TL:DR – Understanding ADHD: 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.
Here are links to Part 1 and Part 2:
- ADHD (main directory page)
- ADHD Primer, Part 1 – The Medical History and Evolution of ADHD
- ADHD Primer, Part 3 – Autism and ADHD aka AuDHD, why are they strongly connected?
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 Norepinephrine (Noradrenaline) a form of Adrenaline that we use as a Neurotransmitter.
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.
How Medication Led to Understanding ADHD
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.
Further investigation into both how Amphetamine and Methylphenidate affect brains led us to recognising that they increase the available Dopamine to certain regions that are associated with “higher levels of though”. We now describe the mental abilities of these areas of teh brain “Executive Function”.
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 between neurons in the brain.
Understanding Mood and ADHD Mood
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 (in an area of the brain that we’ll call the Emergency Centre) of the situation and that feeling comes with some default actions. Those actions can vary in strength from suggestions to commands. The base biological feelings that give us a quick assessment of the situation are fear, anger [Link], 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, that is I could show someone the affect of “happy” while I am actually quite scared.
So, feelings are quick, moods last and emotions are signals we show to others that indicate what we are feeling (or what we want them to think we are feeling).
Even though they are technically different, be aware that frequently in scholarly literature and in popular social discourse people interchange the words “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 defined almost always about feelings and moods rather than literally problems communicating those feelings and moods to others.
Our fundamental feelings evolved far before civilisation, and are integral to our survival system. They are strongly tied to our freeze, flight, fight and fawn reflex. The evolved sequences goes like this:
- Perceive a situation
- Assess a category for the situation and simplify it into the category of
- Based on the situation, give a strength value to the feeling (absent, weak, moderate, strong, urgent)
- Based on the feeling category, supply an appropriate default action
- Based on the strength value, on a sliding scale engage the frontal lobes to consider the recommended action or solve for a better option at one end, all the way to ignore the thinking just do the action at the other end
The more we feel we must act, the more we generate Adrenaline to empower that action.
Adrenaline has two forms, the standard “Adrenaline (Epinephrine)” used for high levels of urgent action, and “Noradrenaline (Norepinephrine)” used to be awake/alert and as a Neurotransmitter to manage mood and connect “wants” to “actions”.
To make Norepinephrine in the brain, we modify another hormone/neurotransmitter called Dopamine, the chemical at the heart of many of the ADHD medications. Consider, though, if you are struggling to make and or retain enough brain Dopamine, it can be hard to make the right amount of Norepinephrine, which can then lead to mood dysregulation.
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. Our imagination can trigger the feelings, which can then trigger these Neurotransmitters. Sometimes our brain can randomly misfire for a range of reasons (eg: we can have a reaction to a food, drug, illness, medication; or other physical occurrence) and 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 –
- Events trigger feelings, feelings prompt a location for the cause and trigger the release of certain biochemicals, these biochemicals empower action to resolve the event trigger
- Erroneous release of certain biochemicals, biochemicals triggers feelings, feelings prompt a location for the cause (which is wrong but assumed to be right) and further biochemicals, these biochemicals empower action to resolve the assumed (and mistaken) event trigger, often leading to problematic actions and consequences
I’m going to explain that second part a bit more. 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 a recent one that will almost work, we will generally distort our perception of that experience to match our feeling. In the absence of a relevant recent experience, we will make something up that can fit how we feel on the faulty assumption that we must be feeling like this for a good reason. 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 biochemical mistake, and failing to find a real world thing that might reasonably explain your fear, you will create a reason to explain that fear by either distoriting a recent event/situation to match that fear, or reaching back to a historical event that was fearful as if that is currently relevant. This erroneous connection and reason is not real – it isn’t why you had the feeling. Your next action to address that fictitious fear is wrong and likely to cause you problems.
Frequently ADHDers that are not balancing their life, food, exercise, social and medication have significant difficulties getting accurate reports from their emergency centre of the present and upcoming situations, leading to erroneous feelings such as anxiety (fear), anger, and disgust. These then lead to misattributing motives to people, or misconstruging the level of safety or risk of a situation, or completely fabricating a series of events. To the person, this is all real and very hard to see through the illusions.
Our brains are trying to keep the level of Dopamine and Norepinephrine in the optimal level for best thinking, the Goldilocks Zone of Optimal Performance – not too high, not too low. People with Neurotypical brains don’t struggle very much to achieve this, they just make more when they are too low, or flush excess away when they are too high. ADHDer brains create actual or ficticious situations to force their brains to make more Dopamine or Norepinephrine to regulate the relevant Neurotransmitter into the Goldilocks Zone. This is then mistaken for Anxiety, Depression, Anger issues, paranoia and delusional thinking. This can also lead to substance misuse (beyond the scope of this article’s discussion).
The Dopaminergic System
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 and importantly simplified tour.
Dopamine, Norepinephrine, Epinephrine, Serotonin and Melatonin are all related chemicals, a chain system where the next link is made from the previous link. It is more complicated than this, but effectively if you do not make enough Dopamine for your Executive Function, then you likely don’t make enough of the rest of these neurotransmitters. Dopamine, Norepinephrine and Epinephrine trigger the Sympathetic (alert) body/brain system. Serotonin and Melatonin trigger the Parasympathetic (calm down) body/brain system.
- Protein (eaten in food)
- Tyrosine is made from protein via digestion, which is then converted to L-Dopa (Levodopa)
- L-Dopa passes the Blood Brain Barrier (the Dopamine made in your adrenal gland can’t, which is why you don’t treat ADHD by ingesting or injecting Dopamine)
- Dopamine is made by recombining L-Dopa from your blood in the brain (first link in Dopaminergic chain)
- Empower the Executive Function
- Holds short term ideas / data (like mental math rather than writing it down)
- Problem solving, creative solutions, finding more complex viable answers than the Emergency Centre
- Big picture task prioritisation
- Comprehension and connecting ideas, integral to learning concepts
- Being alert, present and higher levels of thinking
- Manages Muscle Movement
- Reinforces activities that improve ancient human survival, aka The Reward System
- Enjoying food
- Aquiring goods (browsing shops and or buying goods)
- Positive Social
- Empower the Executive Function
- Norepinephrine is made from unused Norepinephrine
- Situational Assessment via Sensory interpretation and Focus
- Hyperfocus vs distractability vs impulsiveness
- Feelings / Mood / Emotions
- Freeze / Flight / Fight / Fawn reflex when an emergency is detected
- Connects “want” and “plans” to “physical actions”
- Manage pain perception, ties in with Endorphins (we think)
- Situational Assessment via Sensory interpretation and Focus
- Epinephrine (aka Adrenaline) is made from unused Norepinephrine
- At high levels, disengages the higher thinking centre and engages primal survival actions, supresses pain perception
- At moderate levels, appears to be connected to long term memory storage
- Serotonin is made from unused Epinephrine
- Powers the neurotransmitter homeostatic system (prompting direct creation/deletion of neurotransmitters to get to he Goldilocks Zone where able) – this is currently conjecture and we need more studies to confirm this
- First link to decrease alertness/agitation (soporiphic/sleep, parasympathetic trigger)
- Melatonin is made from unused Serotonin, and also from your bodies adrenal gland as this last link in the Dopaminergic chain can pass through the Blood Brain Barrier
- High levels, prompts the brain to consider sleeping now if the adrenal level is low
- Being in darkness / dim light prompts the body to produce Melatonin
- Low levels, prompts the brain to be awake
- Bright light / daylight (especially sky blue) prompts the body to delete Melatonin
- High levels, prompts the brain to consider sleeping now if the adrenal level is low
A Closer Look at Dopamine, Norepinrphrine and Adrenaline in an ADHD context and Common Misdiagnoses
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 freeze, 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 further actions to conserve energy. This is quite easy to mistake for a the symptom 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, your brain notes there is not enough Norepinephrine, so it tries to quick convert Dopamine into Norepinephrine, or substitute Epinephrine (regular Adrenaline, the next chemical down the pipeline from Norepinephrine).
If your brain is low on Dopamine, it will normally be reluctant to release it for such mundane tasks as planning a possible future. In the face of a sufficient crisis, this reluctance is overriden, allowing the Dopamine to be converted to Norepinephrine to power up the Emergency Centre, and thus the Fight / Flight response. This allows you to be present to the moment, but with reduced comprehension and creativity. 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 subconscious brain convinces us that there is a problem, it can trick the Emergency Centre (in our hindbrain), into thinking that we are in crisis, and therefore taking crisis action which includes quick converting Dopamine into Noradrenaline or at higher levels of crisis, releasing reserve Adrenaline. This is experienced as anxiety (the freeze and flight reaction); or anger / aggression (the fight part). Again, often these symptoms are misdiagnosed as separate medical conditions.
Objectively, crises are not that common. In the absence of a local crisis, your brain will have to either create one, or bring you to one. Some common mechanisms to trigger the anxiety is to 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, cockroaches or people. 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 lack of supportive evidence or ignoring real evidence to the contrary.
It is important to understand that Adrenaline based thinking is emergency based thinking. In an emergency, we don’t have time to solve problems, because the problem is here and deadly. This messes up time perception – it 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 over commit resources to things that just don’t matter, or we miss doing things that actually do. We also feel like we can’t actually do any kind of reality check, because everything feels so darn urgent. As an outsider, people in this state seem to be quite irrational – failing to acknowledge logic, evidence or reason.
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 into a crisis. This can lead to some 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 various self harm – actions that harm you psychologically, social, or physically. This can lead to thoughts and actions to directly harm your body, or thoughts and actions about taking your own life.
An Important Look at Self Harm and Suicidal Ideation
– A Call for Help Needs to be Taken Seriously.
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, or are given the wrong 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 injuries and kick people 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 both the talking therapy (CBT etc) and the neurotransmitter side of mental health, and medication.
Type II ADHD?
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 to navigate the ever present crisis – even when it has gone.
I estimate that of 20 ADHDers, 5-8 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 5-6 in 20 very low N ADHDers, while ADHD medication will help the feelings of Anxiety and Anger, it won’t be enough and often an extra NRI will be needed (Norepinephrine Reuptake Inhibitor). For most, the common ADHD medication is enough to boost Norepinrphrine. For that 1 in 20, while the extra Dopamine decreases brain fog and improves focus, the experience of Anxiety and or Anger will significantly rise. There are medications that can help decrease high Norepinephrine, 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. In my experience, most SSRI medications are 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, then Adrenaline. 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, eventually, higher. This is one way that we think that some Serotonin medications have a small but positive effect on ADHD. The SSRI medications that seem to be more effective are also known to have a very mild side effect that acts as a kind of NRI or DRI (Norepinephrine or Dopamine Reuptake Inhibitor) effectively prompting the brain to keep a bit more of that Neurotransmitter around (weak but direct).
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. Bright lights (such as daylight) can also interfere with Melatonin, so when wanting to go to sleep, dimn the lights down for between 30 to 60 minutes first.
In Part 3 we will look at how Autism and ADHD are connected.