ADHD is essentially a disorder of executive functions leading to an inability to stay organized, excessive procrastination, difficulty paying attention, emotional impulsivity, and a focus on short-term rewards over long-term benefits. While increased impulsivity and exploratory behavior were in part evolutionarily adaptive, in the modern world they are usually not.
How ADHD manifests
Phenotypically, ADHD is a combination of the triad of
- hyperactivity
- inattentiveness
- impulsivity
Different individuals have different combinations of these three traits.
Not everyone with ADHD exhibits impulsivity and hyperactivity, and some individuals struggle primarily with focus. Interestingly, many individuals with ADHD can focus just fine on things they inherently enjoy or find interesting but mostly have problems with focusing on things they do not want to do (e.g., school, staring at spreadsheets all day).
A friend of mine, who has pretty prototypical ADHD can hardly sit still and always “needs to do something”. Consequently, he has a tough time relaxing. To help him relax, he uses weed. Being on time is pretty much impossible. He has quite a severe inability to concentrate, especially on things that do not intensely interest him.
Before being treated, it was also hard for him to engage in a meaningful conversation as he had a challenging time listening to and engaging with what the other person was saying. He was frequently interrupting others. He also had difficulties with accepting other people’s boundaries, in part because he was living in his own little micro-universe, where, according to him, thoughts are usually racing and constant distraction rules.
He plans a lot, constantly re-decides, and sometimes tries to do many things at once, in the end usually accomplishing nothing. His emotions were at times quite volatile and all over the place, and at times hardly present at all (anhedonia).
Before treatment, he found ways to subconsciously counter-regulate the dopamine dysregulation by way of constant snacking (especially sugary foods), energy drinks, snus, video games, online poker, and weed.
He was being treated with atomoxetine, and for him, treatment had more downsides than upsides, so he switched over to lisdexamphetamine, which was too potent, and he started to neglect diet and sleep even more than he already had. While being treated with bupropion, he lost his creativity, wit, and excitement about things. He is currently off treatment.
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What causes ADHD?
While ADHD has a cultural component to it, it is (most likely) not solely an artifact of modern diagnostics but also rooted in true brain abnormality on both a structural as well as a functional level. “True” ADHD has a strong genetic component, and the heritability is thought to be above 60%. Many of the genes associated are genes responsible for dopamine metabolism & signaling. However the “exact” nature of the disorder is not understood – similar to other mental disorders.
ADHD is thought to be characterized by catecholamine dysregulation. More specifically, it is thought that baseline firing rates of dopamine neurons are low relative to the spike firing rates. Thus, low baseline dopamine levels make it hard to allow for sustained focus when nothing in particular is going on. Furthermore, in ADHD, the default mode network (DMN) is generally overactive, while the task-positive network (TPN) is generally hypoactive.
The high dopamine spike (in relative terms) then causes even small stimuli to be excessively salient and therefore people to lose and shift focus constantly. There also seem to be aberrances in glutamate, acetylcholine, and noradrenaline signaling (the science of these neurotransmitters is discussed here).
Personal thoughts on why having “some” ADHD is not necessarily bad
ADHD is a spectrum and not an “all-or-nothing” thing. This is the case with most mental disorders – even autism and schizophrenia.
Severe ADHD, which is usually diagnosed in early childhood, can be very disruptive to life. Treatment with stimulants is known to improve brain development, and a host of other domains such as academic achievement, self-esteem, and social function.
However, some researchers have pointed out that in many “light” cases of ADHD, treatment is often used as an instrument for social control to “slow down” hyperactive children and to please parents.
Many of my friends who I consider particularly intelligent exhibit light ADHD symptoms due to them having fast brains and minds. Speculatively, if their light “ADHD” had been treated from early on, treatment may have been a net harm as they may not have been so curious, creative, and exploratory, and they may have turned out less intelligent (given that the brain develops depending on how it is used – similarly to a muscle or a bone).
Having some ADHD tendencies (which is not the same as having “true” ADHD) is not necessarily bad and they may be as much an asset as they are a burden. It is no coincidence that the prototypical scientist is distracted. Some of history’s greatest minds are thought to have had many symptoms resembling AHDH, including Albert Einstein, Winston Churchill, Benjamin Franklin, and Wolfgang Amadeus Mozart.
While ADHD treatment can be life-changing in cases of “true” ADHD, I believe that many ADHD diagnoses are not “true” ADHD but rather represent a state where people are not interested in something, such as school, but need or want to function well in a modern society.
Social media and the way most people engage with technology also seem to play a role in producing ADHD-resembling phenotypes. If 15 minutes of meditation per day are known to produce tangible brain changes in a couple of months (as evidenced by MRI & fMRI data), then what do 8 hours per day of jumping and scrolling?
In cases of non-true ADHD, there are many downsides to treatment with conventional ADHD drugs. For example, before treatment, my friend was quick and witty but the longer he was on ADHD meds, the duller he got. Also, letting his mind aimlessly wander around seemed impossible, and he also got less excited about things.
Treatment
Disclaimer: I am not a psychiatrist, and the following represents my personal opinion.
Lifestyle treatment can go a long way and should always be exhausted first. Not because I am against pharmaceutical treatment, but rather because current pharmaceutical options have considerable downsides, as explained above.
Lifestyle treatment
- A proper exercise regimen can do wonders (especially cardiovascular exercise).
- Sleep hygiene
- Meditation
- Avoiding sugar
- Reducing social media
Pharmacological treatment
- Stimulants: lisdexamphetamine, amphetamine, methylphenidate
- Non-stimulant options: reboxetine, modafinil, guanfacine, nicotine
- Semi-stimulant options: bupropion
The long-term effects of chronic use of ADHD medications need more attention and discussion. I personally believe that amphetamine-based drugs may be more neurotoxic than what they are made out to be by the medical community (long-term studies are mostly absent). I discuss this issue in more detail here: Are Amphetamines Neurotoxic?
High-dopamine-subtype of ADHD
Most cases of ADHD are thought to be due to low baseline dopamine relative to spike firing rates. However, very high levels of dopamine can cause ADHD symptomatology as well – as is the case in e.g., schizophrenia, anorexia nervosa, or hyperthyroidism. If treatment is desired, these are best treated with low doses of atypical antipsychotics, such as low-dose risperidone or aripiprazole.
Sources & further reading
- Scientific review: Neurobiology of Attention Deficit/Hyperactivity Disorder
- Scientific review: Systematic review of meditation-based interventions for children with ADHD
- Podcast: Andrew Huberman – ADHD & How Anyone Can Improve Their Focus
Disclaimer
The content available on this website is based on the author’s individual research, opinions, and personal experiences. It is intended solely for informational and entertainment purposes and does not constitute medical advice. The author does not endorse the use of supplements, pharmaceutical drugs, or hormones without the direct oversight of a qualified physician. People should never disregard professional medical advice or delay in seeking it because of something they have read on the internet.