The confusing relationship of ADHD & PTSD

The confusing relationship of PTSD & ADHD

Jessica Kant, MSW, LICSW, MPH

Last updated: April 9, 2023

As always when we talk about the human nervous system, it’s important to remember that our brains evolved with the goal of survival first, with everything else a distant second. However this evolution occurred in an environment so different from our material realities today that the functions of survival look almost accidental, and at times are at odds with our present-day material needs.

The very first thing your brain does when it senses a threat is jettison information it deems irrelevant. You may take in other data, but not really parse it. Or, as happens to many people, you may stop taking in all information save for a few crucial senses like hearing or, oddly enough, smell.

A quick refresher: the stress response system

When our autonomic nervous systems take over, they do so by shutting down the frontal cortex — the part of our brains most responsible for rational decision making — and turn the reins over completely to our limbic systems, specifically the amygdala.

This creates a sort of tunnel vision, and begins a cascade of processes that prepare our bodies for fight or flight, including the hyper-oxygenation of our hemoglobin and the release of adrenaline, cortisol and glycogen stores to serve as ready fuel. The combination of greater amounts of oxygen and fuel allows us to be stronger and faster than we are normally. And this is really great if you need to fight a mountain lion. It is demonstrably less good if you need to concentrate for a test.

Over time, brains which find themselves too rapidly going through this process begin to lose the capacity to stop it from happening. For many people, this means that our brains begin to detect threats where they may not be there, at an ever-increasing false-positive rate that can lead people to thinking that they’re losing their minds. We call this hypervigilance. Hypervigilance is the process by which our brains become conditioned to scan for threats constantly, often at the expense of other resources. Many of us become hyper-attuned to specific cues, but miss more obvious or mundane ones.

For example, latency age children experiencing abuse may tune out verbal language, but are on some preconscious-level able to detect subtle cues in facial expressions, tone of voice and even gait.

In families this may cause conflicts where youth begin to attribute minor deviations in speech inflection as condemnation, and react accordingly. Unaware of why chidlren are suddenly behaving differently, adults may attribute this to “copping an attiitude” and take personal offense. A hypervigilant child in turn notices this, prompting the release of more adrenaline, while also validating on some level that the negative interpretation of events was an accurate one. This creates a feedback loop whereby both parties become increasingly certain of their own interpretations, while simultaneously driving farther and farther away from a more objective, dispassionate view of what is actually happening.

One of the diagnoses in the DSM with the most amount of misinformation about it floating around on the internet, ADHD is a disorder with several subtypes that don’t all look the same. In the kinetic or “predominately hyperactive” type", ADHD makes it difficult to sit still. While in the “predominately inattentive type” it can make it difficult or near impossible to focus.

Okay, so what is ADHD?

To make it more confusing— because it isn’t psychiatry if it’s easy to follow— there are also “combined” types which prominently feature both types of presentation. The net effect of this is a condition with such a heterogeneity of presentation that there is no easy way to describe, as it manifests differently from person to person.

While during the heyday of ADHD diagnosis in the 2000’s it was actually primary care doctors who wrote a substantive portion of the prescriptions for medications like Adderall and Ritalin, so difficult is the differential diagnosis, that lately health centers have started requiring prospective ADHD patients to see a psychiatrist. But first, they have to undergo comprehensive neuropsychological testing that can take hours or even days to complete. The waiting lists for these services are a mile long, and there’s a crisis of access that no one seems ready to tackle. This is exacerbated by the DEA‘s bizarre choice in recent years to create an artificial shortage of medications used to treat ADHD, such as Adderall.

While there are many proposed mechanisms for the development of ADHD, no one knows for sure what causes it. We do however know that imaging studies have shown differences in the development of key regions of the brain associated with decision making, inhibition and attentiveness— namely, the cortico-limbic system. We do know that early childhood instability and unpredictability can lead to different pathways of brain development that vary from those without similar life experiences. It is not much of a stretch to imagine therefore that challenging early childhoods might predispose people to developing difficulties with executive function later in life. In epidemiology, there are also variables called mediators to consider, which may have a relationship to the independent variable that change the degree and direction of the outcome. For example, logically enough poverty is positively correlated with food instability. Food instability is also positively correlated with neglect. A lack of steady nutrients, compounded with malnutrition and the constant worry associated with malnourishment and hunger may exacerbate the effect of trauma. Or, conversely, access to dependable, nutritious meals may have a protective effect reducing the severity of post-traumatic symptoms.

On top of all of this, ADHD can look an awful lot like hypervigilance at first glance.

Take for instance a kid at their desk might who look up for every sound or every new visitor in the room. Are they distracted? Or are they scanning for threats? What if the answer is both?

People with ADHD tend to seek novelty and stimulation. In fact, we often crave it. Stimulation can make an otherwise interminable class much more interesting, and being interested in something does actually appear to have a large effect on whether or not we can pay attention to something. This was always a large point of contention for parents I worked with— why, they would ask, can my daughter focus on a video game for seven hours but math homework for a maximum of 30 minutes?

The answer, unfortunately, is that our internal resources for focus appear to be somewhat dependent on something tickling out reward systems, the part of the brain that releases dopamine and tells us we feel good. Things that lead to distress, like math homework, have a very short shelf life, while Minecraft simply doesn’t.

But the same kid might look up for a totally different reason— to scan for danger. Hypervigilance is an ongoing process, and all of our senses are constantly collecting, parsing and evaluating sensory data for the first sign of danger. The same person walking into the classroom may be a source of amusement for one child but a source of anxiety for another. However, from the perspective of an exasperated teacher with too many students and not enough resources, the net result may appear the same.

On memory

Memory is an odd thing. As far as we can tell, the human brain stores information in an integrated fashion most of the time. This is why sounds and smells can pull up events and even emotions. It makes associative memory possible— the process whereby one thought makes it easier to retrieve another. This is why we don’t have to know exactly what we’re searching for in our minds, or even have to be intentionally searching at all.

But this ready retrieval is most possible when we store memory in an integrated fashion. That is, when we’re not in a fear-state, as we encode memory differently when we're fearful. Information encoded properly is stored in the hippocampus, and can be retrieved in whole or part at will, although sometimes it takes a little jogging. However, when our autonomic nervous system takes over, it prioritizes certain data over others, it all gets stored disparately. Instead of a single movie file, it get stored as a thousand still images, short audio clips and blurry videos, all stored with seemingly-random filenames.

This is why we can be fearful of things but not know why, can have a vague sense that a place is dangerous but no cogent idea of why that actually is; almost like the place is haunted. We might have flashes of imagery or physical sensations and emotions, but lack clear context. People with PTSD, and those who are in target groups in times of extreme political stress, will notice that their brains are pulling them to look for certain information. We have an innate need to know if a threat is coming for us, even if we don't know that's why we're doing it. The challenge is that when you're having trouble concentrating, what you need may differ depending on the source of the difficulty.

Treatment of ADHD often demands stimulation; PTSD often recoils at it. Stimulants work wonders for focus, but can exacerbate anxiety and peritraumatic sequelae. While this varies from person to person, whether or not the answer is that third cup of coffee largely depends on what is causing you to have trouble relaxing.

Enter the anti-hypertensives…

Bruce Perry, MD, PhD, neuroscientist, psychiatrist and best-selling author of “The Boy Who Was Raised As a Dog” was one of the first people to start to experiment with the idea that anti-hypertensives might be useful in the management of PTSD systems.

Perry and colleagues, after noticing the role of heart rate and blood pressure in youth who had experienced traumatic stress prescribed medications to relax the blood vessels and reduce heart rate. Many of the kids to whom this had been prescribed experienced a striking reduction in loss of focus, reductions in irritability, general improvements in mood and perhaps most interestingly for therapists, a decline in nightmares. It turns out that the brain, in triggering its own fight-or-flight response may actually “spook itself”, seeing your physiological state of arousal as actual evidence of danger, rather than a response to perceived danger initiated by this same brain. By relaxing the blood vessels and reducing heart rate, this interrupted the feedback loop of toxic stress, and many patients found themselves able to regulate in ways they could not previously.

Think for a moment about that child above, who looks up every time a stranger comes into the classroom. This is where the why really matters between PTSD and ADHD. Contrary to what I’ve seen a lot of Instagram influencers claim, as far as we know ADHD is not a traumatic stress disorder. At least, it is not classified as such yet. There are statistical associations between lifetime trauma and ADHD diagnosis later in life, but an exact causal linkage hasn’t been determined. The same is not true for PTSD, which presumes a direct linkage between a traumatic life events (or events) and the development of post-traumatic sequalae.

While psychiatrists have been arguing about this for a long time, traumatic reactions that cause inattentiveness or hyperkinesis are a different class of disorders. Although we’re still in heavy debate about what to call them, the majority of us agree with the label “Developmental Stress Disorders.” Regardless, after seeing so many kids diagnosed with ADHD because they couldn’t focus, only to have medications like Ritalin (methylphenidate) prescribed just prior to that same youth having even greater difficulties in school, it became clear that adding stimulants to the mix for many children with complex trauma histories is just gasoline on the fire. Not only might the diagnosis be wrong, but there may be other non-stimulant options that won’t necessarily overexcite the nervous system.

As a community-based therapy team leader, I used to heavily encourage cliinicians working for youth with this sort of presentation to be have much closer relationships with prescribing psychopharmacologists. Often as therapists we can be tricked into thinking therapy and medication are separate, but if we’re doing our jobs correctly, all behavioral health providers should work in concert. And we did, and in so doing, more and more, we found that PTSD was a much better explanation, or, perhaps just as often, a co-occurring phenomenon. When their prescribers switched to non-stimulants or anti-hypertensives like guanfacine, symptoms reduced. Fights at school started to diminish. Relationships improved. Nightmares and bed-wetting stopped.

The changing face of psychopharmacology

In the past ten years, increasing emphasis has been placed less on anxiolytic medications like benzodiazepines (think: Ativan or Valium), but a class of medications called beta-blockers, such as propranolol. Beta blockers inhibit the body’s reaction to stress hormones like adrenaline. Rather than calm you down by pushing out calming neurotransmitters like GABA, beta blockers do the amazing work of preventing us from getting too worked up at all in the first place by putting our adrenergic systems on mute.

Another class of medications, alpha blockers, are used to prevent the constriction of blood vessels, which may play a critical role in night terrors. Medications like prazosin, an alpha blocker, have been used extremely successfully to reduce the severity of nightmares. While they may not make the nightmares go away altogether, they lose that electric, incoherent quality that leads so many of us to wake up in the morning covered in sweat in a jolt. I’ve been on prazosin for about six months, and the difference it has made has been live-giving.

Ultimately, PTSD is just as much a disorder of the body as the mind. Since our regulatory systems, specifically those that regulate heart rate, breathing, blood pressure and hormone levels are intimately tied to our emotions, our perceptions of danger may cause physiological changes as I describe here. One aspect of stress that can be measured quantitatively is something called heart rate variability or HRV. The space between heartbeats has some fluctuation, and our bodies when they work well are able to push into an excited space and back down to a resting heart rate (RHR). A lower RHR and a higher HRV are generally considered good indicators of health. Stress, and specifically traumatic stress impacts both of these things.

The body has a level of strain upon it that is measured by a handful of variables as described above. The exact toll on our body at any given time is called “allostatic load”. When the rate at which your body is able to calm down is lower than the rate of introduction of new or perceived threats, your body is in a positive feedback loop (this is one of those annoying times where “positive” does not mean good). As it gets harder and harder to flush cortisol from your body, it builds up in a process called bioaccumulation. As cortisol accumulates, it prevents your heart from going back down to a low RHR, and your average RHR climbs over time. The body can then become flooded with the constant instructions to “rev up”, and become less responsive over time. This means that ironically while your average heart rate may go up, after extreme amounts of toxic stress, some people’s brains lose the ability to suddenly focus. We become on edge but distracted. We lose focus and feel uncomfortable all the time.

For a lot of us, that means we do more and more things to attempt to focus. Perhaps we head to the energy drink aisles that seem to consume more and more of the average gas station, or perhaps we use loud music or take B-vitamin complexes. If, rather than stimulate us into focus these appear to make the problem worse, or have no readily discernible effect, you may have reached your maximum capacity wherein more stimulation will not help. There’s no world in which 200mg of caffeine should have no measurable impact on your level of fatigue. If you do find yourself in a place where you can seemingly drink caffeine endlessly with no effect, it may be worth talking to your doctor about the best way to discern why.

If, like me, you live with a brain that struggles with both ADHD and PTSD, this gets messy really fast. You may want to talk to your therapist about decreasing caffeine intake, or scheduling small movement breaks to get that heart rate up. Evidence suggests that running up and down a flight of stairs when you’re stressed, while not anyone’s favorite activity (except for that one woman I dated in grad school), intense cardiovascular exercise, even in only a few minutes, can reset your heart rate. Movement helps flush toxic stress from your body, as does vastly increasing your water intake.

Annoyingly, alcohol actually inhibits our ability to process cortisol and adrenaline, the primary hormones released when we're stressed. While everyone needs to do whatever they need to do to get through the day, sometimes it makes sense to skip the drink you really want to relax at the end of the day. Reading also helps, especially fiction.

But most important, I would strongly encourage you to find ways to monitor your body more objectively, such as a heart rate monitor on a smartwatch if that’s in your price range. Some of these may actually be accessible through your health insurance, and others through research studies. While it doesn’t provide the same steady stream of data over the course of days and months to track trends, all smartphones with cameras and a flash are able to measure rate heart using something called photoplethysmography. By shining light into your skin, the camera can detect when the blood perfuses your capillaries. I’ll be putting up a guide to DIY vitals monitoring soon.

❤️ Jess.

References

Perry, Bruce & Initiative, Civitas. (1999). Neurobiological Sequelae of Childhood Trauma: Post-traumatic Stress Disorders in Children.
Perry B. D. & Szalavitz M. (2008). The boy who was raised as a dog : and other stories from a child psychiatrist's notebook : what traumatized children can teach us about loss love and healing. Basic Books.
Hudson, Steven M et al. “Prazosin for the treatment of nightmares related to posttraumatic stress disorder: a review of the literature.” The primary care companion for CNS disorders vol. 14,2 (2012): PCC.11r01222. doi:10.4088/PCC.11r01222
Antshel, K. M., Kaul, P., Biederman, J., Spencer, T. J., Hier, B. O., Hendricks, K., & Faraone, S. V. (2013). Posttraumatic stress disorder in adult attention-deficit/hyperactivity disorder: clinical features and familial transmission. The Journal of clinical psychiatry, 74(3), e197–e204. https://doi.org/10.4088/JCP.12m07698
Gehricke, J. G., Kruggel, F., Thampipop, T., Alejo, S. D., Tatos, E., Fallon, J., & Muftuler, L. T. (2017). The brain anatomy of attention-deficit/hyperactivity disorder in young adults - a magnetic resonance imaging study. PloS one, 12(4), e0175433. https://doi.org/10.1371/journal.pone.0175433

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