I'm A Neuroscientist: Don't Blame All Your Problems On Trauma
Overlap between PTSD and ADHD shows that it’s always both nature and nurture.
Baptista Ime James | Unsplash In the 30-plus years since I started working as a psychiatrist, there’s been a huge surge in therapists focusing on trauma. For the most part, this is a good thing. We know that trauma, defined as an experience that is perceived as dangerous, violent, or threatening, plays a large role in determining who develops post-traumatic stress disorder (PTSD), substance abuse, depression, anxiety, and personality disorders.
Helping people work through trauma has enabled many to lead healthier, happier, more predictive lives.
Overemphasizing trauma has its downsides because it can lock some people into a stance of victimhood.
Focusing on particular trauma experiences can cause resentment among others who feel that their adversities are being minimized, a situation that plays a large role in our currently contentious politics.
Life presents dangers, but seeing trauma in even the slightest threat can render the term meaningless. Furthermore, viewing trauma as the source of all human misery can blind suffering individuals, and their therapists, to other factors that might contribute more substantially to that person’s anguish and dysfunction.
As someone who has worked extensively with adults with ADHD, I’ve seen how confusing the intertwining of PTSD and ADHD can be. I’ll delve into this entanglement in more detail, not only because effective treatment depends upon accurate assessment, but also because it illuminates a current manifestation of our struggle to understand the ongoing roles of nature and nurture in human behavior.
Diane (not her real name), a reporter, had worked with a well-respected psychotherapist before she was referred to me during a bout of depression. She described how, during twelve years of therapy, she and the therapist had been unsuccessful in uncovering why Diane repeatedly “self-sabotaged.”
Diane missed deadlines for filing her articles, interrupted sources during interviews, showed up late for staff meetings, and distracted her bosses and interviewees with her pencil tapping, fidgeting, and voicing her disgruntlement out loud.
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Her therapist had told Diane that there must be a subconscious explanation for why she constantly undermined herself at work and home. Diane accepted that framework, but a few hundred therapy sessions hadn’t turned up any convincing explanations. Diane had grown up in a supportive, middle-class home, without experiencing any major disasters, losses, or rejections.
I pointed out that Diane met the full criteria for ADHD. We reviewed how she displayed a full range of inattentive, hyperactive, and impulsive symptoms that had been present since childhood.
Her behaviors were a reflection of how her brain worked differently than mainstream brains, not a response to some hidden trauma.
Diane’s depression resolved after a few weeks on Cymbalta. Intellectually, she understood that ADHD explained the behaviors that kept derailing her. Yet she was so wedded to the belief that she was intentionally, unconsciously interfering with her own life, and so trusting of her caring but clueless therapist, that she opted not to pursue further treatment for her ADHD.
In my office, and in response to my writings and videos, I’ve interacted with numerous individuals with ADHD who were told that they didn’t have ADHD and that their symptoms were all a manifestation of trauma. Some were told that ADHD didn’t even really exist and that all imagined cases of it were due to trauma. I’ve seen how misdiagnosis and misconceptions can lead to distorted views of the self and ineffective or counterproductive treatment.
PTSD
PTSD is defined as a disturbing, excessive, unhelpful, and sustained response to a serious, traumatic event. The diagnosis requires:
- experiencing a major traumatic event
- distress or dysfunction for a month or longer after the interaction
- states of hyperarousal
- re-experiencing the trauma
- avoiding reminders of the trauma
- negative cognitive or emotional responses to the trauma
Initial formulations of PTSD described major traumatic events as those likely to cause death, loss of limbs, or impairment of important bodily functions. The definition was then extended to embrace situations in which one witnessed severe trauma happening to others, without experiencing direct physical harm to oneself.
More recently, the definition expanded further to include repeated exposure to severe trauma in a vocational role, such as a policeman investigating murder scenes, or a screener who has to check and remove videos of child sexual abuse from an internet server.
Many people are exposed to major trauma without developing PTSD. Numbers vary depending on the precise definitions of trauma, and the population surveyed, but anywhere from half to three-quarters of Americans confront seriously traumatic situations, while only 10% develop the dysfunctional, distressing, prolonged response of PTSD. Some of the susceptibility to PTSD is genetically driven, and some depend on prior life experiences.
Situations that appear to threaten our lives or limbs trigger fear. Usually, once the situation passes, and we’re in relative safety, our brain works to extinguish the fear. Much of the research on PTSD indicates that it arises from defects in the fear extinction pathways.
As a result, there is chronic activation or disruption of hormones such as cortisol and neurotransmitters like norepinephrine and epinephrine. Our fight-or-flight sympathetic nervous system remains overactivated. These biochemical and neurologic onslaughts result in the rewiring of the brain, an example of neuroplasticity in a maladaptive direction.
Common symptoms of hyperarousal include:
- an exaggerated startle reflex
- disruptions of sleep
- pacing, fidgeting, and other signs of hyperactivity
- difficulties with concentration and distractibility
- impulsivity
- explosive emotions
The most common re-experiencing symptoms involve nightmares and daytime ruminations about the traumatic event. Some of the daytime recollections can become so intense that the person dissociates or loses contact with what is going on around them at the moment.
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Avoidance can entail consciously or subconsciously staying away from locations, people, situations, animals, or other reminders of the trauma. It can also involve mentally refusing to think about the trauma, or items or issues associated with the trauma.
Negative cognitive responses may include distorted recollections of the actual trauma. Or one might generalize from the trauma to create an unrepresentative view of the whole world, or oneself. PTSD can cause people to withdraw from social contact, or restrict it severely. It can also result in persistent fear, anger, guilt, or shame that pervades situations not directly tied to the trauma.
PTSD can impair one’s job performance and one’s social interactions. It increases the risk of developing several mental health and physical health problems. It increases the risk of dying by suicide.
Complex PTSD
The American Diagnostic Manual of Psychiatric Disorders recognizes PTSD, while the WHO classification also identifies an additional condition of complex PTSD or CPTSD. Some clinicians use the unofficial term “developmental PTSD” to describe CPTSD. Other professionals resist the creation of a new diagnostic category, feeling that its boundaries are too imprecise, and formal research too meager.
CPTSD reflects that two of the most important variables affecting response to trauma are the age at which trauma occurs and whether the trauma is a single event or a repeated one. CPTSD emphasizes that pervasive trauma, even when it is not as severe as required for classic PTSD, can create many of the same symptoms of hyperarousal, avoidance, re-experiencing, and cognitive and emotional dysregulation.
In particular, CPTSD is often characterized by disrupted cognitive and emotional development which can contribute to significant relationship difficulties and a profound sense of low self-worth. CPTSD also increases the risk for physical health problems, including, but not limited to, hypertension, digestive, and autoimmune issues.
CPTSD also clarifies that PTSD is not an all-or-none categorical condition but rather exists on a spectrum. PTSD requires that the trauma be a “threat of death or serious injury”. We may all agree that the loss of a limb is serious, but is the loss of a finger? A fingertip? Being cut without risk of risk of bleeding to death?
ADHD
ADHD is a common type of neurodiversity, or differential brain wiring, that manifests in childhood, tends to persist throughout life, and is characterized by hyperactivity, impulsivity, and challenges with time management; directing, sustaining, and switching attention; prioritizing, organizing, initiating, and completing tasks; and emotional dysregulation.
Twin studies and extensive genetic analyses confirm a large heritable component of ADHD. Environmental factors play a smaller, but not insignificant role in determining who develops ADHD. Children who are adopted more closely resemble their biological relatives than their adoptive families on measures of ADHD.
There is considerable overlap in symptoms between those with PTSD and those with ADHD, including difficulties with:
- concentration and attention
- memory
- emotional dysregulation
- regular sleep
- higher rates of substance abuse problems
- impaired social interactions
- shame around being different or feeling impaired
In addition to PTSD and ADHD being confused with each other, an individual can also have both conditions. When they do co-occur, they share an intimate, two-way relationship.
One meta-analysis of more than two dozen studies found that those with ADHD were two to three times more likely to develop PTSD than their peers. Rates of ADHD among those with PTSD were approximately double that of ADHD in the general population.
ADHD contributing to PTSD
In many ways, ADHD is a perfect set-up for developing PTSD. Because of impulsivity (not thinking of the consequences), hyperactivity (bouncing into dangerous situations), and inattention (missing cues about risky actions, areas, and actors), those with ADHD are substantially more likely to suffer serious trauma. Individuals with ADHD get injured about twice as often as others their age.
Furthermore, some research indicates that even controlling for the same amount of physical trauma, those with ADHD are more likely to develop PTSD. Children with ADHD, who have no history of trauma, when exposed in a laboratory to a fearful condition showed poorer extinction of fear than did non-ADHD kids. Scans displayed less activation in the front of the brain in these ADHD children, reflecting less cognitive control over their emotions. They also showed less activation of the hippocampus, possibly indicating a decreased ability to use memory to put their fear experience in a broader context, and move on from it.
The differential neural wiring intrinsic to ADHD, including greater activity of the sympathetic nervous system, could make children with ADHD more susceptible to developing PTSD. It’s also possible that neurodivergent ADHD children, even before experiencing major trauma, were treated differently, with more criticism, bullying, and rejection. This could create a subthreshold CPTSD, thereby making the child more likely to develop full-blown PTSD when exposed to a major trauma.
PTSD contributing to ADHD
Trauma can rewire the brain. In some individuals, trauma can replicate the full range of ADHD symptoms. Undoubtedly some cases of ADHD arise as a result of trauma. Trauma can even cross generations to contribute to ADHD. Trauma to a mother resulting in the presence of PTSD during pregnancy, doubles the risk of that child later developing ADHD.
The whole trauma industry has promoted the view that ADHD is always the result of trauma. Proponents of this view claim that in all cases the behavioral, cognitive, and emotional problems that we call ADHD arise because of a punishing environment that warps a child’s development.
That’s simply wrong. Many individuals with ADHD experience supportive family and school environments. Extensive explorations, backed by corroboration from other sources, fail to reveal any significant trauma history in many individuals with ADHD.
Many individuals with ADHD who do incur major injuries from life events, don’t have re-experiencing, avoidant, or other PTSD symptoms stemming from their trauma.
Twin, adoption, and whole-genome analyses repeatedly indicate that within a population, genetics play a larger role than the environment in determining who will develop ADHD. That’s not to deny that in many respects we live in a world that for many is physically, emotionally, and socially severely challenging and unhealthy.
But environmental factors, including trauma, aren’t the major origin of ADHD.
In particular, rates of trauma have decreased significantly over the last thirty years. Between 1990 and 2010, sexual abuse in the US declined by 62%, and physical abuse declined by 56%. Over the same span, ADHD rates have been increasing. Decreasing rates of trauma can’t be an explanation for more cases of ADHD.
Telling PTSD and ADHD apart
A simple checklist is usually not helpful in discerning whether an individual has PTSD, ADHD, or both. Investigating the time course of problems can provide vital information to differentiate the two. Comparing behaviors to internal mental states also offers some help in distinguishing symptoms of ADHD from PTSD.
ADHD develops early in childhood. Individuals with ADHD may have the intelligence, charisma, or family resources to successfully master social milestones.
For years it may appear as if they are functioning “normally, even though they display ADHD symptoms of inattentiveness, distractibility, poor time management, impulsivity, poor prioritization, and hyperactivity. With classic PTSD, years of normal functioning are interrupted and altered in the aftermath of a major traumatic experience. This may be much harder to discern with CPTSD, where there is not just a single, catastrophic event.
Although some people can suppress memories, most often they remember major traumatic events. The absence of memories, reminiscing, nightmares and avoidance of certain triggering environments or situations makes PTSD an unlikely explanation for symptoms.
With classic PTSD, certain people, situations, or thoughts trigger intense sympathetic nervous system overdrive that can look like ADHD. Most often, but not always, the individual with PTSD is aware of what these triggers are, either in advance or after they have elicited a bout of PTSD symptoms. In PTSD, symptoms, particularly severe symptoms tend to be most prominent in very specific contexts.
In ADHD, symptoms such as distractedness, poor attention to detail, hyperactivity, and impulsivity tend to be more pervasive, occurring in a variety of environments, without clear triggers. However, inconsistency can be a hallmark of ADHD.
Someone with ADHD may be raptly engaged in a video game or other activity where it appears that their distractibility and other ADHD symptoms are absent. But usually, they can explain that they find the current task extremely interesting so that it commands their attention.
Another clue to differentiating between ADHD and PTSD involves matching someone’s internal mental state with their behavior. Both ADHD and PTSD can manifest as restless fidgeting, explosive outbursts, or trouble turning off their brain and falling asleep.
Most people with PTSD can identify that anxiety, (or fear, anxiety, shame) is driving their thoughts or feelings. When they can’t shut their mind off to fall asleep, it’s because they are suffused with dread, worry, or guilt. In contrast, similar behaviors in those with ADHD are often described as thoughts “jumping around” without any particularly strong negative emotions.
The risk of adverse responses to medications is one important reason to come up with an accurate diagnosis before starting treatment. Stimulants have a high rate of success in treating ADHD but pose a substantial risk for worsening PTSD. Sometimes the response to a trial of medication is used to confirm a diagnosis.
Undoubtedly some individuals develop a full picture of ADHD driven by a traumatic event.
At the same time, genetic research, careful history-taking, and epidemiological information show that trauma is not the major driving force in most cases of ADHD. Arguing that all ADHD derives from PTSD is not just inaccurate, but harms individuals by creating a false self-identity. It can prevent effective treatment and trigger harmful interventions.
There’s already too much violence and negativity in the world. Trauma is a significant force warping brain development. We have entered an era where bullying, belittling, and disregard for the feelings of others are enshrined at the top of our political system. As these modes of interacting with others permeate our society, we are likely to see many more cases of CPTSD.
One paradox of being human is that we share features with all other people, but are also each unique. Life requires us to navigate a world of people who are similar to us, but none of whom are the same as ourselves. Each of us is shaped by both our genetic heritage and our interactions with the world. We need to find ways to recognize and appreciate our intrinsic differences. If we attribute everything important in our life to trauma, that diminishes us. It limits our options, locks us into blame games, and guarantees a future of conflict with others.
“Traum,” the German word for “dream,” shares an origin with the English word “trauma.” We should be careful not to immerse ourselves in a dream world where trauma is used to explain all misery.
If you or somebody that you know is experiencing a mental health crisis, there is a way to get help. Call SAMHSA’s National Helpline at 1-800-662-HELP (4357) or text "HELLO" to 741741 to be connected with the Crisis Text Line.
John Kruse MD, PhD is a psychiatrist, neuroscientist, and author. He writes regularly about mental health on Medium.com, as well as talks weekly on YouTube channels about adult ADHD and related issues.
