Could Treatment-Resistant ADHD Be a Matter of Personality?

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Of the diagnoses sporting treatment-resistant proneness, ADHD is a top contender. Recent estimates (Chen and colleagues, 2019) put ADHD at a 20-40 percent treatment resistance rate. While treatment-resistant depression is narrowly defined as two antidepressant failures, where the line is drawn for ADHD has not, as far as I could find, been clearly delineated. Regardless, if one works with children and families, chances are, they've encountered frustrated patients who, regardless of medication, therapy, and effort, experienced little relief.

Provided there's no medical condition or substance-related culpability and that trauma, anxiety, and chronic depression, all of which can ostensibly present as ADHD, have been ruled out, what's left?

The hypomanic, or exuberant, personality is a distinct possibility.

The hypomanic personality

As expanded on in an earlier post, this personality style was distinctly recognized by historical giants like Bleuler and Schneider. Called hyperthymic personalities in that earlier time, such individuals were described as exhibiting baseline hypomanic traits and characteristics, with no true cycling mood episodes.

Marked by restlessness, a need for novelty and stimulation, being cognitively scattered, and a cheerful affect that can quickly become irritated, it might be what was referred to as a cyclothymic personality in the DSM-II and DSM-III. Unfortunately, in those days, conditions received a mere few sentences of description. Therefore, it's hard to differentiate if cyclothymic personality was simply a precursor name to cyclothymia (more clearly delineated baseline moods and not as enduring as a personality, as discussed in this post) or a catch-all for anything not of true bipolar proportions.

Provided the DSM is the most popular diagnostic resource, it is no surprise that such a personality has, outside of a niche few (for example, Karam and colleagues, 2010; Akiskal, 2011; Millon, 2011; McWilliams, 2013), gone unrecognized after the DSM-III update.

But updates are not always improvements.

The hypomanic personality, for instance, is believed by some modern researchers to be a valuable component to gaging risk of later full bipolar episodes and thus could play a role in prevention practices (for example, Blechert and Meyer, 2010). Analysts continue to find it useful to recognize as a defensive framework against poor self-image (McWilliams, 2013).

As someone with a chief clinical interest in personality, and who has evaluated myriad youth with alleged ADHD whose symptoms never improve, I can't help but notice that some of these cases suggest youth with hypomanic personalities. ADHD intervention hasn't worked because medication can't fix personality, nor can ADHD coping skills. Continuing to ignore this personality type might just be robbing some populations of better treatment outcomes.

Assessing ADHD vs Hypomanic Personality

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Unfortunately, it will likely not be until high school or young adulthood that any differential clarity can be established. This is not only because the conditions share such close similarities, but ADHD treatment may not commence until well along in elementary or into middle school, and it can take several years to establish a clear record that interventions, despite effort and compliance, aren't effective.

Curious clinicians should pay attention to the following clues to differentiate a possible hypomanic personality from ADHD:

• A teen or young adult presents with seemingly implacable "ADHD" symptoms despite a childhood full of ADHD intervention attempts.
• There's no family history of ADHD, and pregnancy risk factors, like maternal smoking, preeclampsia, or gestational diabetes aren't in the gestational history.
• Not only are "ADHD" symptoms present, but the person exhibits an established inflated sense of self-worth or grandiosity. This is unusual in people significantly impaired by ADHD, as they often feel like an outcast for lack of achievement or needing a lot of assistance to achieve what their peers do naturally.
• The restlessness includes minimal sleep requirements to function optimally. While people with ADHD might have a hard time relaxing to get to sleep, they nonetheless require it and often sleep well once asleep. The hypomanic personality can seem like someone in a traditional hypomanic episode when a mere few hours per night suffices.
• People with ADHD are stimulation-seeking, but someone with a hypomanic personality is likely to exhibit a general, devil-may-care attitude. This could manifest in endeavors like risk-taking in the name of productivity, perhaps taking out a big loan for a project with little chance of success, or starting numerous big idea projects that never gain traction. When reflecting on the poor impulse control and handling of the ideas, the person responds cheerily that at least they tried. They don't learn from their mistakes.
• Those with ADHD can be irritable, often as a result of low frustration tolerance. However, someone with a hypomanic personality tends to have a more mercurial mood with a particular penchant for irritability. Millon (2011) explained the inherent moods of this personality as frequently, "notably volatile and quicksilverish, at times unduly ebullient, charged up and irrepressible." Others, detailed Millon, may appear emotionally stable, but experience periodic superimposed emotional explosions similar to what the DSM refers to as intermittent-explosive disorder.
• Lastly, people with this personality tend to have a history of repeated traumatic separation that was never emotionally processed (McWilliams, 2013). This personality, according to McWilliams, can be conceptualized as a shield of denial for someone who is depressed at their core, and thus a defense. Considering this, standardized testing will likely indicate depressive material lurking just beneath the surface. It's not unusual that this shield can only be held for so long before the person is exhausted and experience a significant depressive spell. Thus, another clue is that the person's baseline "ADHD" is occasionally punctuated with a major depressive episode.

Treatment Implications

If treatment-resistant ADHD could be a matter of personality, the therapist might consider shifting to a focus on the affective experiences of the patient, be it irritability or depressive episodes. It might help to shift by explaining that their history of unsuccessful interventions, coupled with the established pattern of moodiness, suggest that, what seemed like ADHD in earlier years could well be part of a mood pattern.

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Next, as treatment shifts, it must be considered that the bulk of ADHD intervention is behavior-focused. Some therapists are also familiar with addressing affective matters like irritable reactivity or depression-anxiety corollary to the ADHD struggles. Thus, they may have a leg up if they choose to continue working with someone with a hypomanic personality. This is because it will be important to engage in exploratory work to learn more about the patient's emotional landscape. Shifting to a more relational approach to this can help in establishing a deeper trust that may allow this defensive individual to be vulnerable and share painful histories full of conflicts that were never resolved that influence their ongoing struggle.

From this exploration and sharing, which might require much patience, the therapist can then hopefully guide the patient into resolutions, dismantling the need to further hide behind the maladaptive, hypomanic mask.

Disclaimer: The material provided in this post is for informational purposes only and is not intended to diagnose, treat, or prevent any illness in readers or people they know. The information should not replace personalized care or intervention from an individual’s provider or formal supervision if you’re a practitioner or student.