and therapy, only the poor self-management methods. If you are taking medication and or getting therapy and you don’t like who you are becoming, then it is likely that either the medication isn’t right for you (70%+) or the therapist’s goals and your goals don’t align.
Anxious People Pleaser
Social anxiety, Rejection Sensitivity, Conflict Avoidant, People Pleasing, Mediator, Over achiever, Perfectionist, OCD,
Strong Negative Self-Talk Track.
Often mistkaen for OCD, GAD
Depressed Emo Self Harmer
Low to no enjoyment, prefers to be alone doing very little, self harm and suicidal ideation are common.
Strong Negative Self-Talk Track.
Often mistaken for Depressed.
Self centred, power hungry, reality distortion field and truth is a variable idea. Often mistaken for NPD and Socialpathic/Psychopathic.
Nothing Else Matters
Punishments don’t work, because they don’t care. Rewards are not a driver, because while they do enjoy them, not enough to do something to get it.
Dramatic, adrenalin seeking, escapist
Which includes Workaholic
Anger management struggles, PDA, ODD, Break the System, Revolutionary, “Does not work well with others”, often mistaken for ASPD
Generally the Creative Arts, often a prolific producer, sometimes perfectionistic
Describes itself, won’t take “pharma drugs”, but happy to take “natural remedies” that are far more toxic.