Tuesday, March 24, 2009

The 4 Fs of Complex PTSD Trauma Typology

Here is the other article posted in its entirety which can be found at the following link http://www.pete-walker.com/fourFs_TraumaTypologyComplexPTSD.htm

In medical school they teach about the 4 Fs which are functions of the hypothalamus: fight, flight, feeding and reproductive urges.  This article terms these actions as fight, flight, freeze and fawn.

The 4Fs: A Trauma Typology in Complex PTSD By Pete Walker

This paper describes a trauma typology for differentially diagnosing and treating Complex Post Traumatic Stress Disorder. This model elaborates four basic defensive structures that develop out of our instinctive Fight, Flight, Freeze and Fawn responses to severe abandonment and trauma (heretofore referred to as the 4Fs). Variances in the childhood abuse/neglect pattern, birth order, and genetic predispositions result in individuals "choosing" and specializing in narcissistic (fight), obsessive/compulsive (flight), dissociative (freeze) or codependent (fawn) defenses. Many of my clients have reported that psychoeducation in this model has been motivational, deshaming and pragmatically helpful in guiding their recovery.

Individuals who experience "good enough parenting" in childhood arrive in adulthood with a healthy and flexible response repertoire to danger. In the face of real danger, they have appropriate access to all of their 4F choices. Easy access to the fight response insures good boundaries, healthy assertiveness and aggressive self-protectiveness if necessary. Untraumatized individuals also easily and appropriately access their flight instinct and disengage and retreat when confrontation would exacerbate their danger. They also freeze appropriately and give up and quit struggling when further activity or resistance is futile or counterproductive. And finally they also fawn in a liquid, "play-space" manner and are able to listen, help, and compromise as readily as they assert and express themselves and their needs, rights and points of view.

Those who are repetitively traumatized in childhood however, often learn to survive by over-relying on the use of one or two of the 4F Reponses. Fixation in any one 4F response not only delimits the ability to access all the others, but also severely impairs the individual's ability to relax into an undefended state, circumscribing him in a very narrow, impoverished experience of life. Over time a habitual 4F defense also "serves" to distract the individual from the accumulating unbearable feelings of her current alienation and unresolved past trauma.

Complex PTSD as an Attachment Disorder
Polarization to a fight, flight, freeze or fawn response is not only the developing child's unconscious attempt to obviate danger, but also a strategy to purchase some illusion or modicum of attachment. All 4F types are commonly ambivalent about real intimacy because deep relating so easily triggers them into painful emotional flashbacks (see my article in The East Bay Therapist (Sept/Oct 05): "Flashback Management in the Treatment of Complex PTSD". Emotional Flashbacks are instant and sometimes prolonged regressions into the intense, overwhelming feeling states of childhood abuse and neglect: fear, shame, alienation, rage, grief and/or depression. Habituated 4F defenses offer protection against further re-abandonment hurts by precluding the type of vulnerable relating that is prone to re-invoke childhood feelings of being attacked, unseen, and unappreciated. Fight types avoid real intimacy by unconsciously alienating others with their angry and controlling demands for the unmet childhood need of unconditional love; flight types stay perpetually busy and industrious to avoid potentially triggering interactions; freeze types hide away in their rooms and reveries; and fawn types avoid emotional investment and potential disappointment by barely showing themselves - by hiding behind their helpful personas, over-listening, over-eliciting or overdoing for the other - by giving service but never risking real self-exposure and the possibility of deeper level rejection. Here then, are further descriptions of the 4F defenses with specific recommendations for treatment. All types additionally need and benefit greatly from the multidimensional treatment approach described in the article above, and in my East Bay Therapist article (Sept/Oct06): "Shrinking The Inner Critic in Complex PTSD", which describes thirteen toxic superegoic processes of perfectionism and endangerment that dominate the psyches of all 4F types in varying ways.

The Fight Type and the Narcissistic Defense
Fight types are unconsciously driven by the belief that power and control can create safety, assuage abandonment and secure love. Children who are spoiled and given insufficient limits (a uniquely painful type of abandonment) and children who are allowed to imitate the bullying of a narcissistic parent may develop a fixated fight response to being triggered. These types learn to respond to their feelings of abandonment with anger and subsequently use contempt, a toxic amalgam of narcissistic rage and disgust, to intimidate and shame others into mirroring them and into acting as extensions of themselves. The entitled fight type commonly uses others as an audience for his incessant monologizing, and may treat a "captured" freeze or fawn type as a slave or prisoner in a dominance-submission relationship. Especially devolved fight types may become sociopathic, ranging along a continuum that stretches between corrupt politician and vicious criminal. 

TX (treatment): Treatable fight types benefit from being psychoeducated about the prodigious price they pay for controlling others with intimidation. Less injured types are able to see how potential intimates become so afraid and/or resentful of them that they cannot manifest the warmth or real liking the fight type so desperately desires. I have helped a number of fight types understand the following downward spiral of power and alienation: excessive use of power triggers a fearful emotional withdrawal in the other, which makes the fight type feel even more abandoned and, in turn, more outraged and contemptuous, which then further distances the "intimate", which in turn increases their rage and disgust, which creates increasing distance and withholding of warmth, ad infinitem. Fight types need to learn to notice and renounce their habit of instantly morphing abandonment feelings into rage and disgust. As they become more conscious of their abandonment feelings, they can focus on and feel their abandonment fear and shame without transmuting it into rage or disgust - and without letting grandiose overcompensations turn it into demandingness.

Unlike the other 4Fs, fight types assess themselves as perfect and project the inner critic's perfectionistic processes onto others, guaranteeing themselves an endless supply of justifications to rage. Fight types need to see how their condescending, moral-high-ground position alienates others and perpetuates their present time abandonment. Learning to take self-initiated timeouts at the first sign of triggering is an invaluable tool for them to acquire. Timeouts can be used to accurately redirect the lion's share of their hurt feelings into grieving and working through their original abandonment, rather than displacing it destructively onto current intimates. Furthermore, like all 4F fixations, fight types need to become more flexible and adaptable in using the other 4F responses to perceived danger, especially the polar opposite and complementary fawn response described below. They can learn the empathy response of the fawn position - imagining how it feels to be the other, and in the beginning "fake it until they make it." Without real consideration for the other, without reciprocity and dialogicality, the real intimacy they crave will remain unavailable to them.

The Flight Type and the Obsessive-Compulsive Defense
Flight types appear as if their starter button is stuck in the "on" position. They are obsessively and compulsively driven by the unconscious belief that perfection will make them safe and loveable. As children, flight types respond to their family trauma somewhere along a hyperactive continuum that stretches between the extremes of the driven "A" student and the ADHD dropout running amok. They relentlessly flee the inner pain of their abandonment and lack of attachment with the symbolic flight of constant busyness.

When the obsessive/compulsive flight type is not doing, she is worrying and planning about doing. Flight types are prone to becoming addicted to their own adrenalization, and many recklessly and regularly pursue risky and dangerous activities to keep their adrenalin-high going. These types are also as susceptible to stimulating substance addictions, as they are to their favorite process addictions: workaholism and busyholism. Severely traumatized flight types may devolve into severe anxiety and panic disorders. 

TX: Many flight types are so busy trying to stay one step ahead of their pain that introspecting out loud in the therapy hour is the only time they find to take themselves seriously. While psychoeducation is important and essential to all the types, flight types particularly benefit from it. Nowhere is this truer than in the work of learning to deconstruct their overidentification with the perfectionistic demands of their inner critic. Gently and repetitively confronting denial and minimization about the costs of perfectionism is essential, especially with workaholics who often admit their addiction to work but secretly hold onto it as a badge of pride and superiority. Deeper work with flight types - as with all types -gradually opens them to grieving their original abandonment and all its concomitant losses. Egosyntonic crying is an unparalleled tool for shrinking the obsessive perseverations of the critic and for ameliorating the habit of compulsive rushing. As recovery progresses, flight types can acquire a "gearbox" that allows them to engage life at a variety of speeds, including neutral. Flight types also benefit from using mini-minute meditations to help them identify and deconstruct their habitual "running". I teach such clients to sit comfortably, systemically relax, breathe deeply and diaphragmatically, and ask themselves questions such as: "What is my most important priority right now?", or when more time is available: "What hurt am I running from right now? Can I open my heart to the idea and image of soothing myself in my pain?" Finally, there are numerous flight types who exhibit symptoms that may be misperceived as cyclothymic bipolar disorder; I address this issue at length in my article: "Managing Abandonment Depression in Complex PTSD".

The Freeze Type and the Dissociative Defense 
Many freeze types unconsciously believe that people and danger are synonymous, and that safety lies in solitude. Outside of fantasy, many give up entirely on the possibility of love. The freeze response, also known as the camouflage response, often triggers the individual into hiding, isolating and eschewing human contact as much as possible. This type can be so frozen in retreat mode that it seems as if their starter button is stuck in the "off" position. It is usually the most profoundly abandoned child - "the lost child" - who is forced to "choose" and habituate to the freeze response (the most primitive of the 4Fs). Unable to successfully employ fight, flight or fawn responses, the freeze type's defenses develop around classical dissociation, which allows him to disconnect from experiencing his abandonment pain, and protects him from risky social interactions - any of which might trigger feelings of being reabandoned. Freeze types often present as ADD; they seek refuge and comfort in prolonged bouts of sleep, daydreaming, wishing and right brain-dominant activities like TV, computer and video games. They master the art of changing the internal channel whenever inner experience becomes uncomfortable. When they are especially traumatized or triggered, they may exhibit a schizoid-like detachment from ordinary reality. 

TX: There are at least three reasons why freeze types are the most difficult 4F defense to treat. First, their positive relational experiences are few if any, and they are therefore extremely reluctant to enter the relationship of therapy; moreover, those who manage to overcome this reluctance often spook easily and quickly terminate. Second, they are harder to psychoeducate about the trauma basis of their complaints because, like many fight types, they are unconscious of their fear and their torturous inner critic. Also, like the fight type, the freeze type tends to project the perfectionistic demands of the critic onto others rather than the self, and uses the imperfections of others as justification for isolation. The critic's processes of perfectionism and endangerment, extremely unconscious in freeze types, must be made conscious and deconstructed as described in detail in my aforementioned article on shrinking the inner critic. Third, even more than workaholic flight types, freeze types are in denial about the life narrowing consequences of their singular adaptation. Because the freeze response is on a continuum that ends with the collapse response (the extreme abandonment of consciousness seen in prey animals about to be killed), many appear to be able to self-medicate by releasing the internal opioids that the animal brain is programmed to release when danger is so great that death seems immanent. The opioid production of the collapse or extreme freeze response can only take the individual so far however, and these types are therefore prone to sedating substance addictions. Many self-medicating types are often drawn to marijuana and narcotics, while others may gravitate toward ever escalating regimes of anti-depressants and anxiolytics. Moreover, when they are especially unremediated and unattached, they can devolve into increasing depression and, in worst case scenarios, into the kind of mental illness described in the book, I Never Promised You A Rose Garden.

The Fawn Type and the Codependent Defense
Fawn types seek safety by merging with the wishes, needs and demands of others. They act as if they unconsciously believe that the price of admission to any relationship is the forfeiture of all their needs, rights, preferences and boundaries. They often begin life like the precocious children described in Alice Miler's The Drama Of The Gifted Child, who learn that a modicum of safety and attachment can be gained by becoming the helpful and compliant servants of their parents. They are usually the children of at least one narcissistic parent who uses contempt to press them into service, scaring and shaming them out of developing a healthy sense of self: an egoic locus of self-protection, self-care and self-compassion. This dynamic is explored at length in my East Bay Therapist article (Jan/Feb2003): "Codependency, Trauma and The Fawn Response" (see http://www.pete-walker.com/).

TX. Fawn types typically respond well to being psychoeducated in this model. This is especially true when the therapist persists in helping them recognize and renounce the repetition compulsion that draws them to narcissistic types who exploit them. Therapy also naturally helps them to shrink their characteristic listening defense as they are guided to widen and deepen their self-expression. I have seen numerous inveterate codependents finally progress in their assertiveness and boundary-making work, when they finally got that even the thought of expressing a preference or need triggers an emotional flashback of such intensity that they completely dissociate from their knowledge of and ability to express what they want. Role-playing assertiveness in session and attending to the stultifying inner critic processes it triggers helps the codependent build a healthy ego. This is especially true when the therapist interprets, witnesses and validates how the individual as a child was forced to put to death so much of her individual self. Grieving these losses further potentiates the developing ego.

Trauma Hybrids
There are, of course, few pure types. Most trauma survivors are hybrids of the 4F's. There are for instance, three subsets of the fawn type: the fawn-fight (the smothering-mother type) who coercively or manipulatively takes care of others, who smother loves them into conforming with her view of who they should be; the fawn-flight type who workaholically makes herself useful to others (the "model" secretary) in the vein of her favorite role model Mother Theresa; and the fawn-freeze type who numbingly surrenders herself to scapegoating or to a narcissist's need to have a target for his rageaholic releases (the "classic" domestic violence victim).Space in this article only allows for the description of two other common hybrids: the Fight/Fawn and the Flight/Freeze. 

The Fight/Fawn, perhaps the most relational hybrid and most susceptible to love addiction, combines two opposite but magnetically attracting polarities of relational style - narcissism and codependence. This defense is sometimes misdiagnosed as borderline because the individual's flashbacks trigger a panicky sense of abandonment and a desperation for love that causes her to dramatically split back and forth between fighting and clawing for love and cunningly or flatteringly groveling for it. This type is different than the fawn/fight in that the narcissistic defense is typically more in ascendancy. The fight/fawn hybrid is also distinct from a more common condition where an individual acts like a fight type in one relationship while fawning in another (the archetypal henpecked husband who is a tyrant at work), and from the many "nice" mildly codependent people who have critical masses where they will eventually get fed up and blow up about injustice and exploitation. The borderline-like fight/fawn type however may dramatically vacillate back and forth between these two styles many times in a single interaction. 

The Flight/Freeze type is the least relational and most schizoid hybrid. This type avoids his feelings and potential relationship retraumatization with an obsessive-compulsive/ dissociative "two-step" that severely narrows his existence. The flight/freeze cul-de-sac is more common among men, especially those traumatized for being vulnerable in childhood, and those who subsequently learned to seek safety in isolation or "intimacy-lite" relationships. Many non-alpha type males gravitate to the combination of flight and freeze defensiveness stereotypical of the information technology nerd - the computer addict who workaholically focuses for long periods of time and then drifts off dissociatively into computer games. Many sex addicts also combine flight and freeze in a compulsive pursuit of a sexual pseudo-intimacy. When in flight mode, they obsessively scheme to "get" sex and/or compulsively pursue and/or engage in it; when in freeze mode, they drift off into a right brain sexual fantasy world that is often fueled by an addictive use of pornography; and even during real time sexual interaction, they often engage more with their idealized fantasy partners than with their actual partner.

Self-Assessment. Readers may find it informative to self-assess their own hierarchical use of the 4F responses. They can try to determine their dominant type and hybrid, and think about what percentage of their time is spent in each type of 4F activity. Finally, all 4Fs progressively recover from the multidimensional wounding of complex ptsd as mindfulness of learned trauma dynamics increases, as the critic shrinks, as dissociation decreases, as childhood losses are effectively grieved, as the healthy ego matures into a user-friendly manager of the psyche, as the life narrative becomes more egosyntonic, as emotional vulnerability creates authentic experiences of intimacy, and as "good enough" safe attachments are attained. Furthermore, it is also important to emphasize that recovery is not an all-or-none phenomenon, but rather a gradual one marked by decreasing frequency, intensity and duration of flashbacks.

Non-hyperactive ADD: a women's issue

When you go to the American Psychological Association www.apa.org website, if you search for "adhd women ptsd", you will find the following google link for an APA article published in February 2003 called "ADHD, a women's issue" www.apa.org/monitor/feb03/adhd.html

I have cut and pasted this article in its entirety here.  It is noteworthy that women are diagnosed with PTSD at significantly higher rates than men.  I will post another article later on Complex PTSD and its treatment.  Hope you find this article interesting in the context of my hypothesis that ADHD, Asperger's, autism, and asthma (all of which are increasing in incidence at much faster rates geographically towards the eastern and western coasts of United States) are all anxiety spectrum disorders which are all related in that they are triggered, induced and perpetuated through similar anxiety-related mechanisms.

"Historically, research on ADHD has focused almost exclusively on hyperactive little boys, and only in the past six or seven years has any research focused on adult ADHD. And the recognition of females [with the disorder] has lagged even further behind."
Kathleen Nadeau Chesapeake Psychological Services of Maryland
ADHD: a women's issue

Psychologists are fighting gender bias in research on attention-deficit hyperactivity disorder.
By Nicole Crawford  Monitor Staff  February 2003, Vol 34, No. 2

When psychologist Stephen P. Hinshaw, PhD, published two studies on attention-deficit hyperactivity disorder (ADHD) in girls last October, psychologist Kathleen Nadeau, PhD, was heartened that females with ADHD were finally beginning to receive long overdue attention from researchers.

"Hinshaw is one of the first to study girls themselves," says Nadeau of the lead author's work, published in the Journal of Consulting and Clinical Psychology (Vol. 70, No. 5). "Most of the few prior studies have focused on comparing girls to boys--using boys' ADHD symptoms as the marker against which girls should be measured."

For Nadeau, Hinshaw's research was vindication for what she had observed clinically for years: "that girls experience significant struggles that are often overlooked because their ADHD symptoms bear little resemblance to those of boys." It was also a signal for her to push even harder to raise the awareness of the needs of women with the disorder. Through advocacy and groundbreaking research and writing, Nadeau and a small group of psychologists are fighting to bring the issues of ADHD in women from the fringes of research to center stage.

"Historically, research on ADHD has focused almost exclusively on hyperactive little boys, and only in the past six or seven years has any research focused on adult ADHD," says Nadeau, an expert on the disorder in women and director of Chesapeake Psychological Services of Maryland in Silver Spring. "And the recognition of females [with the disorder] has lagged even further behind."

According to Nadeau, this lagging recognition of girls and women is due to current diagnostic criteria--which remain more appropriate for males than females--and to parent and teacher referral patterns, spurred by the more obvious and more problematic male ADHD behaviors. Some deny that the disorder exists in females--or in anyone at all.

Researcher and educational therapist Jane Adelizzi, PhD, theorizes that females with ADHD have been largely neglected by researchers because hyperactivity is usually missing in girls, who typically have attention deficit disorder (ADD), the inattentive type of ADHD. But for advocates, the bottom line is this: Girls with undiagnosed ADHD will most likely carry their problems into adulthood, and left untreated, their lives often fall apart.

"Girls with untreated ADHD are at risk for chronic low self-esteem, underachievement, anxiety, depression, teen pregnancy, early smoking during middle school and high school," says Nadeau.

As adults, they're at risk for "divorce, financial crises, single-parenting a child with ADHD, never completing college, underemployment, substance abuse, eating disorders and constant stress due to difficulty in managing the demands of daily life--which overflow into the difficulties of their children, 50 percent of whom are likely to have ADHD as well," Nadeau adds.

"Girls with ADHD remain an enigma--often overlooked, misunderstood and hotly debated," says Ellen Littman, PhD, one of the first psychologists and researchers to focus on gender differences in ADHD and to advocate for a re examination of how the disorder is defined.

Littman theorizes that girls with ADHD aren't identified and helped earlier in their lives because male ADHD patterns have been over-represented in the literature. "As with all diversity issues, the danger lies in assuming that these more typical patterns characterize all children with ADHD," says Littman, who runs a clinical practice in Mount Kisco, N.Y. "Therefore, while there appears to be an abundance of information available on ADHD, we may have a false sense that we know more about the experience of girls with ADHD than we really do."

More research on gender issues in ADHD is needed for several reasons, says Julia J. Rucklidge, PhD, assistant psychology professor at the University of Canterbury in Christchurch, New Zealand, who has studied ADHD in Canadian women. "We can't make assumptions that what applies to males will apply to females--females have different hormonal influences to start with that can greatly affect their behavior." Also, Rucklidge says, females are socialized differently and therefore tend to express themselves in a different manner, and are more susceptible to such problems as depression or anxiety that again influence behavior. This suggests that ADHD "will manifest and express itself differently in females," she says. "But only research can tell us this definitively. Until then, these are assumptions that we make."

The mommy factor
Many women are in their late 30s or early 40s before they are diagnosed with ADHD. "One of the most common pathways to a woman being diagnosed is that one of her children is diagnosed. She begins to educate herself and recognizes traits in herself," says Nadeau. "These women are [usually] going to be older," because children are typically diagnosed with ADHD in mid-to-late elementary school.

Women with ADHD typically present with tremendous time management challenges, chronic disorganization, longstanding feelings of stress and being overwhelmed, difficulties with money management, children or siblings with ADHD, and a history of anxiety and depression, says Nadeau, who didn't recognize her own ADHD until middle age and has a daughter and a brother with the condition.

The disorder is typically treated with a combination of stimulant medication and ADHD-focused psychotherapy, "which is very structured, goal-oriented, and uses many 'coaching' techniques, as well as standard psychotherapy techniques," says Nadeau. "Women more than men with ADHD struggle with low self-esteem, and this needs to be a major focus of therapy," she adds.

Many of the women who come to clinical and neuropsychologist Mitchell Clionsky, PhD, for ADHD testing fit the typical profile. One 42-year-old patient he diagnosed with ADD was referred by a psychiatrist treating her for depression. Her marriage was troubled, and she had low self-esteem, says Clionsky, the cofounder of the ADD Center of Western Massachusetts in Springfield. Since childhood, the patient had thought she was lazy and irresponsible because she didn't complete things she started. A "very bright woman," she completed a few years of college, and "probably would have gone farther had her problem been identified sooner," he says.

The tragedy is "these are people significantly underachieving and [who] end up going the depression route, mostly the result of life failure," Clionsky says. "It's like they're running life's race with lead weights on their ankles."

Pioneering research
Some psychologists are building up the literature on ADHD among women. Julia Rucklidge began studying the area while working on her doctorate in psychology at the University of Calgary in Alberta, Canada. "When I started in 1995, there was very little research in the adult population [and] maybe one or two studies looking specifically at women with ADD," she says.

Rucklidge, with colleague Bonnie Kaplan, PhD, studied 102 women ages 26 to 59, with a mean age of 41. Half of the women interviewed had ADHD and half did not. All of the women in the study had a child with ADHD--therefore all subjects could relate to the stressors involved in parenting a child with the disorder.
Rucklidge's findings, published in the Journal of Attention Disorders(Vol. 2, No. 3) and the Journal of Clinical Psychology (Vol. 56, No. 6), shed light on the experiences of women diagnosed in adulthood:

* Women with ADHD were more likely to have a "learned helpless style" of responding to negative situations than were women without the disorder and tended to blame themselves when bad things happened.

* Women with ADHD were likely to believe that they couldn't control the outcomes of life events, resulting in a vicious cycle, reports Rucklidge. "A woman with ADHD is less likely to make efforts to finish challenging tasks due to her belief that she has no power to change the negative outcome. By giving up, she further reinforces the belief that she is unable to accomplish things in life," she says.

* Women with ADHD were also more likely to report a history of depression and anxiety. They had also been in psychological treatment more often and had received more prescriptions for psychotropic medications than had women without ADHD.

Jane Adelizzi's research explored a rarely mined area of ADHD: its similarity to post-traumatic stress disorder (PTSD). Three of her studies looked at women diagnosed with attention and learning problems who also showed PTSD symptoms as a result of experiencing classroom trauma--which she defines as a significantly unpleasant external event or stressor occurring within the confines of an educational environment that is of a psychological nature.

"As a result of classroom trauma over a span of years, some women develop a set of symptoms that are recognizable--by some professionals--as post-traumatic stress symptoms," reports Adelizzi, coordinator of the Adult Center, Program for the Advancement of Learning at Curry College in Milton, Mass. "These symptoms are also similar--too similar--to ADHD behaviors and symptoms."

It's not always clear which comes first, the post-traumatic stress symptoms, the ADHD symptoms or the trauma, says Adelizzi. But, she argues, these women's ADHD symptoms can't be helped without looking into the coexisting panic and anxiety that can be triggered many years later--if, for example, they decide to return to school.

'Cutting-edge advocacy'
In addition to pushing for more studies on gender issues, these psychologists use a range of forums to raise awareness of ADHD in women. With pediatrician Patricia Quinn, MD, Nadeau recently founded the National Center for Gender Issues and ADHD (NCGI) to promote awareness and research on the disorder in females (www.addvance.com/ADDvance/NCGI.htm). Nadeau and Quinn also developed Advantage Books, an ADHD specialty press, and have co-edited several volumes on ADHD issues in girls and women (seeFurther Reading). Nadeau is also editor of ADDvance Online News, NCGI's monthly e-newsletter.
"We're doing cutting-edge advocacy," says Nadeau, who has lectured on the issue nationally as well as in Norway, Japan, Puerto Rico and Germany, and has discussed the topic in the popular media, including on NBC's "Today Show."

Networking is also a crucial part of Nadeau's advocacy work. She's formed alliances with national ADHD groups, including the Attention Deficit Disorder Association and Children and Adults with Attention-Deficit/Hyperactivity Disorder.

Since the 1990s, Adelizzi has been running support groups for women with ADD--and other learning disabilities--who are attempting college. She also gives seminars and has developed two certificate programs for professionals who work with women with attentional and other disorders. And she's continuing to study these women--most recently looking at how they express their emotions through art.

In addition, Littman and Nadeau are pushing for changes to be made to the next edition of the Diagnostic and Statistical Manual for Mental Disorders.

"I hope that psychologists, especially those who specialize in adult ADD issues, will play an active role in advocating for more appropriate diagnostic criteria--for adults, and especially for women--before DSM-V comes out," says Nadeau. "I hope that such issues are dealt with at the [next] APA convention in a vocal fashion--the lives of many people are at stake."