Month: October 2022

TL:DR – ADHD is mostly about Dopamine. Norepinephrine is also often important. Understanding how Dopamine and Norepinephrine affect our feeling is key to understanding a great deal about ADHD.

Last time we covered that ADHD is a neurological condition that is poorly defined, but does affect a fair percentage of the population. The name means Attention Deficit Hyperactivity Disorder: where on observation, some ADHDers do seem to have trouble with attention. We will see that the conclusion is simplistic, and that this method for defining the group of ADHD is misleading.

We established that certain types of medication can really help. What these medications have in common is their ability to increase a chemical in the brain called Dopamine. I also stated that there is frequently a problem with regulating another chemical called Adrenaline.

We will be covering here what that is about, what it tells us, what the consequences to the individual can be, and what you can do about it.

Originally, methylphenidate, commonly called Ritalin, and a classification of medications called Amphetamines, were observed to help people who fit the description of Hyperkinetic – that is, they move too much, which was a precursor to the name ADHD. Amphetamines are categorised as a medication called “stimulant”. Ritalin was classified as a medication to modulate blood pressure. One would think that giving a stimulant to a person who has trouble sitting still would make it even harder for them to do so – but the reverse happened. These people found it easier to sit still. More importantly, they found their concentration vastly improved, and often, their mood easier to regulate.

This tells us that Dopamine is a key component to the category of ADHD. Dopamine is a chemical our body uses in various ways for various things. It is classified as a Hormone (like testosterone, oestrogen and insulin) and a Neurotransmitter, a chemical specifically involved in how signals are sent and received around the brain.

We need to do a quick side track about mood, which will help us understand both neurotransmitters and some important ADHD aspects.

ADHDers often find their mood dysregulated in the absence of medication. First, what the heck is mood?

We feel in response to an occurring or expected event. The feeling is the result of a super quick assessment of the situation and that feeling comes with some default actions. Those actions can vary in strength from suggestions to commands. The common biological feelings that give us a quick assessment of the situation are fear, anger, disgust, surprise, sadness and joy.

If that feeling persists, it becomes our mood. When we show that internal state to others, it is an emotion. I don’t have to show others how I feel, but sometimes showing that feeling helps them respond to the situation or me better. My emotion doesn’t have to match my feeling or my mood.

So, feelings are quick, moods last and emotions are feelings or moods that we are signalling to others.

Even though they are technically different, be aware that both socially and frequently in scholarly literature people interchange feeling, mood and emotion. A mood disorder can be more about feelings than moods, moods than feelings, or a balance of both. Emotional disorders are almost always about feelings and moods rather than communicating those feelings and moods to others.

Our fundamental feelings evolved far before civilisation, and are integral to our survival system. As such, they are strongly tied to our freeze, flight and fight reflex. Freeze, flight and fight are more or less controlled by a chemical called Adrenaline. When we detect risk, we assess the situation, get a report in the form of a feeling, get a default action in the form of an urge, and release Adrenaline to prepare the body for action depending on the strength of that urge.

Adrenaline has a few forms. An important one is Norepinephrine, which is classified as both a hormone and a neurotransmitter. In the brain, we make Norepinephrine made from a different hormone/neurotransmitter called Dopamine, the chemical at the heart of many of the ADHD medications. Norepinephrine empowers our getting on with tasks and is part of regulating our state of alertness – sleep, relaxed, alert, anxious and panicked.

The feelings most closely tied to the neurotransmitter Norepinephrine are pain, fear, anger, disgust and surprise. While Sadness is also related, it is complex to describe and beyond the scope of this quick exploration. As part of your survival mechanism, each of these feelings has evolved to help you avoid damage now or in the future. They aren’t inherently good or bad per se; they are good if they are doing their job and they are bad if they aren’t.

In the same vein as the previous feelings, Joy evolved before civilisation. Joy is the feeling we have when we have done an action that promotes our wellbeing, such as eating food, acquiring goods, connecting socially to people, succeeding at tasks and so on. Joy is connected to the neurotransmitter Dopamine. When we do one of these activities, Dopamine is released and we feel good (a form of joy), and it will reinforce us doing this activity again. Much like the other feelingings, Joy isn’t inherently good or bad. This cycle is great for our survival when in balance, but when out of balance can cause havoc.

We can co-opt the Dopamine reward release to power up the Executive Function. More on that a bit further down.
To review, so far we have experiences that trigger feelings, which will then trigger certain Neurotransmitters to be released in our brains, which can then power certain abilities such as solving, freeze, flight and fight. These feelings will then affect the decisions and actions that we take.

It is important to note that you don’t need an experience to have a feeling. On the one hand, we humans have active imaginations, which ideally help us plan and solve problems before they happen. However, our imagination can also trigger the feelings, which can then trigger these Neurotransmitters. On the other hand, sometimes our brain can randomly misfire; we can have a reaction to a food, drug, illness, medication; or other physical occurrence can also trigger the release of these Neurotransmitters. These erroneously released neurotransmitters will then trigger feelings that are not connected to the usual kind of stimulus (real life event).
The point of this side track is both to understand how our feelings and these Neurotransmitters are tied together, and to recognise that they work in both directions – feelings trigger the release of certain chemicals, and the release of certain chemicals can trigger feelings.

When we humans have a feeling that doesn’t obviously correspond to an experience, we search for an experience to connect it to. If we find one that will almost work, we will generally distort our perception of that experience to match our feeling. In the absence of an experience that fits well enough with the type and strength of the feeling we have, we will make something up that can fit how we feel. So far as our brain is concerned, this is a nice and tidy bit of accounting – the feeling is now tied to an experience, so we can act on it. The problem is that the faulty allocation of a “reason” for our weird feeling often leads us to make awful decisions. For example, if you suddenly feel fear due to a body chemical mistake, and failing to find a real world thing that might reasonably explain your fear, you will create a reason to explain that fear based on the situation you are in. This made up reason is not real. Your next action to address that fictitious fear is wrong and likely to cause you problems.

I keep talking about these Neurotransmitters. We need to take another side journey to understand those a bit better, and why they are so important to understanding what ADHD actually is. I’m going to focus on the big three for a moment – Dopamine, Norepinephrine and Serotonin. I am also going to add in a bonus Neurotransmitter, Melatonin. Please keep in mind that this is going to be a quick approximate tour.

Dopamine, Norepinephrine and Serotonin are related chemicals. I’m not going to go into every step, although it is very fascinating. Each of these chemicals becomes another, with a distinct chemical formula and traits.

Firstly, when you eat protein, your digestion turns it into base amino acids. One of these amino acids is called Tyrosine. Tyrosine is used to make various different parts of your biology, which aren’t relevant here. The one that is relevant is called levodopa (L-Dopa). Levodopa can pass through your blood brain barrier and is the first point at which what you eat becomes the base product of this series of neurotransmitters that your brain needs. After a few transitions (each of which are used for various brain functions), it becomes Dopamine. While your body also makes Dopamine elsewhere in the body, this Dopamine can’t pass the blood brain barrier. Dopamine powers the Executive Function and is a Reward hormone that helps you feel good. Dopamine is then turned into Norepinephrine, which empowers both getting on with tasks, and is part of our defensive feeling system. A few more steps and Norepinephrine becomes Serotonin. Serotonin is often ascribed to regulating and affecting all of the things that I’ve described for both Dopamine and Norepinephrine, and I think that this description is overly simplistic, often mis-ascribed, but still a part of a complex picture. A few more steps and Serotonin becomes Melatonin, often used to indicate to your brain that it is time to sleep.

Dopamine is used in various parts of your brain for various tasks, such as regulating muscle movement, memory storage, memory retrieval, comprehension, problem solving, prioritisation, sleep, learning, lactation and more. Some of these are very relevant to ADHD. Effectively Dopamine powers your Executive Function.
Yet another side trip to explore the Executive Function. In this context, the Executive Function is a network of parts of your brain that plans tasks that improve our chances of survival. It tells us what are the priority tasks right now, how to do them, gives us temporary memory storage (working memory) to facilitate that solution (like doing mental math instead of having to write it down), finding clever solutions to problems, activating us starting on those problems and then keeps us on track. It is an integral part of our ability to do several tasks in quick succession, a basic kind of multitasking.

This all sounds fairly standard and normal, unless you have an ADHD brain, in which case some or all of these things are literally hard to do. When we give a medication that increases the available Dopamine in the brain by just a tiny bit, the ADHDer finds each of these much easier. That tells us that ADHD is fundamentally a problem getting Dopamine to the parts of the brain that do these functions.

If the availability of Dopamine is low, your brain will be reluctant to use it for something as mundane as solving non urgent problems. This makes it hard to make sensible plans, hard to remember details, and hard to anticipate what is next. The ADHDer will also often feel disconnected from the world and disassociated as Dopamine being used by the motor cortex becomes minimised to conserve remaining Dopamine resources for potential crises.
Next along the pipeline, Dopamine becomes Norepinephrine, one of the forms of Adrenaline. Norepinephrine is integral to our defensive feelings and fight/ flight and fight reactions. If there isn’t enough Dopamine, then there generally isn’t enough Norepinephrine, which means that a person is going to feel very down, “emotionally” numb, and unmotivated. This will also often feel like being “out of energy”, which prompts actions to conserve energy. This is quite easy to mistake for a condition called Depression.

Our brains are primarily geared towards survival, and without enough Norepinephrine, it is very hard to power up the system that makes a quick and accurate assessment of the situation. If your brain detects that something is going wrong, it tries to fix it, and in the failure of fixing, compensate. In this case, it notes there is not enough Norepinephrine, so it tries to convert Dopamine and substitute Epinephrine (regular Adrenaline, the next chemical down the pipeline from Norepinephrine). Epinephrine is not used much directly in the brain (other than some very fascinating memory storage action when combined with glucose), so it is often available, prior to moving further down the pipeline towards becoming Serotonin.

While your brain will be reluctant to use limited Dopamine for such mundane tasks as planning a possible future, a sufficient crisis will override this caution, and allow the Dopamine to be converted to Norepinephrine.This allows you to be present to the moment, but with reduced intelligence. That is, you can do something now, but because it is viewed through the filter of crisis, solutions are often very black and white, very now, and often look like freeze, flight and flight.

If you recall, earlier we explored how feelings can trigger chemical release, and that chemical release can trigger feelings. If our brain convinces us that there is a problem, it can trick the hindbrain, that is, the part of the brain specialised in survival, into thinking that we are in crisis, and therefore taking crisis action which includes releasing Adrenaline. This is experienced as anxiety (the freeze and flight reaction); and or aggression / anger problems (the fight part). Again, misdiagnosis is something to be aware of.

Crises are not that common, so your brain will have to either create one, or bring you to one. Some common mechanisms to trigger the anxiety is that either fool you into thinking that something is horribly wrong out there, perhaps everybody hates you, exercising negative self-talk such as “I’m a loser and can’t get anything right”, or prompting a fear of something common and everywhere such as germs or cockroaches. Some common mechanisms to trigger the anger are thoughts like “everyone is against me”, “it is me versus the world”, “everyone is just getting in my way” or designating key people in your life as the enemy despite any real evidence.

It is important to understand that Adrenaline based thinking is emergency based thinking. In an emergency, we don’t have time to solve problems, when the problem is here and deadly. This makes it hard to assess how much time is passing, how much time a task will take and when actions should actually be done. It also makes it hard to plan, because the stakes of failure seem so high. We also feel like we can’t actually do any kind of reality check, because everything feels so darn urgent.

If your brain doesn’t use this crisis mechanism, then it won’t have enough Adrenaline to substitute for Norepinephrine. This will often be mistaken for Depression. This kind of “depression” feels like you wanting to do things, you even have a plan… you just can’t actually do it for some odd reason. It feels like something is in the way, like something is stopping or blocking you. It feels like an insurmountable barrier that can only be solved by escalating how you feel. This can lead to two very concerning behaviour patterns. I’ll outline the main three.

The first concerning behaviour is using lots of stress, fear or negative self talk to drive yourself to break the barrier. While you can sometimes get things done, it feels absolutely awful. This can really affect your self-esteem and confidence.

Another concerning behaviour is to reframe your life such that nothing matters anymore. If you can’t get anything done, and nothing seems to help you feel good, you stop wanting to do anything. Change out of this becomes very, very hard, because it seems like there is no point. This can devolve into anhedonia – an absence of joy. While there are other mechanisms that can get a person to anhedonia, this is one of the more common mechanisms, and it is frequently overlooked.

The other pathway is both dramatic and dangerous. To break through the lack of Norepinephrine, and in the face of failure to create enough anxiety or anger to substitute Adrenaline, your brain will go down a path of self harm. Either actions that harm you psychologically, social, or physically. This can lead to thoughts and actions to directly harm your body, or taking your own life.
I’m going to pause here for a moment and state that one of the first things I do when a client comes to me with thoughts or actions of deliberate self-harm, and or thoughts of taking their own life, is check to see if I am actually face to face with someone who is an undiagnosed or untreated ADHDer. The risk of death is both real and high for people who cannot get help. No one talks about self harm and death for long without something being wrong. Anyone who has accidentally hurt themselves can appreciate that self-harm hurts – and someone who tries to do this “for the attention” won’t try it for long, because it hurts and has little tangible reward. So someone who is repeatedly self-harming is someone who needs to trigger the Adrenaline that this harm brings to function. So please, take the call for help seriously and get a proper assessment.

Unfortunately, in my experience, most public hospitals are not good at assessing long term help. They are focused on getting people out as fast as possible, so they are motivated to patch up and kick out. If you, or someone you know, is going through this, please see an ADHD informed and trained professional. While your brain may not be an ADHD brain, the professional should be well trained in Self-Harm and Suicide, and be able to help out. You are looking for a therapist that understands the neurotransmitter side of mental health, and medication.

It is also important to recognise that some ADHDers do not actually have a problem with a lack of Norepinephrine. Some have excess. This can lead to very odd thinking anxiety and or aggression. The mechanism isn’t clear, but essentially with a lifetime of either using anxiety or anger to trigger the Adrenaline response, or having experienced enough traumatic events, your brain becomes locked on to crisis mode. This quickly depletes Dopamine to keep the Norepinephrine and Epinephrine levels high.

I estimate that of 20 ADHDers, 5-7 will have very low Norepinephrine levels, most will have low to moderate Norepinephrine levels, and 1 will have high Norepinephrine levels. ADHD medications not only increase your Dopamine, they also increase your Norepinephrine. For the 5-7 in 20 very low ADHDers, while ADHD medication will help the feelings of Anxiety and Anger, it won’t be enough. For most, this boost is good enough. For that 1 in 20, the experience of Anxiety and or Anger will significantly rise. There are medications that can help offset both outer outcomes, taken additionally with or instead of regular ADHD medication.

Serotonin is the next major neurotransmitter of interest down the pipeline. It is of interest only because it is the target of the most common mental health medications. It is mostly not directly important to ADHD. That pipeline analogy comes into fruition here though. If you block up part of the pipeline, then everything blocks up a bit, slowing the flow down. As Levodopa is continuing to cross the blood brain barrier, it continues to create more Dopamine, and then subsequently more Norepinephrine. As these can’t really go too much further because the Serotonin section is a bit full, the overall availability of Dopamine and Norepinephrine is effectively higher. This is why we think that some Serotonin medications have a small but positive effect on ADHD. Some of these medications work better than others at affecting this chemical pipeline. Some are next to useless.

Finally, a few more steps down the pipeline, Melatonin is created. The longer you are awake, the more Melatonin accumulates. A mechanism that our brain uses to determine if enough wake time has elapsed that we should now go to sleep is to check how much Melatonin has accumulated. If your brain finds that there is lots, it triggers the “tired now, go to sleep” mechanism. While you are asleep, Melatonin is flushed out.

Melatonin is one of the few Neurotransmitters that can actually pass the blood brain barrier. Many ADHDers struggle to sleep well, possibly due to insufficient Melatonin production, often due to an excess of Adrenaline overriding the sleep mechanism. Fortunately, Melatonin is also a medication you can be scripted. Melatonin medication is not a sedative, per se. It merely helps your brain realise that it is time to sleep. Excess Adrenaline can negate this signal, so it is important to learn how to either calm this down, or discuss with your doctor medication that can help this aspect.